WURMSER, L. (1974) PSYCHOANALYTIC CONSIDERATIONS OF THE ETIOLOGY OF COMPULSIVE DRUG USE. J. AMER. PSYCHOANAL. ASSN., 22:820 (APA)
PSYCHOANALYTIC CONSIDERATIONS OF THE ETIOLOGY OF COMPULSIVE DRUG USE
LEON WURMSER, M.D.
UNTIL NOW, THERE HAS BEEN very little systematic exploration into the etiology of drug abuse. Glasscote et al. (1972) described the situation most aptly:
It may be fruitless to make the effort to identify a group of universal causes of susceptibility. In any case, while there has been some interest in determining what drug users are like, by means of interviews and standardized tests, there has been little systematic effort to delineate and quantify causes. On the other hand, there has been much hypothesizing about the conditions, events, and circumstances that lead to drug abuse, most of which fall into three categories: the physical, the internal or intrapsychic, and the social and environmental [p. 19].
A study to fill at least part of the gap is envisioned here: viz., to delineate in a systematic way the etiology of drug abuse on the basis of large-scale clinical experience with all types of this phenomenon.1
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Inasmuch as most "drug abusers" are inaccessible to psychoanalysis proper, it is not surprising that, despite the huge upsurge over the last decade of drug abuse in general, and of intensive, compulsive drug use in particular, only a few psychoanalytic studies have appeared which could try to explore in depth the possible etiology of this illness. The contributions of Chein et al. (1964), Krystal and Raskin (1970), Wieder and Kaplan (1969), Dora Hartmann (1969), Savitt (1963), Panel (1970), Zinberg and Robertson (1972), and Khantzian et al. (1974) are notable examples. Earlier works—the essays of Rado (1926), (1933), (1963), Glover (1928), (1932), Savitt (1954), Limentani (1968), and the comments of Fenichel (1945), although still very interesting, seem outdated and barely applicable to most categories of drug abuse seen nowadays.
The question we intend to answer, then, is: What are the causes of drug abuse? This in turn raises the further question of what exactly is meant by "drug abuse." The term is so wide and imprecise, contains such a hodgepodge of clinical and social phenomena, and is so dependent on the bias of the observer, that a systematic study of its etiology would be as vast and comprehensive as an inquiry into the etiology of fever. It will therefore be necessary to define what we mean before embarking on our investigation.
Some Basic Distinctions and Definitions
The usual definition of drug abuse is based simply on sociolegal criteria. According to Jaffe (1965), it is: "the use, usually by self-administration, of any drug in a manner that deviates from the approved medical or social patterns within a given culture" (p. 285). Jaffe narrows this broad definition by focusing on those "drugs that produce changes in mood and behavior." Similarly, Glasscote et al. (1972), apply the term drug abuse "to illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at a minimum, culture alien" (pp. 3–4).
Such sociolegal definitions obviously carry strong connotations of moral judgment and are based on specific ethical values. I believe a further delimitation can be made if the problem is viewed
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psychiatrically: drug abuse is the use of any mind-altering drug for the purpose of inner change, if it leads to any transitory or long-range interference with social, cognitive, or motor functioning or with physical health, regardless of the legal standing of the drug. Here, the judgment is based on impaired functioning and thus on an observable medical criterion, vague though it might still be.
For most purposes, however, even this definition is unsatisfactory because of its breadth. For a careful study of etiology, we had better set apart all those occasional or irregular drug users in whom the impairment is merely transitory; this latter group seems particularly heterogeneous and contingent. Our starting point is thus the discernment of two groups placed on the two extremes of a continuum. At the one end, we have the experimenters or casual users who represent the vast majority of participants in drug abuse (according to both definitions given above)—probably 90 per cent. They present, medically and psychiatrically, very few and rare problems. Yet, much of the public's attention, the law's concerns and energies, the preventive efforts, are dedicated to these people. The experimenter takes a mind-altering drug a few times and feels he does not really need and require its effect. Out of curiosity, and just as much in order to avoid shame by not conforming with the adolescent peer group, he wants to prove that he has partaken of the initiation, that he knows what it is all about.
At the other end of the continuum, we have the compulsive drug abuser. He is the real problem. To him applies the statement that drug use is just a symptom of deep underlying problems. Only those relatively few experimenters proceed to compulsive drug abuse who carry the set of profound deficiencies and conflicts that we are going to explore in this study. It is the compulsive drug abuser who feels that the drug-induced state relieves him of what bothers him and gives him what he is missing, so that he feels unable to renounce the "high," regardless of dangers and threats he is usually fully cognizant of.
In the broad area between these two groups we encounter the so-called recreational user of drugs like alcohol or marijuana. For many recreational users the goal is merely relaxation, not intoxication; the amount of the active substance is so small that no interference with motor or mental functioning is noticeable. In many more so-called recreational users, the goal is indeed occasional
or frequent intoxication. They usually claim that their temporary abdication of rational controls is an entirely free, noncompulsive activity. I have not reached any final conclusion about this group, but on the basis of my clinical experience, I would associate the first type of recreational users, the relaxers, with the experimenters, the second type, those striving to get "stoned," "high," or "down," with the compulsive users.2
We turn now to this problem of "compulsive drug abuse" (cf. also Jaffe, 1965); (Glasscote et al., 1972).
Of course, the question arises: how far is this compulsiveness of a physical nature? Is that not just what led to the prohibition of these drugs in the first place—that they induce inevitably or at least very often a physiologic dependence which henceforth cannot be broken?
If we carefully study, on the one side, history and treatment experience and, on the other side, the interesting observations in medically and psychiatrically induced addictions, (e.g., when opiates were used to treat melancholics), we are forced to assign very little valence in the long range to this factor of physical dependence. In other words, as Hamlet said, "the readiness is all."
Those who work closely with compulsive drug users observe time and again that if their drug of predilection is taken away (or more precisely, if their drug effect of choice is removed), they sooner or later tend to substitute other symptoms. Neurotic depression and suicidal attempts, acts of violence, stealing, running away, severe attacks of anxiety, found prior to the use of drugs and sometimes accompanying the full-blown drug use, once the resorting to drugs is blocked, frequently reappear in exacerbated form and are often more destructive than drug use itself. Still more frequently, we encounter the replacement of a suddenly unavailable type of drug by a pharmacologically completely unrelated class: i.e., patients deprived of narcotics typically resort to alcohol and sedatives (especially barbiturates), which have no bearing on any physical withdrawal
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phenomena, but solely on the psychological need for a drug-induced relief. In other words, compulsive drug use is merely one symptom among others, the expression of an underlying disturbance, not the illness itself.
One implication of this observation is, of course, that the really difficult task in treating these patients is not the withdrawal from drugs, but the coping with the emotional need to use a drug, to use any drug, and to use many other equally harmful external means, to find relief. In other words: I have never yet seen a compulsive drug user who has not been emotionally deeply disturbed, who has not shown in his history the ravages of borderline, or even psychotic conflicts and defects. Only secondarily do we encounter the devastations caused by the drugs themselves. We may go one step farther: Not only do we encounter many other signs of pervasive severe psychopathology—most frequently of the borderline type—but the very criterion used to single out this group as compulsive drug users, namely "compulsiveness," leads us straight into the tangled thicket of how to define psychological health and illness, since this observable quality of compulsiveness or peremptoriness has been used by several psychoanalytic theoreticians (notably Waelder, 1936) and (Kubie, 1954) to define illness:
"The essence of normality is flexibility in all of these vital ways. The essence of illness is the freezing of behavior into unalterable and insatiable patterns. It is this which characterizes every manifestation of psychopathology, whether in impulse, purpose, act, thought, or feelings" (Kubie, 1961, pp. 20–21). Our "habitués" are, without exception, paradigms for people overwhelmed with such "unalterable and insatiable patterns."
Hierarchy of Causes
Even if we select an apparently homogeneous group, e.g., narcotics addicts, we still are bewildered by the variety of causes and, correspondingly, the vast array of proffered, discussed, and disputed cause-and-effect relationships. We may try to discern layers of causes (or, to be more precise, layers of reasons [Schafer, 1973, p. 268]), ordered according to causative specificity, and start off with a superficial distinction between two factors that always appear to be present: The first is a psychological hunger or "craving,"
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which we might describe as the addictive search—an entire group of activities, predating, accompanying, and following the compulsive drug use; they all are used to provide external relief for an internal urge of overpowering drivenness. We refer to activities such as irresistible violence, food addiction, gambling, alcohol use, indiscriminate "driven" sexual activity, or running away. The second factor is the more or less contingent, even accidental entrance of various drugs, in forms of both accessibility and seduction. This factor we shall call the adventitious entrance of drugs.
Behind this phenomenological distinction we can perceive a logical and historical structure of causes which we now examine, viewing them as a hierarchy of causes of various specificity. As is very often the case with such differentiations, what in this analysis is torn asunder into various groups and layers of reasons is in reality a continuum, ranging from high to low specificity.
Freud (1895) distinguished four types of causes for an emotional disorder: (a) precondition; (b) specific cause; (c) concurrent cause; and (d) precipitating cause. This distinction seems to have been an original contribution of Freud to the philosophy of causation. With it, he tried to apply the basic concepts of accidental, necessary, and sufficient causes—which had originated with Aristotle and had been developed by d'Alembert, Leibnitz, and Schopenhauer—to the problems of motivation, in particular, to the causation of emotional illness. He used a precursor of this four-part model in Draft B (1893), replacing it later on by the concept of the complementary series (Sherwood, 1969).
I was not able to consider all the philosophical roots, merits, or weaknesses of this model as a basic logical concept, but I feel it may serve us heuristically better than other models of causation. Some of the following layers will be explored more in detail later on.
a. A cardinal, indispensable, but broad layer of reasons is the precondition: "The factors which may be described as preconditions are those in whose absence the effect would never come about, but which are incapable of producing the effect by themselves alone, no matter in what amount they may be present" (Freud, 1895, p. 136). Applied to our problem, these inevitable preconditions can be located in a life history of massive narcissistic disturbances and in a rather specific pattern of family pathology. I
describe this in more detail below (cf. also Wurmser, 1972a), (1972b). Here, it should be only stated that the narcissistic conflicts referred to pertain to massively overvalued images of self and others. The term narcissistic is used in the (precise) psychoanalytic sense of Freud (1914), Kohut (1971), (1972), Kernberg (1970), and Pulver (1970), namely, to denote an archaic overvaluation of the self or of others, a host of grandiose expectations, and the abyssmal sense of frustration and letdown if these hopes are shattered.
b. "The specific cause is the one which is never missing in any case in which the effect takes place, and which moreover suffices, if present in the required quantity or intensity, to achieve the effect, provided only that the preconditions are also fulfilled" (Freud, 1895, p. 136).
Most people would now be inclined to seek the specific reason for compulsive drug use in the temptations by peers or pushers. I believe this would be misleading; it is, though semantically correct, clinically and theoretically wrong. We earlier differentiated "addictive illness' and "adventitious" appearance of the drug, and can now repeat that we find an emotional illness brewing independently, whether the drug enters or not. The specificity for its outbreak in manifest form lies in an experience of overwhelming crisis, accompanied by intense emotions like disillusionment and rage, depression, or anxiety, in an actualization of a lifelong massive conflict about omnipotence and grandiosity, meaning and trust—what we have just described as a narcissistic conflict. This actualization inevitably leads to massive emotional disruption and thus to the addictive search. In other words, if we focus on the illness "addictive syndrome," the specific reason is a more or less acute external and internal crisis bringing about an exacerbation of a narcissistic disturbance. We may call this a "narcissistic crisis." In contrast, if we focus on the symptom "drug abuse," we are wiser to talk about precipitating, rather than specific reasons, a category I shall mention shortly. Even without the advent of the drug itself, we still have the characteristic seeking for a way out, for an escape, a driven desperate attempt to find a crutch outside of oneself.
Much vaguer and several steps removed are the reasons ("causes") that litter the literature, all of which we can put in the next category. Their nature is very unspecific, broad, of little predictive value. They are shared by many who do not join in the illness,
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and vice versa. Yet, they indeed are the only reasons (and indeed "causes") which epidemiological and sociological studies are apt to find. The statistical methods employed by these disciplines tend to bring out the background factors leading to heightened incidence, but not the more specific correlations.
c. "As concurrent causes we may regard such factors as are not necessarily present every time, nor able, whatever their amount, to produce the effect by themselves alone, but which operate alongside of the preconditions and the specific cause in satisfying the aetiological equation" (Freud, 1895, p. 136).
The most general of these concurrent reasons are widespread value conflicts in our culture and basic philosophical questions about the limitations of human existence. One crucial element is the conflict between democratic philosophies, postulating the dissolution of most external representatives of the superego, the increasing abolition of the restraining powers of authority and tradition, of external structures and restraints, and totalitarian philosophies, imposing the most tyrannical forms of such authority and power. Drugs are for many the shibboleth of liberation from authority, a symbol of protest and extreme privacy ("doing one's own thing").
A second element is the paradox with regard to mastery and domination of our outer and inner life: most of the ancient dreams of mankind about outer control have been fulfilled, whereas most of the techniques used in the past to gain an (albeit often spurious) sense of inner mastery and control have been discarded. Drugs provide a sense of magical domination and manipulation over one's inner life, analogous to that which science and technique appear to have over the outside.
Another socially more relevant value conflict is that between easy pleasure, immediate material gratification, and indulgence versus the often bizarre harshness of the responses by representatives of punitive and often corrupt authority (the death penalty for some small drug sales, sentences of 25 years for the giving away of one marijuana cigarette, entrapment and degradation of drug users by law enforcement officials). Thus, belonging to a drug-using countergroup can serve as protest against a profound inconsistency in the cultural fabric.
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Another such factor may be the changed role of genital sexuality. For many, easily accessible sexuality is a source, not of anxiety, despair, and commitment, but of tedium and routine. The denied, split-off emotions involved in sexual yearnings are sought instead in other avenues, particularly with the help of pharmaca. Moreover, we might wonder how much the shallowness of, and presentation of shortcuts to, gratification by television, viewed for many hours daily from early childhood on and thus substituting a passive form of presentation for the development of an active fantasy life, may contribute to this search for easy stimulation (Grotjahn, 1971).
But most of all, we have to cite the social factors in the slums: social degradation, overcrowding, and overload in stimuli (especially noise and violence); the socially important role of the drug-using peer group as a substitute for the lacking family structure; and the even more relevant function of the drug traffic, and the black market needed to feed it, as an economic equalizer between ghetto and dominant middle-class society. All in all—these are unspecific broad factors—valid as much for occasional and recreational users (if indeed not more so) as for compulsive drug users.
Finally, we have to return to what I described phenomenologically as the "entrance of the drug" and labeled "adventitious":
d. "… we may characterize as the precipitating or releasing cause the one which makes its appearance last in the equation, so that it immediately precedes the emergence of the effect. It is this chronological factor alone which constitutes the essential nature of a precipitating cause" (Freud, 1895, pp. 135–136).
We would assign the previously mentioned easy availability of drugs and the seduction by peers to this category ("social compliance" [cf. Hartmann, 1939]. The advent of the drug suddenly allows the previous desperate search to crystallize around the one object and activity that relieves the unbearable tension. In sum: there is no compulsive drug use without this trigger factor; but there is still an overriding emotional compulsiveness directed toward other activities and objects. It can be assumed that only the latter two sets of factors (concurrent and precipitating ones) are identical for experimenters and compulsive users alike.
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Clinical Observations About Preconditions and Specific Reasons
We turn now to a more detailed study of the first two sets of factors: what has been found so far in regard to the essential personality structure predisposing to, and the acute crisis immediately evoking drug use, and how these factors are matched by the pharmacological effect of various drugs.
The psychological factors of impulsiveness and low frustration tolerance are well known and undisputed. I should like to attempt an analysis that goes beyond these sweepingly general characterizations and may open the way to a deeper understanding of some actions and attitudes of these patients (perhaps of "sociopaths" in general?). Much is vague, tentative, even contradictory in what follows. Large gaps need to be filled. Careful longitudinal studies in depth, particularly in psychotherapy, psychoanalysis, and family research are needed to advance our knowledge.3
The Defect of Affect Defense
We start with what I believe to be the most important concept in a dynamic understanding of drug use. I consider all compulsive drug use an attempt at self-treatment.4 The importance of the effect of the drug in the inner life of these patients can perhaps be best explained as an artificial or surrogate defense against overwhelming affects. Moreover, there evidently exists some specificity in the choice of the drug for this purpose. Patients prefer those drugs which specifically help them to cope with the affects that trouble them most.
In the past, the satisfying, wish-fulfilling aspects of the drug effects have been emphasized. To put this in a catch phrase: drug use was seen as an expensive search for a cheap pleasure. This is certainly the popular and unreflective concept of why people take drugs. Earlier analytic theoreticians (Glover, 1932), (Rado, 1926), (1933),
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(1963) subscribed to this idea, except that they saw in drug use, as in other symptoms, the satisfaction of unconscious wishes.
In other psychological studies of drug abuse, the focus was on the symbolic (again chiefly wish-fulfilling) meaning of drug intake as such (as oral supplies, illusory penis, or its self-destructive, self-punitive aspects) with little regard for the psychodynamic impact of the pharmacological effects themselves.
The view that drug use is an escape has also been popularly held, but largely with regard to intolerable external situations. The concept of the need for drugs as a defense against intolerable internal factors—and, more specifically, affects—has been described but scarcely until a very few years ago. Most tragically, legislation and public policy totally disregard this central factor.
Homer sang of Helena having "drugged the wine with an herb that overcomes all grief and anger and lets forget everything bad."
Freud (1930), too, described narcotics as a means of coping with pain and disillusionment. Glover (1932) was explicit with regard to "drug addiction" (referring to cocaine, paraldehyde, and presumably also to opiate addictions): "Its defensive function is to control sadistic charges, which, though less violent than those associated with paranoia, are more severe than the sadistic charges met with in obsessional formations" (p. 202) and: "Drug addiction acts as a protection against psychotic reaction in states of regression" (p. 203). In turn, he saw in unconscious homosexual fantasy systems "a restitutive or defensive system … [acting] as a protection against anxieties of the addiction type" (p. 203).
Rado (1963) named this aspect of affect defense "narcotic riddance" and opposed it to what he called "narcotic pleasure" and "narcotic intoxication" (a climactic sense of triumphant success). Fenichel (1945, p. 380) wrote: "… the addiction can be looked upon as a last means to avoid a depressive breakdown…" Similarly, Chein et al. (1964) have described the "opiate's capacity to inhibit or blunt the perception of inner anxiety and outer strain… In this sense, the drug itself is a diffuse pharmacological defense" (p. 233). Dora Hartmann (1969) pointed out that the conscious motivation for the use of drugs was in most cases "the wish to avoid painful affects (depression), alleviate symptoms, or a combination of these factors" (p. 389).
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Wieder and Kaplan (1969) describe the drug of choice as "acting as a psychodynamic-pharmacogenic 'corrective' or 'prosthesis'" (p. 401). Their approach is almost identical to the one here suggested. They write:
Chronic drug use, which we believe always occurs as a consequence of ego pathology, serves in a circular fashion to add to this pathology through an induced but unconsciously sought ego regression. The dominant conscious motive for drug use is not the seeking of 'kicks,' but the wish to produce pharmacologically a reduction in distress that the individual cannot achieve by his own psychic efforts [p. 403].
Krystal and Raskin (1970) emphasize the dedifferentiated, archaic, resomatized nature of the affect; because of the traumatic nature of affects in such persons, "drugs are used to avoid impending psychic trauma in circumstances which would not be potentially traumatic to other people" (p. 31).
The idea of defense against affects is also a well-known analytic concept and has been elaborated by Jones (1929), Anna Freud (1936), Fenichel (1934), and Rapaport (1953).
In all categories of compulsive drug use, the preeminence of archaic, chiefly narcissistic, conflicts is evident; what changes are some of the affects presenting the most immediate problem to the patient concerned. These affects are close to consciousness, are not really repressed, but cannot be articulated for a reason I shall subsequently describe.
Narcotics and barbiturates apparently calm intense feelings of rage, shame, and loneliness and the anxiety evoked by these overwhelming feelings.5 In the words of a 22-year-old white heroin addict: "Everything in my life has to have its peak. I cannot accept things for what they are. The actual happening is a letdown compared to the anticipation. It seems then as if all of life comes down on me—in a sense of total despair. Then my first reaction is to get me some dope—not to forget, but to put me farther away from the loneliness, estrangement, and emptiness. I still feel empty
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and lonely when I am on dope, but it does not seem to matter as much. All is foggy and mixed up."
Heroin, for him, was a cure for disillusionment. He went so far as to say: "Heroin saved my life. I would have jumped out of the window—I felt so lonely." He wants to re-create the feeling of full acceptance and union, a fantasy whose reality he postulates as having characterized his early childhood; "I was given everything. I had a protector. Later, I realized I did not have it anymore: no protector, no shield—only myself" (Wurmser, 1972b).
This effect can be witnessed with particular clarity in patients who are put on methadone maintenance—especially if they are followed in psychotherapy both during periods of abstinence and while on the narcotic. I have seen 19 such patients in intensive psychotherapy, 14 of them for a prolonged period (several months to several years). A summary of these observations (Wurmser, 1972b) follows.
All the patients described feelings of loneliness, emptiness, and depression, of meaninglessness and pervasive boredom preceding drug use and following withdrawal. In all of them, very intense feelings of murderous rage and vengefulness; or of profound shame, embarrassment, and almost paranoid shyness; or of hurt, rejection, and abandonment, were discovered during psychotherapy. In all of them, these feelings of rage, shame, and hurt were reduced as soon as they were on methadone; in a few of them, they disappeared altogether; in some, they still occurred occasionally, but had a less overwhelming quality. Some of the patients said the drug made them feel normal and relaxed—implying that they felt those pervasive feeling states to be abnormal, sick, intolerable. Others said it helped them "not to think of the depression." Several said they felt bored, but that they preferred this to the overwhelming feelings before. The patient quoted above had this to say about methadone maintenance: "At least I do not feel that superlonely and excluded; I feel more at ease, although empty and bored. I still cannot be with people, but I can cope with the loneliness better. It keeps me from a showdown with myself; from the dilemma either to destroy myself completely or to move in a new direction without the aid of anything… When I stop methadone, I cannot put up with any frustration. I cannot get enjoyment out of anything. I get frantic about every problem."
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It was obvious that in none of these patients were the underlying inner problems resolved, but that the dampening of the mood disorder brought about by methadone was experienced as a great relief. Both the resulting boredom and the insufficient relief from the underlying conflicts led most of them to occasional or habitual use of other drugs while on methadone: mainly cocaine, Ritalin, or alcohol. (Since 1970, when most of these observations were made, the preference has shifted to Quaalude, Valium—and, still, alcohol.) One girl continued using barbiturates and eventually succeeded in killing herself with sedatives (albeit after discharge from methadone maintenance), quite in line, incidentally, with her mother's expectations, who had years before bought a cemetery plot for this, her youngest daughter, then in her late teens.
These patients try to re-establish an omnipotent position wherein either their self is grandiose and without limitations or where the other person ("the archaic self-object" of Kohut ) is treated as all-giving and is required to live up to the highest ideals. As soon as limitations are imposed, the archaic emotions mentioned before emerge; they are uncontrollable and remind us much of those in psychotics. Rage is the most prominent one. Typically, this narcissistic rage is close to murderous or suicidal dimensions: when the ideal self or the ideal world has collapsed, only total devastation remains. Shame is the second one. It is the outcome of the conflict between the limited, disappointing self and the grandiose ideal self. Hurt, loneliness, rejection, abandonment, the third basic emotion in these patients, is the outcome of the experience that the other person (mother, father, girl friend, boy friend) is not as great and redeeming, as all-giving as expected; anything short of total union with this person is experienced as total isolation and rejection. The importance of narcotics, including methadone, lies in their effect of reducing or even eliminating these basic three affects.
All patients describe states of craving after past or current withdrawal. The real content of this craving (after the physiologic symptoms have subsided) consists precisely in the upsurge of these most disturbing affects. The craving can be equated to a rapid narcissistic decompensation and the breakthrough of those archaic feelings evoked by a most massive sense of narcissistic frustration. In a few, this breakthrough is even experienced as fragmentation. The reinstatement of methadone leads to a prompt recompensation.
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Psychedelic drugs counteract the emotional state of emptiness, boredom, and meaninglessness. The drug-induced illusion that the self is mystically boundless and grandiose and that the world becomes endowed with unlimited meaning seems to be a direct antidote to the pervasive sense of disillusionment in the ideal other person. It artificially re-creates ideals and values when they have been irreparably shattered inside and outside. It is important that this artificial ideal formation has a peculiarly passive-receptive ring, most like the identification with a hero in a movie or on TV. Indeed, there seems to be a remarkable similarity between the psychedelic experience and the turning on and turning in to TV; several patients actually compare it to an inner movie.
Amphetamines and cocaine have superficially much in common with what I just described with regard to psychedelics in that they also eliminate boredom and emptiness. But these more or less conscious affects appear mostly to be caused by repression of feelings of rage, whereas with the compulsive users of psychedelics these moods are induced by the collapse of ideals without the same prominence of aggression. Accordingly, these stimulants provide a sense of aggressive mastery, control, invincibility, and grandeur, whereas the psychedelics impart a sense of passive merger through the senses. But there is more to it: The amphetamine effect serves as a defense against a massive depression or general feelings of unworthiness and weakness. In the few cases of compulsive amphetamine abuse which I was able to treat in intensive psychotherapy, long-term abstinence was accompanied by intense self-directed aggression, in some by suicidal rage and despair, in others by lethargy and self-degradation. Thus, amphetamine abuse can, at least in some patients, be called an artificial normalizing or even manic defense against the underlying affect of depression.
In all three categories, the intended functioning of the pharmacological effect itself as a defense against intense affects is quite certain and supported by statements from many other observers. Also, there is good clinical evidence to show some specificity in the correlation between drug choice and affect combatted. But the nature of this pharmacogenic defense is less clear. The affects themselves are of heterogeneous origin, but never just of "signal" nature; they are always of massive, "unneutralized," overwhelming
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character. Their connection with narcissistic conflicts is far more evident than with conflicts in object relations.
Just as the warded-off affects are of global and overwhelming nature, so is the pharmacogenic defense. I do not think that the latter can simply be identified with other well-known defense mechanisms, e.g., denial, or externalization. Yet, is it a defense sui generis? Is it a particular form of splitting? Or does it simply support a welter of well-known and individually varying defense mechanisms? The nature of this defense needs a separate, systematic study.
From this most cursory and tentative survey, we recognize the central role of narcissistic conflicts in all types of compulsive drug use. The choice of the drug of preference—often found only after long shopping around—is specifically related to the affects engendered by these conflicts: when the inner structures fail as defenses, the pharmacogenic effect has to serve this purpose of inner barrier.
If we suppress this attempt at self-treatment without massive support to the patient's ego, we often force him into more serious forms of decompensation: violent, even homicidal, rage in the narcotics addict, severe suicidal depression in the amphetamine user, a careless apathetic drifting in the user of psychedelics.
What has been described in these thoughts about the artificial defense is consonant with Kohut's (1971) statement: "The drug … serves not as a substitute for loved or loving objects, or for a relationship with them, but as a replacement for a defect in the psychological structure" (p. 46), although there are indications that drugs, drug effects, and ambience are not as devoid of object character as Kohut appears to state.
It should be noted, finally, that both defense and wish-fulfillment are relative concepts. Gill (1963) pointed out convincingly that every defense is simultaneously the fulfillment of a wish: "… a behavior is a defense in relation to a drive more primitive than itself, and a drive in relation to a defense more advanced than itself" (pp. 122–123).
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Faulty Formation of Ego Ideal
Another aspect, implicit in some of what I have already described, is the superego pathology, the lack of meaning-giving, life-determining, life-guiding values and ideals, or, in their personified form, all-powerful myths. The affects just described usually emerge during or following a crisis wherein such central values, ideals, and myths have been shattered or when the need for such an ideal has become particularly prominent, its absence or unreliability particularly painful. And here the family pathology enters.
The following comments do not do justice to the importance of family pathology as etiological factors; a separate study is in preparation (cf. also Chein et al., 1964). The crucial factors in the family pathology appear, to date, to be consistency, setting of limits, and trustworthiness versus narcissistic indulgence and rage. Parents who did not provide a minimum of consistency, of reliability, of trustworthiness, of responsiveness to the child, especially during his developmental crises, are not usable as inner beacons; instead they become targets of rebellious rage and disdain. Parents who vacillate between temper tantrums and indulgence, who allow themselves to live out their most primitive demands, parents who are more interested in their careers and their clubs and travels than in their children's needs to have them available, or parents who are absent for economic reasons and cannot impart the important combination of love and of firmness—all these parents, unless replaced in their crucial functions by capable substitutes, make it very difficult for their children to accept them as secure models for conscience and ego ideal, to internalize them, and to build them up as inner guardians against transgressions. It is my impression that the ego ideal in patients having such parents has remained archaic, unreliable, global; more mature parts quickly collapse during adolescence or never emerge.
The "high," the relief and pleasure sought with the help of the drug, is a surrogate ideal, a substitute value, a chemical mythology, which normally would be supplied by the internal sense of meaning, goal-directedness, and value orientation. Moreover, peer group, drug culture and, most of all, the "hustling" itself, the whole chasing after the drug, and the ideal of the successful pusher who can beat the hated establishment (particularly in the ghetto), are
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powerfully determining models and values (cf. Preble & Casey, 1969).
The next aspect is the least secure and most presumptive one; yet, it may prove to be easier to observe and even quantify than the others.
With this, I refer to the frequent observation of a general degradation, contraction, or rudimental development of the processes of symbolization and, with that, of the fantasy life. This curtailed ability or inability to symbolize pertains particularly to the patient's inner life, his emotions, his self-references. One example of this is the inability of most of these patients to articulate feelings. Many, if not all, relevant affects are translated into somatic complaints—e.g., craving and physical discomfort—or into social accusations—"It's all society's fault." They remain preverbal as affects. The same constriction seems to hold true for the entire fantasy life. It is just this lacuna—whether it is a conflict-induced scotoma, or a genuine deficiency—which makes psychotherapy so particularly difficult and frustrating. After all, psychotherapy employs precisely the verbal band out of the spectrum of symbolic processes as its instrument. Tentatively, I dub this defect "hyposymbolization"; I consider it identical with what I found in Blos' (1971) concept of "concretization." Obviously, drugs do not function as a substitute for the lacking symbolization; nor do most enrich the impoverished fantasy life (except for what Louis Lewin  called the Phantastica, i.e., the psychedelic drugs). Rather, their function lies in removing that vague discomfort and tension which replaces the not perceived and not articulated affect and is experienced as "something wrong" in the body or the environment. Thus, the drugs are employed to alter body image and world image into a less unpleasant and more meaningful one.
Archaic Object Dependency
We have so far examined the psychodynamic role of the various pharmacological effects of these drugs. There is a further dynamic implication which is very important and far better known than these three: "Among the unconscious motivations (in addition to oral gratification and passive identification with a parent), the need
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to replace a lost object seemed to play a very important role" (D. Hartmann, 1969, p. 389). Many patients talk about their drug and the paraphernalia and circumstances surrounding it with a loving tenderness, as if it were a love partner. Obviously, it is the object character of the drug that assumes a central motivating power here rather than its pharmacological character. Actually, the very term, "drug dependency" reminds us of what we are dealing with, namely an archaic passive dependency on an all-giving, sempiternal, though narcissistically perceived—i.e., hugely inflated—object, as is evidenced by the singleminded devotedness and frenzy of the chase after the beloved, in the incorporative greed, the masturbatory and orgiastic aspects of the use, and in the mixture of ecstatic idealization and deprecation vis-à-vis the drug ("star dust," "blue heavens," "white lady" versus "shit," "scag") (Wieder & Kaplan, 1969); (Chein et al., 1964). Much of this reminds us of fetishism. Dynamic similarities and dissimilarities between these two syndromes need to be worked out: Do we find a similar split of the ego in addictive illness to the one described in fetishism? Glover implicitly raised this question in 1932; "… in the transition between paranoidal systems and a normal reaction to reality, drug addiction (and later on fetichism) represent not only continuations of the anxiety system within a contracted range, but the beginnings of an expanding reassurance system" (p. 211). He called fetishism the companion problem of addiction.
The problem raised by Kohut (1959), (1971) remains unsolved: Is this obvious relationship to archaic, easily replaceable part objects only secondary, and is it accurate to explain the dependence on drugs primarily not "as a substitute for object relations but as a substitute for psychological structure" (Kohut, 1959, p. 476)? In many cases this hypothesis seems to be borne out. Yet in others where a symbiotic relation or the dedication to a treatment community completely supplants a former drug dependence, I am quite inclined to see in the latter also an archaic, narcissistically experienced object relation.
Very well known is the self-destructive, self-punitive aspect of drug abuse (Glover, 1932). In some cases, we may observe the direct equivalency of drug use with suicide. If we take the first away,
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the second may become the menace. Drug abuse in itself can often (not always) be considered a tamed and protracted suicidal attempt, though we have to be cautious not to fall into the pitfall of the teleological fallacy (post hoc, proper hoc). In line with the other aspect of superego pathology, described above, where the faulty ideal formation was underlined, we may now add the important role of archaic forms of shame and guilt—as reflected (but not recognized) in many of the vindictive measures used at Synanon and other therapeutic communities, as well as in most of our legislation (Wurmser, 1973a), (1973b); (Wurmser et al., 1973). There is no question that very primitive and global fears of humiliation and revenge play a dominant role in the social interaction of these patients; these are usually not simply the consequence of society's reaction, but part of the patient's make-up to begin with. The vindictiveness and corruptibility of the archaic superego is well known and is easily observed among our patients. This dynamic datum, however, is so frequent and general that I assign it a very low specificity for this type of pathology.
This aim of drug use, also mentioned by Homer (Odyssey, Book IX, 90–97), has been studied most extensively. My previous emphasis, especially on the notion of the artificial affect defense, has been used to counterbalance the historical emphasis on this aspect. Both are obviously two sides of the same coin.
From all the forms of regressive gratifications attained with the help of the drug, it appears that the increase in self-esteem, the re-creation of a regressive narcissistic state of self-satisfaction is the most consistent one. This is particularly relevant when we see this aim of drug use as an integral part of the narcissistic crisis which typically marks the onset of compulsive drug use and to which we now turn.
As discussed earlier, the specific reason for the onset of compulsive drug use lies in an acute crisis in which the underlying narcissistic conflicts are mobilized and the affects connected with these conflicts break in with overwhelming force and cannot be coped with without the help of an artificial affect defense.
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Such a mobilization quite typically first occurs during adolescence, rarely earlier, and still more rarely later. Often the relapse from abstinence into drug use is regularly marked by the recurrence of such a crisis—which in turn is usually triggered by an external event's setting in motion the juggernaut of pervasive anxieties, rages, and narcissistic demands. This narcissistic crisis is thus the point at which the conflicts and defects converge with a particular external situation and with the availability of the seeming means of solution: the drug. By definition, a "narcissistic crisis" would have to entail a particularly intense disappointment in others, in oneself, or in both—so intense because of the exaggerated hopes, and so malignant because of its history's reaching back to very early times. Precipitating external events of such a crisis can most typically be found in family crises, coinciding with the maturational crisis of adolescence.
Conclusions: The Etiological Equation
It appears very likely that it is the convergence of at least some, if not all, of six elements—massive defect of affect defense, the defect in value formation, the hyposymbolization, the desperate search for an object substitute, the intensely self-destructive qualities, and the search for regressive gratification—together with the intensity of the underlying narcissistic conflicts that forms the predispositional constellation for the "addictive illness" in general and for compulsive drug use in particular. It appears that the most specific of these predispositional factors are the need for affect defense and the compelling wish for regressive gratification; but only further research, including predictive studies, can elucidate the relative relevance of these six factors.
The specific reason is the mobilization of the underlying narcissistic conflict in what I called the narcissistic crisis.
The precipitating reason is the advent of the drug on stage, functioning only like the crucial though irrelevant messenger in the antique tragedy, a hapless catalyst: "I that do bring the news made not the match" (Antony and Cleopatra, II, V, 67).
Some or all of the six predispositional factors described may be necessary reasons. The combination of the narcissistic crisis (specific reason)—viz. a consequence of these predispositions, mobilized
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by maturational and environmental factors—with the adventitious entrance of the drug (precipitating reason) represents the sufficient reason.
It appears appropriate to end with two quotations that emphasize the necessity of etiological analysis. The first is from Vergil's Georgica II: "Felix qui potuit rerum cognoscere causas" (Fortunate is he who has been able to recognize the causes of things). The second is from Bacon's Novum Organum, I. (1620) and was in a sense the motto opening up the time of progress in science and technology: "Scientia et potentia humana in idem coincidunt quia ignoratio causae destituit effectum" (Human knowledge and power coincide in that regard that ignorance of cause prevents effective intervention).
Blos, P. 1971 Adolescent concretization: a contribution to the theory of delinquency In:Currents in Psychoanalysis ed. I. M. Marcus. New York: International Universities Press, pp. 66–88
Chein, I., Gerard, D. L., Lee, R. S., & Rosenfeld, E. 1964 The Road to H. New York: Basic Books.
Fenichel, O. 1934 Defense against anxiety, particularly by libidinalization In:Collected Papers First series. New York: Norton, 1953 pp. 303–317
Fenichel, O. 1945 The Psychoanalytic Theory of Neurosis New York: Norton.
Freud, A. 1936 The Ego and the Mechanisms of Defense. The Writings of Anna Freud Vol. 2 New York: International Universities Press, 1966 pp. 31–34
Freud, S. 1895 A reply to criticism of my paper on anxiety neurosis Standard Edition 3 123–139 London: Hogarth Press, 1962
Freud, S. 1914 On narcissism: an introduction Standard Edition 14 69–102 London: Hogarth Press, 1957
Freud, S. 1930 Civilization and its discontents Standard Edition 21 59–145 London: Hogarth Press, 1961
Gill, M. M. 1963 Topography and Systems in Psychoanalytic Theory [Psychological Issues Monogr. 10]. New York: International Universities Press, pp. 122–123
Glasscote, R. M., Sussex, J. N., Jaffe, J. H., Ball, J., & Brill, L. 1972 The Treatment of Drug Abuse. Programs, Problems, Prospects Washington, D.C.: American Psychiatric Association and National Association on Mental Health.
Glover, E. 1928 The Etiology of Alcoholism In:On the Early Development of Mind New York: International Universities Press, 1956 pp. 81–90
Glover, E. 1932 On the Etiology of Drug Addiction In:On the Early Development of Mind New York: International Universities Press, 1956 pp. 187–215
Grotjahn, M. 1971 The Voice of the Symbol Los Angeles: Mara Books, pp. 1–23
Hartmann, D. 1969 A study of drug-taking adolescents The Psychoanalytic Study of the Child New York: International Universities Press, 24 384–398
Hartmann, H. 1939 Ego Psychology and the Problem of Adaptation New York: International Universities Press, 1960
- 841 -
Jaffe, J. H. 1965 Drug addiction and drug abuse In:The Pharmacological Basis of Therapeutics ed. L. S. Goodman & A. Gilman. New York: Macmillan, pp. 285–311
Jones, E. 1929 Fear, guilt and hate In:Papers on Psychoanalysis Boston: Beacon Press, 1967 pp. 314–319
Kernberg, O. F. 1970 Factors in the psychoanalytic treatment of narcissistic personalities This Journal 18 51–85
Khantzian, E. J., Mack, J. F., Schatzberg, A. F. 1974 Heroin use as an attempt to cope: clinical observations Amer. J. Psychiat. 131 160–164
Kohut, H. 1959 Introspection, empathy, and psychoanalysis This Journal 7 459–483
Kohut, H. 1971 The Analysis of the Self New York: International Universities Press.
Kohut, H. 1972 Thoughts on narcissism and narcissistic rage The Psychoanalytic Study of the Child 27 360–400 New York: Quadrangle Books.
Krystal, H. & Raskin, H. A. 1970 Drug Dependence. Aspects of Ego Functions Detroit: Wayne State University Press.
Kubie, L. S. 1954 The fundamental nature of the distinction between normality and neurosis Psychoanal. Quart. 23 167–204
Kubie, L. S. 1961 Neurotic Distortion of the Creative Process New York: The Noonday Press.
Lewin, L. 1924 Phantastica, Narcotic and Stimulating Drugs: Their Use and Abuse New York: Dutton, 1931 reprinted1964 London: Routledge & Kegan.
Limentani, A. 1968 On drug dependence: clinical appraisals of the predicaments of habituation and addiction to drugs Internat. J. Psycho-Anal. 49 578–590
Panel 1970 Psychoanalytic evaluation of addiction and habituation W. Frosch, reporter.This Journal 18 209–218
Preble, E. & Casey, J. J. 1969 Taking care of business—the heroin user's life on the street Internat. J. Addictions 4 1–24
Pulver, S. E. 1970 Narcissism: the term and the concept This Journal 18 319–341
Rado, S. 1926 The psychic effects of intoxicants Internat. J. Psycho-Anal. 7 396–413
Rado, S. 1933 The psychoanalysis of pharmacothymia (drug addiction) Psychoanal. Quart. 2 1–23
Rado, S. 1963 Fighting narcotic bondage and other forms of narcotic disorders Comprehensive Psychiat. 4 160–167
Rapaport, D. 1953 On the psychoanalytic theory of affects In:Collected Papers ed. M. M. Gill. New York: Basic Books, 1967 pp. 476–512
Savitt, R. A. 1954 Extramural psychoanalytic treatment of a case of narcotic addiction This Journal 2 494–502
Savitt, R. A. 1963 Psychoanalytic studies on addiction: ego structure in narcotic addiction Psychoanal. Quart. 32 43–57
Schafer, R. 1973 The idea of resistance Internat. J. Psycho-Anal. 54 259–285
Sherwood, M. 1969 The Logic of Explanation in Psychoanalysis New York: Academic Press, pp. 172–174
Waelder, R. 1936 The problem of freedom in psychoanalysis and the problem of reality testing Internat. J. Psycho-Anal. 17 89–108
Waelder, R. 1962 Psychoanalysis, scientific method and philosophy This Journal 10 617–637
Waelder, R. 1970 Observation, historical reconstruction, and experiment: an epistemological study In:Psychoanalysis and Philosophy ed. C. Hanly & M. Lazerowitz. New York: International Universities Press, pp. 280–326
Wieder, H. & Kaplan, E. H. 1969 Drug use in adolescents: psychodynamic meaning and pharmacogenic effect The Psychoanalytic Study of the Child 24 399–431 New York: International Universities Press.
Wurmser, L. 1972a Drug abuse: nemesis of psychiatry Amer. Scholar 41 393–407
Wurmser, L. 1972b Methadone and the craving for narcotics: observations of patients on methadone maintenance in psychotherapy San Francisco: Proceedings, Fourth National Conference on Methadone Treatment, pp. 525–528
Wurmser, L. 1972c Author's reply Internat. J. Psychiat. 10 117–128
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Wurmser, L. 1973a Psychosocial aspects of drug abuse Maryland State Med. J. 22 78–83
Wurmser, L. 1973b Unpolitic thoughts about the politics of drug-abuse treatment J. Drug Issues 3 178–185
Wurmser, L. Flowers, E., & Weldon, C. 1973 Methadone, Discipline and Revenge Washington: Proceedings, Fifth National Conference on Methadone Treatment.
Zinberg, N. E. & Robertson, J. A. 1972 Drugs and the Public New York: Simon & Schuster.
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