The Psychodynamics of Addiction

187 Pages·2002·4.08 MB·English

The Psychodynamics of Addiction
The
Psychodynamics
of Addiction
Edited by
MARTIN WEEGMA" BA (HoNs), DIPCLINPSYCMH I,N STGA
Gatehouse Drug Sewice, Middlesex
AND
ROBERT COHEN MA, MBBS, MRCPSYCH
Homerton Hospital, London
W
W H U R R PUBLISHERS
L O N D O N A N D PHILADELPHIA
8 2002 Whurr Publishers
First published 2002 by
Whurr Publishers Ltd
19b Compton Terrace, London N1 ZUN, England, and
325 Chestnut Street, Philadelphia PA 19106, USA
Reprinted 2003,2004 and 2006
All rights reserved. No part of this publication may be
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British Library Cataloguing in Publication Date
A catalogue record for this book is available from the
British Library.
ISBN-10: 186156 335 3 p/b
ISBN-13: 978 0 1 86156 335 4 p/b
Contents
Contributors ix
Foreword xi
Professor Edward Kbantzian
Preface xv
Part 1: A review of different schools 1
Chapter 1 3
Container and contained: the school of Bion
Arthur Hyatt Williams
Chapter 2 13
The application of Bowlby’s attachment theory to the
psychotherapy of the addictions
Bill Reading
Chapter 3 31
The vulnerable self: Heinz Kohut and the addictions
Martin Weegmann
V
vi The Psychodynamics of Addiction
Part 2: Therapy 51
Chapter 4 53
The dynamics of addiction in the clinical situation
Robert Coben
Chapter 5 71
The psychodynamic assessment of drug addicts
Martin Weegmann
Chapter 6 84
Psychotherapy with addicted people
Anne Read
Chapter 7 98
Group therapy for addiction
James Mosse and MaryAnn Lysagbt
Part 3: Helping the helpers 115
Chapter 8 117
Psychodynamic aspects of relapse prevention in the treatment of
addictive behaviours
Sbamil Wanigaratne and Francis Keaney
Chapter 9 133
In search of a reliable container: staff supervision at a DDU
Robert Hale
Chapter 10 143
~ ~ ~ ~~
Countertransference: our difficulties in the treatment of substance abuse
Luis Rodriguez de la Siewa
Contents vii
Part 4: Addiction and the familv 141
Chapter 11 155
Growing up with addiction
Martin Weegmann
References 169
Index 177
Contributors
Robert Cohen Consultant Addiction Psychiatrist, DDU, Homerton
Hospital, London
Robert Hale Consultant Psychiatrist and Psychotherapist, Medical
Director, Portman Clinic, London
Arthur Hyatt Williams Retired Consultant Psychiatrist and Psychoanalyst,
London
Francis Keaney Clinical Tutor at the Institute of Psychiatry and Honorary
Senior Registrar, South London and Maudsley Trust
Mary- Lysaght Psychotherapist, Cassel Hospital, London
James Mosse Psychotherapist, Developmental Disabilities Division, St
Andrew’s Hospital, Northampton
Anne Read Consultant Psychiatrist, Plymouth Community Drug Service
Bill Reading Psychotherapist, Manager and Nurse Specialist, Mount
Zeehan Hospital, Canterbury, Kent
Luis Rodriguez de la Sierra Psychiatrist and Psychoanalyst, Private
Practice, London
Shamil Wanigaratne Consultant Clinical Psychologist, South London and
Maudsley Trust and Honorary Senior Lecturer, Institute of Psychiatry
Martin Weegmann Consultant Clinical Psychologist and Group Analyst,
Gatehouse Drug Service, Southall, Middlesex
Foreword
PROFESSOR EDWARDm T Z I A N
Martin Weegmann and Robert Cohen, the editors of The Psychodynamics
of Addiction, have compiled a genre of work of which there have been far
too few. Addiction is the single most pervasive public and mental health
problem of our time. The breadth and scope of the problem seems to
leave programmes and practitioners pressed to offer acute management
and quick solutions, with little time or inclination to explore and address,
at a deeper psychological level, the more complex determinants of
addictive behaviour. This book provides rich clinical and theoretical
material that will stimulate students and clinicians better to appreciate
core issues of suffering and dysregulation (‘container and contained’) that
are central to addictive vulnerability. From the outset the editors and
authors deal with the complexities of addictive suffering. They set the
stage by introducing three psychoanalytic paradigms to explore the world
-
of the addicted person. Three views are adopted Bion’s emphasis on self-
containment, Bowlby’s perspective on the process of attachment and
-
Kohut’s probing of human narcissistic vulnerability and provide an
ample framework to face one of the most central problems of addictions,
‘the capacity to face mental pain’.
In my experience two crucial problems are at the heart of addictive
disorders: (1) human psychological suffering and (2) the inability to
control one’s life. In the former instance, human issues of experiencing
emotions (or affects) are in the extreme: patients’ feelings are
overwhelming and unbearable or they are absent and confusing. In the
latter cases, patients alternate between losing control of their behaviours
and substances, and then, often at the same time, they exert multiple and
varied attempts to gain and maintain control. These polarities have
ultimately led me to adopt a perspective of addictions as a self-regulation
disorder. I have repeatedly emphasised the importance of a disordered
xi
xii The Psychodynamics of Addiction
sense of self and related difficulties in maintaining self-esteem. Not
surprisingly, one consequence of a disordered sense of self is a disordered
capacity to relate to others. These are important and contributory factors
to addictive vulnerability. Important as these factors are in contributing to
addictions, I have concluded that disturbances in regulating affects and
behaviours malignantly combine and are essential in the development of
addictive disorders.
Weegmann, Cohen and associates provide extensive evidence in their
collective efforts to support a perspective of substance use and misuse as
a self-regulation disorder involving deficits in regulating self-esteem,
relationships, affect and behaviours (particularly self-care). In the first
chapter Hyatt Williams draws on Bion’s concept of the container and the
contained and explores how people with infantile feelings of emptiness
or the distress of separation, often played out in the transference, resort
to drugs to contain feelings that are otherwise uncontainable. Chronically
doing so further lessens a person’s capacity to manage and regulate his or
her emotions. In my own work I have used the term ‘disuse atrophy’ to
characterise this process. That is, albeit adaptive when drugs are used
initially, ultimately chronic dependence on addictive drugs undermines
an already diminished capacity to endure or tolerate psychic pain. This is
the sorrowful and illusory nature of addictive disorders; drugs are
compelling because they initially work, but ultimately because of physical
tolerance and evolving diminished psychological capacities, the attempts
at self-correction tragically fail. Little wonder, as Hyatt Williams (and
Rado, whom he cites) indicates, that suicide often becomes a fatal alter-
native. Hyatt Williams concludes by encouraging treating clinicians to
address ‘the progressive loss of containment’ as a critical focus of our
therapeutic efforts.
Bill Reading in his chapter on attachment theory, draws on the work of
Bowlby and provides us with another pivotal area upon which therapists
can focus. Namely, as in other models of psychotherapy, attachment theory
can help clinicians ‘enhance the patient’s ability to locate his or her
symptoms in an interpersonal context’. McLellan and associates have
empirically demonstrated this by exploring how ‘core conflictual
relationship themes’ (CCRT) play themselves out in the treatment
relationship and provide the therapist and patient a basis for under-
standing how these themes precipitate and maintain a dependence on
substances. We have similarly described how self-regulation disturbances,
especially interpersonal ones, play themselves in the group interactions in
modified group therapy (Khantzian et al1990) and provide opportunities
to enhance sekbservation and modify behaviours that predispose to and
make more likely a reliance on addictive substances.
Foreword xiii
The authors in this volume appreciate well why simply identifying
triggers for relapse and related cognitive behavioural treatments alone are
not sufficient to prevent use and reversion to addictive behaviours. They
repeatedly and astutely provide sophisticated underpinning for Rado’s
assertion that it is not the drug but the impulse to use it. It is only through
appreciating the deeper psychodynamic layers of vulnerabilities and devel-
opmental deficits, which are supplied in this book, that we can appreciate
why addictive drugs are so compelling. Weegmann’s chapter on the
vulnerable self provides an important appreciation, based on Kohut’s
work, of how fundamental disruptions in self-organisations cause
individuals to resort to substances to compensate for deficits in self-
structures. When these structures are absent, individuals are prone to
addiction because they cannot achieve or maintain inner coherence, they
cannot comfort themselves, and they are unable to soothe themselves or
assure their self-care. Thus, such individuals are chronically uncomfortable
from within and more often in harm’s way when faced with external
danger, including and in particular the self-harm of addictive drug use.
With this foundation of understanding, Weegmann and his associates
instruct and guide the reader through the challenges of appreciating the
psychodynamics of engaging patients and assessing them in treatment.
They emphasise the subtleties of patient encounters, helping the clinicians
to be patient and empathic, to be ready for denial and ambivalence, to
anticipate and expect resistance and overt hostility but ultimately to trust
that the clinician and patient can gradually build a relationship that
enables understanding and a means to relinquish the patient’s
maladaptive/immature patterns and their attachment to their drug-of-
choice. These psychodynamic precepts are consistently honoured and
sustained in the chapters on individual therapy by Read and group
psychotherapy by Mosse and Lysaght and imaginatively integrated in a
chapter by Wanigaratne and Keaney on relapse-prevention groups. The
editors provide a bonus with relevant and enlightening chapters on super-
vision and the vicissitudes of countertransference in chapters by Hale and
Rodriguez de la Sierra respectively The final chapter on growing up with
addiction by Weegmann takes us beyond superficial aphorisms of what it is
like and again upholds the main thrust and commitment of this book,
namely to explore in depth the inner workings and psychological struc-
tures of an addictive adaptation, in this case how it works in addicted
families.
I applaud Martin Weegmann and Robert Cohen in undertaking the
challenge of compiling this psychodynamic treatise on the addictions.
They have carefully designed a focus and assembled a team of knowl-
edgeable and sophisticated clinicians who uphold the rigour and