Some thoughts on Understanding Addiction its Psychological Underpinnings and Treatment
I recently had a conversation with a colleague about the subtleties of how addiction can manifest and take hold.
I remembered Gabor Maté’s writing on addiction, “Children who suffer disruptions in their attachment relationships will not have the same biochemical milieu in their brains as their well attached, well nurtured peers. As a result, their experience and interpretations of their environment, and their responses to it, will be less flexible, less adaptive, and less conducive to health and maturity. Their vulnerability will increase, both to the mood enhancing effect of drugs and to becoming drug dependent.” (Maté 2018).
There are multiple reasons people become addicted to something, and one of the most significant are experiences of heightened stress.
Developmental traumas and repeated traumatic incidents all have stress in common.
“Stress has everything to do with addiction.” (Matè 2018). Maté describes how stress is an attempt to maintain an organism’s homeostasis both physiologically, biologically, neurochemically and psychologically. From a Transactional Analysis perspective, I would interpret this as maintaining the Script (Berne 1974). - The Script is a life plan made in early childhood, which is ultimately our innate ability to adapt and survive in response to the environment.
My hypothesis is therefore that when trauma is/was present, humans either have an appropriate or adverse multi levelled reaction (stress response) to attempt to maintain their Script, for better or worse, which reminds me of the adage, “Better the Devil you know, that the Devil you don’t…”
This becomes a repetitive and self-fulfilling prophecy as Freud describes as Repetition Compulsion in his 1920 book, “Beyond the Pleasure Principle” (Freud, 1920).
Maté writes about the commonality of major stressors, “Ultimately, they all represent the absence of something that the organism perceives as necessary for survival – or its threatened loss. The threat itself can be real or perceived. The threatened loss of food supply is a major stressor. So is the threatened loss of love – for human beings.” (Maté 2018). Gabor Maté, cites the following quote to emphasize his point further, “It may be said without hesitation that for man the most important stressors are emotional”. (Hans Selye 1956).
With regards to working with addiction, my thoughts are to pay due attention to what sits in internal and interpersonal deficit, conflict or is confused together with what is unexpressed or suppressed by the addiction. Attention to what the addiction serves and to give due credit to this mal-adapted coping strategy.
There are of course many perspectives to look at and work with addiction. Object relations is another area to consider when looking at addiction. From reading Catherine Stuart’s “Addiction from an Object Relations Perspective, Contemporary Psychoanalysis” (1996), she explains how object relations best explain the aetiology of the more compulsive drug user. Addicts have suffered different degrees and manifestations of object loss and therefore are driven to find ways to alter the internalised object representations.
Due to early disruption from parent figures, confusion in the developing psyche can take hold and manifest with addiction to balance the lack of affect (emotions or feelings) regulation.
Addiction to alcohol, sex, drugs, or gambling etc are either compensation for the lost good object. The “Good Object” can be understood in simple terms as a good attuned care giver. A “Bad Object” are experiences of pain, frustration and disappointment etc from the primary caregivers, which become internalised.
Object constancy was never achieved because of environmental and relational disruption, addicts are unable to integrate Good and Bad object representations, and so are unable to adequately tolerate anxiety, aggression, frustration, and the dysphoria that results from a harsh archaic Superego/Parent Ego State (aka the potentially punitive internal critic).
Treatment, therefore, should not reinforce punitive internal voices but rather facilitate the expression of authentic emotional expression. This can promote healthy resolution of the split between good and bad object representations that formed to protect the idealized good object representation.
In the notes I have included a useful diagram of Carlo Moiso’s Projective Transference model (1985): For the purpose of this diagram, the therapist represents the Good/Bad Object
An addiction has a function to distract from inner pain and turmoil. Confusion and fixation of the Good Object, lessening the Bad Object… but the cycle flips and repeats as the Good Object becomes the bad. The cycle continues until broken with appropriate intervention and holding to provide a “Good Enough” relationship. (See further in notes on Good Enough relationship).
Providing a space where the client can experience safety in contact with their therapist in the therapeutic space.
This can be achieved by paying appropriate attention to meeting the clients unmet archaic Relational Needs for example (Erskine 1999, 2003).
Over time accounting for and recognising the clients Relational needs, they can begin experience more of themselves, in what is also known as “The Needed Relationship” (Clarkson 1992).
The presence and consistency of this new therapeutic relationship can create new internal Nurturing Parent voice in the client as it is modelled by the therapist. As this Nurturing Parent takes continual presence and progressive dominance in the psyche, addicted clients develop a sense of internal comforting self-regulation. The inner turmoil’s or splits begin to integrate and resolve.
To conclude my thoughts today on this subject, presence and contact with the client are paramount. To sit in the moment, recognising and accepting their struggle. To respond to clients compassionately and empathically, validating their internal experience, which therefore can recognise un-met archaic relational needs.
Only when this contact in the therapeutic relationship is made, the work can begin the journey of an effective psychotherapy.
References:
Berne, E., 1975. What do you say after you say hello?: The psychology of human destiny. Random House.
Erskine, R.G. and O'Reilly-Knapp, M., 2003. Core concepts of an integrative transactional analysis. Transactional Analysis Journal, 33(2), pp.168-177. (p169)
Freud, S. (1920). Beyond the Pleasure Principle (Standard Edition, Vol. 18, pp. 7-64). London: Hogarth.
Moiso, C., 1985. Ego states and transference. Transactional Analysis Journal, 15(3), pp.194-201.
Clarkson, P. and Pokorny, M., 2013. The handbook of psychotherapy. Routledge.
Catherine Stuart , Ph.D. Published online: 28 Oct 2013. Addiction from an Object Relations Perspective
Pages 486-488 |
Notes
· Donald Winnicott, a renowned paediatrician and psychoanalyst, introduced the concept of "good enough parenting" in his work. The idea is discussed in several of his publications, particularly in his book titled "Playing and Reality" published in 1971. In this book, Winnicott explores various aspects of child development, emphasizing the significance of parental care and the environment in fostering healthy emotional growth in children. His concept of "good enough parenting" suggests that parents don't need to be perfect; instead, they should provide a "good enough" level of care and responsiveness to support a child's development.
· Erskine’s 8 Relational Needs (1999).
(these are not an instruction manual but a fluid relationship informing tool)
• The need for - Security.
• The need for - Validation, affirmation and significance.
• The need for - Acceptance by a stable and dependable other.
• The need for - Confirmation of personal experience.
• The need for - Self-definition.
• The need for - Having an impact on the other.
• The need to - have the other Initiate.
• The need to - Express love.
· Carlo Moiso’s Projective Transference model (1985):
