purplehaze
Jedi Master
(interesting peak inside a psychopath's mind)
LANCE M. DODES, M.D.
Re-printed from The Psychoanalytic Quarterly, 59:398 (1990)
ABSTRACT
In many cases addictive behavior serves to ward off a sense of helplessness or powerlessness via controlling and regulating one's affective state. Addicts have a vulnerability to feelings of powerlessness, which reflects a specific narcissistic impairment. The drive in addiction to re-establish a sense of power is, correspondingly, impelled by narcissistic rage. This rage gives to addiction some of its distinctive clinical properties. The narcissistic vulnerability in addicts is discussed. Several brief clinical cases are provided, and the view proposed is correlated with other psychoanalytic perspectives.
This paper addresses the role of feelings of powerlessness and rage in addiction. Having repeatedly discovered these affects preceding and precipitating addictive behavior, I have found that clarifying, exploring, and interpreting them has been instrumental in understanding the addictive process with many addicted individuals. This experience suggests a model for addictive behavior which both extends and is compatible with other psychoanalytic formulations. In proposing this model, I
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An earlier version of this paper was presented for the Discussion Group on "The Substance Abusing Patient in Psychoanalysis and Psychotherapy" at the Fall 1988 meeting of the American Psychoanalytic Association. I would like to thank Dr. Anton O. Kris for his very helpful criticisms and suggestions, as well as Drs. Edward Khantzian, John Mack, Robert Mehlman, and Malkah Notman for their valuable comments on earlier drafts of this paper.
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wish to be clear that I am focusing on addictive vulnerability and the initiation of or relapse to addictive behavior, rather than on the maintenance of addiction. Factors other than those involved in initiation or relapse, including physiologic ones, are likely to be at work in continuous drug use.
Recent views of addiction have emphasized ego defensive function and defense deficit. The most frequent formulation has been that substances are used for the purpose of managing intolerable affective states. Krystal and Raskin (1970) emphasized a defect in the stimulus barrier, resulting in an incapacity to ward off repeated painful affective experience; they saw substance use as augmenting or substituting for this defective barrier. They also suggested that a normal developmental process of differentiation, desomatization, and verbalization of affects is impaired in addicts. A number of authors have also noted specific affective states which addicts attempt to manage through the use of drugs, including aggressive feelings, anxiety, depression, rage, and shame (Khantzian, 1978); (Milkman and Frosch 1973); (Wurmser 1974). Khantzian (1985) focused attention on a self-medication hypothesis in which an individual's choice of drug is the result of the pharmacological action of the drug ameliorating the individual's principal painful affect.
From a different perspective, Wider and Kaplan (1969), Krystal and Raskin (1970), and Wurmser (1974), among others, have also described the use of drugs as an object substitute for a yearned-for parental figure. Alternatively, Khantzian (1978) and Khantzian and Mack (1983) have observed that addicts seem to have a deficit in a group of ego functions involved in the anticipation of danger and in self-protection, which they have called "self-care" functions. They have emphasized the importance of this deficit psychology in substance abusers, helping to explain the self-destructive nature of drug abuse. Khantzian (1987) has also considered a view that is virtually the reverse, namely, that addictive behavior serves as an attempt at mastery over poorly understood and passively experienced suffering,
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by creating a dysphoria which is controllable and understandable.
Kernberg (1975) saw addictive behavior as a gratification of instinctual needs or a reunion with a forgiving parental object or an activation of "all-good" self and object images. Kohut referred to addictions as "narcissistic behavior disorders" (Kohut and Wolf, 1978). He viewed the disturbance in addicts as due to the mother's failure to function as an adequate idealized self-object, and saw drugs serving "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" (Kohut, 1971, p. 46). Wurmser (1974) also emphasized a "narcissistic crisis" in drug abusers, in which the collapse of a grandiose self or an idealized object leads to feelings for which drug use is an attempted response. He wrote: "… an archaic overvaluation of the self or of others [leads to] the abysmal sense of frustration and letdown if these hopes are shattered… and thus to the addictive search" (p. 826). Like others, he viewed the choice of drug as dependent upon its influence on the affect most troubling: narcotic use for reducing or eliminating rage, shame, and feelings of abandonment, and amphetamines and cocaine for giving a sense of grandeur, defending against underlying depression.
ADDICTION, HELPLESSNESS, AND REASSERTION OF POWER
While there are many valuable psychoanalytic perspectives on addiction, I find in all of them an insufficient attention to the roles of power, helplessness, and rage. I would like to propose an additional mechanism which I have found to be important in many cases of addiction.
First, I would like to consider the role of addiction in managing omnipotence over one's own affective state. The central importance of being in control of one's affective state is highlighted
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by the loss of this control in psychic trauma: i.e., the imposition of a state of helplessness on the ego when it is overwhelmed by an instinctual drive (affect) which it cannot manage without excessive anxiety (Freud, 1926). It is the sense of powerlessness or helplessness in this situation which, as Krystal (1978) has emphasized, constitutes the essence of psychic trauma. The ability to be powerful over oneself and one's internal state may also be described as an inherent aspect of narcissism. Spruiell (1975) noted that among the strands of narcissism is "the pleasure in efficient mental functioning, … the regulation of mood… and … a sense of inner safety and reliability" (p. 590). Socarides and Stolorow (1984-1985) likewise stressed the central importance of steadily regulable, containable affect for the development and organization of self experience, without which affects become traumatic. In describing the "catastrophic reaction" of individuals to an acute brain defect, Kohut (1972) referred to the narcissistic importance of being in control of one's mind. Upon discovering an inability to perform mental functions once done easily, a person may become enraged because "he is suddenly not in control of his own thought processes, of a function which [we] consider to … [belong] to the core of our self, and we refuse to admit that we may not be in control of [it]" (p. 383). Kohut also wrote about the reaction of patients, especially early in analysis, to slips of the tongue: "They are enraged about the sudden exposure of their lack of omnipotence in the area of their own mind… '… the trace of affect which follows the revelation of the slip,' Freud said, 'is clearly in the nature of shame …'" (pp. 383-384).
In light of the core narcissistic importance of maintaining psychic control, it is significant that drugs are a device par excellence for altering, through one's intentional control, one's affective state. Since drug use provides a mechanism to re-establish such a central area of omnipotence, it may serve as a corrective when an addiction-vulnerable individual is flooded with feelings of helplessness or powerlessness. That is, by acting to take control of one's own affective state, addictive behavior may
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serve to restore a sense of control when there is a perception that control or power has been lost or taken away.
There is clearly a paradox here. While I am suggesting a role in addiction for an unconscious process of restoring a sense of control, addictive behavior itself is inherently a matter of being out of control; simultaneously, then, addiction reflects both ego functioning and a loss of elements of ego functioning. The paradox is real, but also may be understood as the result of conflict: between a deeper need to ward off perceived helplessness and powerlessness, and other, healthier elements of the personality which become overwhelmed.
Drugs may be used to re-establish a sense of power quite apart from their pharmacologic effects. Some alcoholics begin to feel relief from tension at the point of ordering a drink, or the point of beginning to drink it, i.e., before there is any pharmacological effect. This suggests that something has been accomplished by the act alone of obtaining the drug. I view it as an initial or signal satisfaction of an attempt to re-establish an internal state of mastery. By initiating the chain of events (ordering the drink) which will lead to alteration of one's affect, one has confirmed the ability to alter and control one's affective state, reaffirming a sense of internal potency.
Experiences of helplessness or powerlessness are in fact central for addicts. Alcoholics Anonymous (and Narcotics Anonymous) make the need to tolerate powerlessness the focus of the first of their twelve "steps" of recovery: "We admitted we were powerless over alcohol …" (Twelve Steps and Twelve Traditions, 1952). Toleration of helplessness is also the essence of A.A.'s "serenity prayer," which centers on the wish to be granted "serenity to accept the things we cannot change" (Living Sober, 1975). Wurmser (1984) has also noted that addicts characteristically experience a "claustrum" feeling, i.e., a feeling of being (helplessly) closed in and imposed upon.
The following briefly summarized cases illustrate the function of drugs that I have described.
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Case 1
Mr. S was a forty-year-old man in psychoanalysis; he was not an addict in the usual sense, but his difficulties with smoking cigarettes illustrate clearly the issues I am trying to highlight. His father had been a violent man, and his mother had been passively compliant with his father's violence toward her; Mr. S described her as being like a "vegetable." As a child, Mr. S had regularly sought refuge from the "crazy adults" by hiding in a secret place in the cellar of their house, where he felt both safe and in control. At the time of this vignette, he had been in analysis for two years. He had previously stopped smoking and now spoke of his renewed craving for cigarettes. In the analysis, he had recently been feeling increasingly dependent, and very uncomfortable with what he considered to be "surrendering"—to the process, or to me. He said about his craving for cigarettes: "I wanted the comfort of it, I wanted to do something … it's paying attention to the anxiety and unhappiness, even if it's destructive." Asked what he would have been doing about these feelings by smoking, he said: "Soothing them, maybe; that's not right … it was a powerful urge, I felt frustrated." Several sessions later he returned to his urge, saying "there's a compulsion, it seems a gesture of defiance, but totally displaced … it's a certain kind of 'fuck you to the world' feeling … maybe it's a reflection of anxiety about the project [a big job he had been preparing at his work]. It's getting close and isn't ready yet … I really don't feel in control." I commented that he had been saying he didn't feel in control in several ways, and perhaps cigarettes were a way to be in control. He said: "I know it's a pleasure, but that's not enough [to explain his intense desire]." I agreed with him. Mr. S continued: "I guess [in smoking] I regain some control over the crazy world; it would be better to throw dishes!" He was surprised at his remark, and after a brief pause, added: "I guess it's a way of letting out some rage."
I agreed with him again, and suggested that smoking for him
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could be driven by rage about not being in control, and would express that rage, as well as resolve the feeling of being out of control, through an action which would yield a sense of taking back control. I commented that this could seem confusing since, overall, resuming smoking certainly would mean being out of control, but looked at very closely, it means just the reverse. Mr. S thought about this aloud a few minutes, then said, "Somehow I feel a great sense of relief right now." He went on to speak of his efforts to be in control of his life through not only cigarettes, but also alcohol (he had been a a moderately heavy drinker) and food. We were then able to consider a wish he had expressed that week to change several appointment times for the following week, as an analogous effort to retake control in the analysis, where he had been feeling frighteningly out of control.
This man made it clear that his impulse toward addictive behavior was a "letting out some rage" about feeling that he was not in control, and simultaneously was a reparative effort to regain mastery, arising in the setting of intensified dependency and anxieties about "surrendering." His initial thoughts about his craving were from the side of external reality, or from superego pressure, i.e., that it would be very foolish to smoke. As is usual with addictive behavior, this approach neither aided his understanding nor reduced his craving. Interpreting the unconscious dynamic behind the craving dissolved it, however, and led to further exploration of his feelings of helplessness and his indirect means of managing them. He did not resume smoking at that time.
Case 2
Mr. C, a fifty-two-year-old man whose advancement in his career as an architect had been severely hampered by his chronic alcoholism, entered psychotherapy after a previous psychoanalysis twenty years earlier. He described an early history of intense envy of his older brother, whose aggressiveness and creativity
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had stood in contrast to his own sense of having been a compliant, good boy. Paradigmatic of his experience was the story told by his mother that when she had caught him masturbating at age three and had told him to stop, he had done so immediately, in contrast to his brother. Characteristic, too, was his experience, as a child, of letting other children painfully bend back his fingers without defending himself.
In his analysis with a woman analyst, he never revealed the extent of his angry, critical feelings toward her. When she became aware that he drank heavily, he reported that she told him to stop drinking; he did so immediately, but the transference meaning of this was never addressed. After the analysis, he resumed drinking. His drinking was secretive in general. He attempted to conceal it from his wife, drinking in his car or when she was away or asleep. These attempts were never ultimately successful, and his wife was quite aware of his heavy drinking and experienced it as anger directed at her. (This is characteristic of the accurate perception by others of the addict's underlying affect, though, of course, without a real understanding of its basis.) His secretiveness was expressed as well in the current therapy, in which he again did not at first reveal his critical or angry feelings, but, it later came out, had a number of devaluing fantasies about my professional ability and my sexuality. His inhibitions were reflected in several ways. As a child he had slept with his mother after having nightmares, until he was twelve years old, and recalled seeing his mother naked in silhouette once, when she stood in her nightgown in front of a light. Later, he developed an inhibition in regard to looking. His analyst had discussed with him his failure to notice her habitual knitting while she sat in analysis. In the current therapy he failed to notice my analytic couch in the room; and while sitting a few feet away at a concert by chance, he failed to notice me. His inhibition of aggression, as in his allowing his fingers to be bent back, expressed itself in adult life, among other ways, through involvement with a con man whom he permitted to steal from him.
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When he began therapy, he was still drinking. Strikingly, he recognized that he was an alcoholic, paid lip service to the need to stop, and described himself as feeling guilty about his drinking, yet had no guilty affect at all. When this was pointed out in an exploratory, nonjudgmental way, he began to speak of a feeling that no one was going to stop him in his drinking, that in fact there were many complaints he had about how he was being treated in a variety of contexts, and that in general he lived with an angry feeling that he had put up with enough. On one occasion early in the treatment when he drank, he said he had the thought, "the hell with it," and added he felt "entitled … I deserved it." When he was questioned about this entitlement, he associated to an occasion when he had bought the wrong item at a store at age seven and his mother had unfairly scolded him. He said he had always thought he had felt guilty then, but in retrospect he saw that he had been very angry and had had the secret thought that he was right in his rage: he was entitled to be treated better and to be enraged, though it had to be kept secret.
On another occasion when he drank, he spoke of feeling that he had been let down. It became clear that one area in which he felt this was with me—after I had challenged his intellectual acceptance of his alcoholism. His association on this occasion was to an incident when he was four years old and had visited his father's business. He had called out proudly to his father, who was leading a meeting. His father had been angry and afterward had spanked the boy. His father's puncturing of Mr. C's exhibitionistic narcissism, and of his wish to join with his father whom he idealized, was an empathic failure which had been re-experienced when I challenged his offer of his prized intellectual understanding. His subsequent drinking was a response to this narcissistic deflation and reflected his rage and reassertion of his potency. Mr. C's final drinking episode in his therapy occurred when he had felt devalued and powerless in response to a combination of my informing him of my vacation, his wife's leaving on a trip, and criticism of his prowess by a
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colleague at work. He associated to a man confined to a wheelchair who had been ignored as unimportant by Mr. C's older brother. It was possible at this time to clarify with him his rage at feeling that he had been placed in a powerless, helpless position, and the value of his drinking as seizing power over his experience, while also defying those (his wife and me) he felt were devaluing him.
Some time later, he reported masturbating, then cutting his finger and dreaming of his collarbone being broken. Subsequently, he associated the experience of drinking without knowing a drinking bout was coming on, with wetting his pants as a child without having been aware he was about to do that. The theme of his castration anxiety and his need to find a secret expression of his phallic wishes became clearer, as did the meaning of drinking as a masturbation equivalent. He said finally, "Masturbation is the ultimate secret activity." He added that it was now clear to him that his "drinking is so crazily involved with 'getting away with it' … thumbing your nose at authority."
While the functions of this man's drinking are complex, characteristic of the complexity of his neurosis, his drinking was fundamentally a (secret) reassertion of his potency, driven by his rage at feelings of powerlessness and helplessness.
Case 3
Mr. G, a professional man in his mid-twenties, was a cocaine abuser and an alcoholic. He had been troubled for most of his life by feelings of weakness and inadequacy, associated with his relationship with his alcoholic father, a tyrannical man who often frightened and humiliated him. He had been abstinent of all substances since beginning once weekly psychotherapy five months before, until I had to reschedule two weeks of appointment hours, shortly before my upcoming vacation. Mr. G then used both cocaine and alcohol, and over the next three weeks
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spoke of feeling deprived and angry. His thought about using drugs was that he wanted to "fuck everyone."
Five months later, again shortly before my vacation and just after Mr. G's girlfriend broke up with him, he reported walking into a bar to buy cocaine (although he did not buy it). He said: "I had a sense of rebellion; I wasn't always going to be a helpless, crying hulk." His associations linked drug use to masturbating with a fantasy of women finding him highly desirable, i.e., a fantasy in which his impotent self-image was reversed. Mr. G continued substance-free for another six months, before using cocaine again in this context: he reluctantly dated a woman, feeling helpless to avoid this because he thought it was a political necessity in his work, and he felt degraded by the experience. After the date, he realized that for several months his great efforts at work had been unconsciously motivated by a wish to advance in order to impress his former girlfriend and win her back. Like his feeling of powerlessness in his recent date, he had the feeling that, during this time, he had been out of control and under the sway of his former girlfriend. He then had the thought, "Fuck them all, I'll make myself feel good," whereupon he sought out, bought, and used three grams of cocaine.
Mr. G used drugs in response to feeling helpless, impotent, and devalued. He made an angry effort to reassert his power—"Fuck them all," he was going to make himself feel good—and his means of expressing this enraged reassertion of his potency was via his drug use.
DEGREE OF NARCISSISTIC IMPAIRMENT
The importance of a sense of helplessness in addicts may arise from any level of psychological development. For some, who describe chronic states of feeling disempowered, or experience dysphoric states when faced with external successes which arouse frightening aspects of a sadistic grandiose self, there is
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clearly a significant degree of general narcissistic fragility, up to and including narcissistic personality disorders. But most addicts are not narcissistic characters. The shame that may be associated with anal and separation-individuation/autonomy issues, or narcissistic injuries associated with oedipal impotence, guilt, and inhibitions, may all provide the underlying basis for a vulnerability to feeling overwhelmed and helpless that is great enough for helplessness to be experienced as a traumatic narcissistic blow. Put another way, since narcissistic injuries occur at all psychosexual levels without resulting in a character that is dominantly narcissistic, the sensitivity to feelings of impotence or powerlessness, which I suggest is important in addiction, may occur in a wide variety of character structures. The narcissistic disturbance I am suggesting as a predisposition to addiction is, in fact, narrower than that in narcissistic personality disorder. (Khantzian and Mack [1987] also described alcoholics as suffering with "sectors" of narcissistic vulnerability.) As a result, addicted individuals have a rather wide range of general emotional health, and the engagement of narcissistic libido in addiction, which I am suggesting, need not be at primitive levels.
CORRELATION WITH OTHER PERSPECTIVES
In the perspective for viewing addiction that I am proposing, drug use is both id derivative and ego defense. It expresses an aggressive drive to be in control of one's narcissistic core self, while also reasserting that control, maintaining potency in the face of threatened helplessness. Correspondingly, the importance of aggression and even rage for maintaining a sense of inner stability and control was noted by Stolorow (1986), who wrote of the utility of "rage and vengefulness in the wake of injuries … [to] serve the purpose of revitalizing a crumbling but urgently needed sense of power and impactfulness" (p. 395). And Krystal (1978) spoke of the defensive value of even "affective storms" for avoiding states of psychic helplessness.
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The function of drug use I am describing might also be viewed as akin to the "ego instincts" of survival, since this use performs a central self-maintenance action. Khantzian and Mack (1983) wrote of the self-soothing and self-preservative functions of the ego and their consecutive development in childhood, the former preceding the latter. While addicts notoriously fail to self-preserve adequately, they clearly self-soothe in their behavior. This self-soothing function is related to the taking over of control (or self-regulation) of one's own affective state which I am describing.
Many of the formulations of drug use cited earlier may also be correlated with the perspective presented here. For instance, in the self-medication hypothesis of drug use (Khantzian, 1985), the choice of substance abused is made on the basis of its ability to alleviate the addict's most intolerable affective state. Put another way, such an overwhelming or intolerable affect threatens to create a feeling of powerlessness, since the affective flooding of the ego (psychic trauma), which is implied by the notion of intolerable affect, is a blow to the core of one's sense of mastery of oneself. Making the choice of a particular drug because it is the best antidote to this most intolerable affect is equivalent to doing one's best to restore internal equilibrium and potency.
McDougall (1984) observed that some patients, whom she called "dis-affected," immediately disperse all emotional arousal in action. She referred specifically to use of alcohol and drugs, as well as other addictive behavior as examples of such dispersion, saying "these all represent compulsive ways of avoiding affective flooding … due to unsuspected psychotic anxieties or extreme narcissistic fragility" (p. 389). She also noted, as I have, that such affective flooding could occur with exciting or positive affects as well as with painful ones. She felt that this condition arose from a relationship between mother and child in which the mother was simultaneously "out of touch with the infant's emotional needs, yet at the same time has controlled her baby's thoughts, feelings, and spontaneous gestures in a sort of archaic
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'double-bind' situation" (p. 391), which results ultimately in "an enraged child who is struggling, with whatever means he has at his disposal, for the right to exist" (p. 406).
While McDougall's description refers principally to psychologically more primitive addicts, I find her observation of an enraged struggle for "the right to exist" in these patients to be in a general way consistent with the view I am suggesting. Though she sees the addictive behavior only as a way to avoid the anxieties associated with experiencing affect, I would emphasize that it is also a direct expression of this urgent insistence upon a "right to exist," and a corrective response. That is, the addictive behavior represents the repeated fighting and (transient) winning of the struggle for the kind of autonomy to which she refers.
Krystal's (1982) observations about alexithymia are also relevant. In speaking of addicts and psychosomatic patients, both groups which he describes as having alexithymia, he wrote that there is "inhibition in regard to assuming the care for one's own self" (p. 361) because such activity is reserved for the mother and is proscribed to the child: "'taking-over' of these maternal functions is forbidden and very dangerous" (p. 361). Further, he said there is a distortion in self-representation, with "all vital and affect functions … experienced as part of the object represenation" (p. 361). Krystal's view that addicts feel they cannot "take over" certain of their own internal affective functions appears consistent with my view of a need to struggle for internal power and control in these patients. I would differ, however, with Krystal's conclusion that addicts in their substance use are only seeking an external agent which will soothe them. In my view, this underestimates the active, though unconscious, struggle to retake that control. An example of the difference in approach this entails may be taken from Krystal's paper. He presented a case vignette in which the patient experienced somatic distress in place of an affective reaction, in the transference. Krystal described the patient as saying that "when he gets in these states of [somatic] distress, he is completely helpless. It
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is not possible for him to help or relieve this distress, except with the use of some external agent such as food or drugs" (p. 362). The therapist in the case interpreted the patient's difficulty to him in these terms: "not only was he unable to soothe or comfort himself, but … such activities were prohibited for him, as was the acquisition of any such skill" (p. 363).
It would be useful, I believe, to also offer an additional interpretation. The key to the patient's feelings appears to be in his statement that when he gets in these states of distress, he is completely helpless. That is, somatic distress is not the final (nor I would say precipitating) affective state which he experiences before using food or drugs—rather, it is his helplessness. I would suggest it is his helplessness that his addictive behavior serves to relieve. I would ask him to consider that while he feels proscribed from acting, he repeatedly acts via his addictive behavior. That is, his feelings of helplessness ential other feelings—of being overwhelmed, disempowered, and enraged—and he regularly acts upon these feelings. (His denial of the active nature of addictive behavior is a commonly seen defense, often expressed by addicts in the externalization that the drug has power "over" them.) In pursuing this understanding with the patient, I would then be interested in exploring with him the history of his feelings of helplessness, and his solutions to them.
Krystal's observations also point to the object role of drugs. Drugs may certainly in part represent a longed-for object, particularly one over which individuals have complete control, and one which can also supply the omnipotence they seek. Analogously, I have described the search for omnipotent objects or omnipotent transitional objects in alcoholics' transferences to Alcoholics Anonymous and to its "higher power" (Dodes, 1988). The use of drugs to overcome traumatic helplessness and to re-establish internal omnipotence through a relationship with an omnipotent object represents an object relations perspective on the view I am describing.
From a different standopint, Wurmser (1984) emphasized
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the use of drugs to relieve pressure from an archaic superego, saying such use was a defiance against the superego and a way of supporting an identity free of its tyranny. This identity, he said, would allow denial and suppression of anxiety, shame, disillusionment, and guilt. I agree with Wurmser that the demands of a punitive superego are commonly a source of difficulty in addicts. When addictive behavior is induced by the superego, it most often appears, in my experience, as a restitutive response to the inhibiting function of the superego. That is, there has been an inhibition of an aggressive action (because it is unacceptable) by the addict in response to some injury or limitation. The drug use then serves, as Wurmser said, as a breaking out of a sense of constraint, or as a coup d'état against the superego. Put another way, the superego creates in the ego a sense of powerlessness as it induces internally a flood of shame or guilt, and externally an inhibition of action. What I would add to Wurmser's view is that the subsequent drug use is then not only to achieve a state which is free of unpleasant superego-induced affects, but also to re-establish the ego's autonomous power, free of imposed dysphoria and helplessness.
Finally, there is the question of the pharmacology of the substances chosen as a factor in addiction vulnerability. While there is clearly some psychic determinism in the selection of drugs, the fact that most addicts readily and often change the drugs they use, and use multiple drugs of entirely different pharmacological effects simultaneously and consecutively, argues against a primary role for the specific drug pharmacology in addiction (a point also made by Wurmser [1974]). The physical property of "addictiveness" of drugs also appears to be only a minor etiological factor in initiation or relapse of addiction (though there is a role of anxiety over physiological withdrawal in maintenance drug use). The minor role of pharmacological "addictiveness" is suggested by the everyday experience of controlled use of addictive drugs by non-vulnerable individuals (e.g., alcohol), and the demonstrated capacity of many addicts to remain abstinent from even the most addictive substances. In
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addition, there is the evidence of heroin-using returned Vietnam veterans. Over 90% of these individuals gave up heroin when they returned to the United States (Zinberg, 1975); once away from the extraordinary setting, their lack of intrinsic addiction-vulnerability readily overcame any physiologic pull to continued use.
ADDICTION AND NARCISSISTIC RAGE
I have described a drive, in addiction, to ward off a sense of helplessness and re-establish a sense of internal power. The drive is clearly aggressive and in the service of narcissistic equilibrium, i.e., to restore a threatened central aspect of "safety and reliability" in Spruiell's (1975) terms. The drive to re-establish the power to which one feels entitled has long been known for its intensity in narcissistically impaired individuals. Murray (1964) described the "massive rage and defiant determination to preserve … at any cost" (p. 493) that to which his narcissistically impaired patient felt entitled, and this man's sense of his right "to destroy … through anger and aggressive fantasies or anally devaluing attitudes" anyone who interfered with his view of his world (p. 494).
This drive may be called "narcissistic rage," though this term requires some clarification. As Nason (1985) has pointed out, the adjectives "primitive," "narcissistic," and "borderline" are frequently applied to rage in psychoanalytic literature, with somewhat differing connotations but perhaps describing a fundamentally unitary entity. A value of the term "narcissistic rage" is its indication of the origin of the affect in narcissistic vulnerability, and it is in this sense that I use it, without implying by this term either a Kohutian metapsychology or a link between this affect and pathological fear and envy (Kernberg, 1975). My focus is on a relatively specific area of "narcissistic expectation," to use Murray's (1964) term, namely, that of control of affective experience.
Nonetheless, Kohut's (1972) description of narcissistic rage provides a particularly clear clinical picture in considering
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the important role of narcissistic rage in addiction. He noted that narcissistic rage is set apart from other forms of aggression by its "deeply anchored, unrelenting compulsion" (p. 380), its "utter disregard for reasonable limitations" (p. 382), and its "boundless" qualities (p. 382). These characteristics are virtually identical to those that describe addiction. Indeed, the most striking aspect of addiction is its compulsive, insistent quality, as Wurmser (1974) emphasized. In addition, it is well known that the most common countertransference responses to addictive behavior are helplessness, frustration, and rage (or the manifestation of these feelings through defensive maneuvers designed to avoid them, such as rescue fantasies and withdrawal). These countertransferences, too, suggest that there is an irrational, unrelenting aggression in the addictive behavior.
There is also a characteristic loss of ego autonomy in both narcissistic rage and addiction. (This loss coexists with the active functioning of unconscious elements of the ego which I have been describing. It is the coexistence of elements of function and loss of function which results in the paradox referred to earlier of simultaneously seeking control while being out of control.) Kohut pointed out that "narcissistic rage enslaves the ego and allows it to function only as its tool and rationalizer" (1972, p. 387), and that in chronic narcissistic rage "conscious and preconscious ideation, in particular as it concerns the aims and goals of the personality, becomes more and more subservient to the pervasive rage" (p. 396). Substituting "addiction" for "narcissistic rage" in these statements creates a perfect description of the acute and chronic addicted state.
From another perspective, Stolorow (1984) described intense, primitive hostility (rage) in the psychoanalytic situation as serving "a restitutive function in restoring an urgently required feeling of omnipotence" (p. 650). Nason (1985) likewise pointed to the affirmative and valuable aspects of rage as an active position which "may be essential for many people in their struggle to survive" (p. 187), and cited George Klein's "principle of active reversal of passive experience" (p. 187). This mechanism of turning passive into active, in narcissistic rage-prone individuals
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(also noted by Kohut [1972], is consonant with the use of substances that I am suggesting, namely, the active remedying of an intense state of helplessness.
Finally, the permanent nature of the risk of resumed substance abuse even in a treated, abstinent abuser, is an almost universally recognized fact of addiction. For instance, it is central to the operation of Alcoholics Anonymous, which speaks of the need for the alcoholic to develop a permanent lifestly, and prescribes a treatment that has no provision for termination (Rosen, 1981). While I do not agree that the need for treatment must be permanent, there is no question that addicts have a permanent regressive potential (Dodes, 1988). This fact is another way in which addiction corresponds to narcissistic rage, as Kohut described: "… it must be admitted that … at the end of a generally successful analysis of a narcissistic personality disturbance … the patient should face openly the fact that there exists in him a residual propensity to be temporarily under the sway of narcissistic rage when his archaic narcissistic expectations are frustrated" (1972, p. 393).
It may be concluded that there is a striking overlap between the characteristics of addiction and those of narcissistic rage. In my view, this is because a central aspect of addiction is its function as response to a narcissistic sensitivity to powerlessness, in which the addiction is both a restorative defense against powerlessness and an expression of the narcissistic rage it produces. The role of narcissistic rage as the drive behind regaining a sense of internal power is a major cause of the "unrelenting compulsion," "utter disregard for reasonable limitations" (Kohut, 1972), and loss of ego autonomy which are characteristic of addiction. Each of the case vignettes described earlier illustrated the role of rage in addictive behavior.
TREATMENT
In keeping with these thoughts, one would expect that elements of narcissistic transferences would be important in the treatment
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of addictive disorders. I have previously noted (Dodes, 1988) that the use of Alcoholics Anonymous and its central concept of a "higher power" may be understood as examples of a search for an idealized object and an omnipotent transitional object, whose powers are utilized in exchange for the loss of power entailed in giving up the drug. Likewise, the therapist or analyst may also be quickly created or perceived to be such an idealized narcissistic object, leading to rapid achievement of drug abstinence. In these cases, the restoration of control, which had been achieved through drug use, is achieved instead via a merger with the idealized object that will provide assurance of power and control. This use of an object, however, is a capacity which is not universally present in addicts, or people in general, and as I have discussed elsewhere, the presence of such a capacity may distinguish those patients who rapidly abstain from those who do not (Dodes, 1984). (And some addicts will abstain from drugs but will be unable to internalize the function of the idealized object, therefore requiring its permanent presence, as via permanent use of AA [Dodes, 1984].) These transference phenomena may serve as the basis for a transference "cure" with early abstention from substance use. But in continued analytic or analytically-oriented treatment, the goals of insight and structural growth, as well as of a less brittle substance-free state, will require interpretation of the unconscious processes underlying the addiction.
A full discussion of treatment is beyond the focus of this paper. However, the illustrations contained in Cases 1 and 2 and in the discussion of Krystal's (1982) case will, I hope, suggest how exploration of the role of narcissistic traumatization around powerlessness, and its resulting rage, may help to understand the addictive process.
SUMMARY
In this paper, I have presented the view that addictive behavior serves to ward off a sense of helplessness or powerlessness and
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to re-establish a sense of internal power, via controlling and regulating one's affective state. The question of powerlessness is inherently an aspect of narcissism and is an area in which addicts appear to have a specific vulnerability. Several brief clinical illustrations were provided.
It was suggested that this narcissistic vulnerability in addiction is narrower than that seen in narcissistic personalities, and may arise from any psychosexual developmental level, consistent with the fact that addicts have a rather wide range of general emotional health. Correlations of this view were made with other psychoanalytic formulations and relevant theoretical perspectives, including those on the role of rage in maintaining internal cohesion; the self-care functions of the ego; the role in addiction of underlying affective disturbances, and of superego pathology; and the self-medication hypothesis.
The importance of narcissistic rage in addiction was discussed. This follows from the aggressive nature of the drive in addiction to restore a sense of power to which one feels entitled. I described the role of narcissistic rage in contributing to the "unrelenting compulsion," "disregard for reasonable limitations" (Kohut, 1972), and loss of ego autonomy which are characteristic of addiction.
Finally, treatment issues were briefly considered. Several illustrations applying the ideas I have suggested were provided in the case vignettes and in discussion of a case of Krystal's.
REFERENCES
DODES, L. M. 1984 Abstinence from alcohol in long-term individual psychotherapy with alcoholics Amer J. Psychother. 38 248-256
DODES, L. M. 1988 The psychology of combining dynamic psychotherapy and Alcoholics Anonymous Bull. Menning. Clin. 52 283-293
FREUD, S. 1926 Inhibitions, symptoms and anxiety S.E. 20
KERNBERG, O. F. 1975 Borderline Conditions and Pathological Narcissism New York: Aronson.
KHANTZIAN, E. J. 1978 The ego, the self and opiate addiction: theoretical and treatment considerations Int. Rev. Psychoanal. 5 189-198
KHANTZIAN, E. J. 1985 The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence Amer. J. Psychiat. 142 1259-1264
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KHANTZIAN, E. J. 1987 Substance Dependence, Repetition and the Nature of Addictive Suffering Unpublished.
KHANTZIAN, E. J. & MACK, J. E. 1983 Self-preservation and the care of the self. Ego instincts reconsidered Psychoanal. Study Child 38 209-232
KHANTZIAN, E. J. & MACK, J. E. 1987 AA and contemporary psychodynamic theory In Recent Developments in Alcoholism Vol. 7 ed. M. Galanter. New York: Plenum.
KOHUT, H. 1971 The Analysis of the Self. A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders New York: Int. Univ. Press.
KOHUT, H. 1972 Thoughts on narcissism and narcissistic rage Psychoanal. Study Child 27 360-400
KOHUT, H. & WOLF, E. S. 1978 The disorders of the self and their treatment: an outline Int. J. Psychoanal. 59 413-425
KRYSTAL, H. 1978 Trauma and affects Psychoanal. Study Child 33 81-116
KRYSTAL, H. 1982 Alexithymia and the effectiveness of psychoanalytic treatment Int. J. Psychoanal. Psychother. 9 353-378
KRYSTAL, H. & RASKIN, H. A. 1970 Drug Dependence: Aspects of Ego Function Detroit: Wayne State Univ. Press.
Living Sober 1975 New York: AA World Services.
MCDOUGALL, J. 1984 The "dis-affected" patient: reflections on affect pathology Psychoanal. Q. 53 386-409
MILKMAN, H. & FROSCH, W. A. 1973 On the preferential abuse of heroin and amphetamine J. Nerv. Ment. Dis. 156 242-248
MURRAY, J. M. 1964 Narcissim and the ego ideal J. Amer. Psychoanal. Assn. 12 477-511
NASON, J. D. 1985 The psychotherapy of rage: clinical and developmental perspectives Contemp. Psychoanal. 21 167-192
ROSEN, A. 1981 Psychotherapy and Alcoholics Anonymous: can they be coordinated Bull. Menning. Clin. 45 229-246
SOCARIDES, D. D. & STOLOROW, R. D. 1984-1985 Affects and selfobjects Annual Psychoanal. 12/13 105-119
SPRUIELL, V. 1975 Three strands of narcissism Psychoanal. Q. 44 577-595
STOLOROW, R. D. 1984 Aggression in the psychoanalytic situation: an intersubjective viewpoint Contemp. Psychoanal. 20 643-651
STOLOROW, R. D. 1986 Critical reflections on the theory of self psychology: an inside view Psychoanal. Inq. 6 387-402
Twelve Steps and Twelve Traditions 1952 New York: AA World Services.
WIEDER, H. & KAPLAN, E. H. 1969 Drug use in adolescents Psychoanal. Study Child 24 399-431
WURMSER, L. 1974 Psychoanalytic considerations of the etiology of compulsive drug use J. Amer. Psychoanal. Assn. 22 820-843
WURMSER, L. 1984 The role of superego conflicts in substance abuse and their treatment Int. J. Psychoanal. Psychother. 10 227-258
ZINBERG, N. E. 1975 Addiction and ego function Psychoanal. Study Child 30 567-588
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http://www.cyberpsych.org/alcohol/dodes.htm
LANCE M. DODES, M.D.
Re-printed from The Psychoanalytic Quarterly, 59:398 (1990)
ABSTRACT
In many cases addictive behavior serves to ward off a sense of helplessness or powerlessness via controlling and regulating one's affective state. Addicts have a vulnerability to feelings of powerlessness, which reflects a specific narcissistic impairment. The drive in addiction to re-establish a sense of power is, correspondingly, impelled by narcissistic rage. This rage gives to addiction some of its distinctive clinical properties. The narcissistic vulnerability in addicts is discussed. Several brief clinical cases are provided, and the view proposed is correlated with other psychoanalytic perspectives.
This paper addresses the role of feelings of powerlessness and rage in addiction. Having repeatedly discovered these affects preceding and precipitating addictive behavior, I have found that clarifying, exploring, and interpreting them has been instrumental in understanding the addictive process with many addicted individuals. This experience suggests a model for addictive behavior which both extends and is compatible with other psychoanalytic formulations. In proposing this model, I
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An earlier version of this paper was presented for the Discussion Group on "The Substance Abusing Patient in Psychoanalysis and Psychotherapy" at the Fall 1988 meeting of the American Psychoanalytic Association. I would like to thank Dr. Anton O. Kris for his very helpful criticisms and suggestions, as well as Drs. Edward Khantzian, John Mack, Robert Mehlman, and Malkah Notman for their valuable comments on earlier drafts of this paper.
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wish to be clear that I am focusing on addictive vulnerability and the initiation of or relapse to addictive behavior, rather than on the maintenance of addiction. Factors other than those involved in initiation or relapse, including physiologic ones, are likely to be at work in continuous drug use.
Recent views of addiction have emphasized ego defensive function and defense deficit. The most frequent formulation has been that substances are used for the purpose of managing intolerable affective states. Krystal and Raskin (1970) emphasized a defect in the stimulus barrier, resulting in an incapacity to ward off repeated painful affective experience; they saw substance use as augmenting or substituting for this defective barrier. They also suggested that a normal developmental process of differentiation, desomatization, and verbalization of affects is impaired in addicts. A number of authors have also noted specific affective states which addicts attempt to manage through the use of drugs, including aggressive feelings, anxiety, depression, rage, and shame (Khantzian, 1978); (Milkman and Frosch 1973); (Wurmser 1974). Khantzian (1985) focused attention on a self-medication hypothesis in which an individual's choice of drug is the result of the pharmacological action of the drug ameliorating the individual's principal painful affect.
From a different perspective, Wider and Kaplan (1969), Krystal and Raskin (1970), and Wurmser (1974), among others, have also described the use of drugs as an object substitute for a yearned-for parental figure. Alternatively, Khantzian (1978) and Khantzian and Mack (1983) have observed that addicts seem to have a deficit in a group of ego functions involved in the anticipation of danger and in self-protection, which they have called "self-care" functions. They have emphasized the importance of this deficit psychology in substance abusers, helping to explain the self-destructive nature of drug abuse. Khantzian (1987) has also considered a view that is virtually the reverse, namely, that addictive behavior serves as an attempt at mastery over poorly understood and passively experienced suffering,
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by creating a dysphoria which is controllable and understandable.
Kernberg (1975) saw addictive behavior as a gratification of instinctual needs or a reunion with a forgiving parental object or an activation of "all-good" self and object images. Kohut referred to addictions as "narcissistic behavior disorders" (Kohut and Wolf, 1978). He viewed the disturbance in addicts as due to the mother's failure to function as an adequate idealized self-object, and saw drugs serving "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" (Kohut, 1971, p. 46). Wurmser (1974) also emphasized a "narcissistic crisis" in drug abusers, in which the collapse of a grandiose self or an idealized object leads to feelings for which drug use is an attempted response. He wrote: "… an archaic overvaluation of the self or of others [leads to] the abysmal sense of frustration and letdown if these hopes are shattered… and thus to the addictive search" (p. 826). Like others, he viewed the choice of drug as dependent upon its influence on the affect most troubling: narcotic use for reducing or eliminating rage, shame, and feelings of abandonment, and amphetamines and cocaine for giving a sense of grandeur, defending against underlying depression.
ADDICTION, HELPLESSNESS, AND REASSERTION OF POWER
While there are many valuable psychoanalytic perspectives on addiction, I find in all of them an insufficient attention to the roles of power, helplessness, and rage. I would like to propose an additional mechanism which I have found to be important in many cases of addiction.
First, I would like to consider the role of addiction in managing omnipotence over one's own affective state. The central importance of being in control of one's affective state is highlighted
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by the loss of this control in psychic trauma: i.e., the imposition of a state of helplessness on the ego when it is overwhelmed by an instinctual drive (affect) which it cannot manage without excessive anxiety (Freud, 1926). It is the sense of powerlessness or helplessness in this situation which, as Krystal (1978) has emphasized, constitutes the essence of psychic trauma. The ability to be powerful over oneself and one's internal state may also be described as an inherent aspect of narcissism. Spruiell (1975) noted that among the strands of narcissism is "the pleasure in efficient mental functioning, … the regulation of mood… and … a sense of inner safety and reliability" (p. 590). Socarides and Stolorow (1984-1985) likewise stressed the central importance of steadily regulable, containable affect for the development and organization of self experience, without which affects become traumatic. In describing the "catastrophic reaction" of individuals to an acute brain defect, Kohut (1972) referred to the narcissistic importance of being in control of one's mind. Upon discovering an inability to perform mental functions once done easily, a person may become enraged because "he is suddenly not in control of his own thought processes, of a function which [we] consider to … [belong] to the core of our self, and we refuse to admit that we may not be in control of [it]" (p. 383). Kohut also wrote about the reaction of patients, especially early in analysis, to slips of the tongue: "They are enraged about the sudden exposure of their lack of omnipotence in the area of their own mind… '… the trace of affect which follows the revelation of the slip,' Freud said, 'is clearly in the nature of shame …'" (pp. 383-384).
In light of the core narcissistic importance of maintaining psychic control, it is significant that drugs are a device par excellence for altering, through one's intentional control, one's affective state. Since drug use provides a mechanism to re-establish such a central area of omnipotence, it may serve as a corrective when an addiction-vulnerable individual is flooded with feelings of helplessness or powerlessness. That is, by acting to take control of one's own affective state, addictive behavior may
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serve to restore a sense of control when there is a perception that control or power has been lost or taken away.
There is clearly a paradox here. While I am suggesting a role in addiction for an unconscious process of restoring a sense of control, addictive behavior itself is inherently a matter of being out of control; simultaneously, then, addiction reflects both ego functioning and a loss of elements of ego functioning. The paradox is real, but also may be understood as the result of conflict: between a deeper need to ward off perceived helplessness and powerlessness, and other, healthier elements of the personality which become overwhelmed.
Drugs may be used to re-establish a sense of power quite apart from their pharmacologic effects. Some alcoholics begin to feel relief from tension at the point of ordering a drink, or the point of beginning to drink it, i.e., before there is any pharmacological effect. This suggests that something has been accomplished by the act alone of obtaining the drug. I view it as an initial or signal satisfaction of an attempt to re-establish an internal state of mastery. By initiating the chain of events (ordering the drink) which will lead to alteration of one's affect, one has confirmed the ability to alter and control one's affective state, reaffirming a sense of internal potency.
Experiences of helplessness or powerlessness are in fact central for addicts. Alcoholics Anonymous (and Narcotics Anonymous) make the need to tolerate powerlessness the focus of the first of their twelve "steps" of recovery: "We admitted we were powerless over alcohol …" (Twelve Steps and Twelve Traditions, 1952). Toleration of helplessness is also the essence of A.A.'s "serenity prayer," which centers on the wish to be granted "serenity to accept the things we cannot change" (Living Sober, 1975). Wurmser (1984) has also noted that addicts characteristically experience a "claustrum" feeling, i.e., a feeling of being (helplessly) closed in and imposed upon.
The following briefly summarized cases illustrate the function of drugs that I have described.
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Case 1
Mr. S was a forty-year-old man in psychoanalysis; he was not an addict in the usual sense, but his difficulties with smoking cigarettes illustrate clearly the issues I am trying to highlight. His father had been a violent man, and his mother had been passively compliant with his father's violence toward her; Mr. S described her as being like a "vegetable." As a child, Mr. S had regularly sought refuge from the "crazy adults" by hiding in a secret place in the cellar of their house, where he felt both safe and in control. At the time of this vignette, he had been in analysis for two years. He had previously stopped smoking and now spoke of his renewed craving for cigarettes. In the analysis, he had recently been feeling increasingly dependent, and very uncomfortable with what he considered to be "surrendering"—to the process, or to me. He said about his craving for cigarettes: "I wanted the comfort of it, I wanted to do something … it's paying attention to the anxiety and unhappiness, even if it's destructive." Asked what he would have been doing about these feelings by smoking, he said: "Soothing them, maybe; that's not right … it was a powerful urge, I felt frustrated." Several sessions later he returned to his urge, saying "there's a compulsion, it seems a gesture of defiance, but totally displaced … it's a certain kind of 'fuck you to the world' feeling … maybe it's a reflection of anxiety about the project [a big job he had been preparing at his work]. It's getting close and isn't ready yet … I really don't feel in control." I commented that he had been saying he didn't feel in control in several ways, and perhaps cigarettes were a way to be in control. He said: "I know it's a pleasure, but that's not enough [to explain his intense desire]." I agreed with him. Mr. S continued: "I guess [in smoking] I regain some control over the crazy world; it would be better to throw dishes!" He was surprised at his remark, and after a brief pause, added: "I guess it's a way of letting out some rage."
I agreed with him again, and suggested that smoking for him
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could be driven by rage about not being in control, and would express that rage, as well as resolve the feeling of being out of control, through an action which would yield a sense of taking back control. I commented that this could seem confusing since, overall, resuming smoking certainly would mean being out of control, but looked at very closely, it means just the reverse. Mr. S thought about this aloud a few minutes, then said, "Somehow I feel a great sense of relief right now." He went on to speak of his efforts to be in control of his life through not only cigarettes, but also alcohol (he had been a a moderately heavy drinker) and food. We were then able to consider a wish he had expressed that week to change several appointment times for the following week, as an analogous effort to retake control in the analysis, where he had been feeling frighteningly out of control.
This man made it clear that his impulse toward addictive behavior was a "letting out some rage" about feeling that he was not in control, and simultaneously was a reparative effort to regain mastery, arising in the setting of intensified dependency and anxieties about "surrendering." His initial thoughts about his craving were from the side of external reality, or from superego pressure, i.e., that it would be very foolish to smoke. As is usual with addictive behavior, this approach neither aided his understanding nor reduced his craving. Interpreting the unconscious dynamic behind the craving dissolved it, however, and led to further exploration of his feelings of helplessness and his indirect means of managing them. He did not resume smoking at that time.
Case 2
Mr. C, a fifty-two-year-old man whose advancement in his career as an architect had been severely hampered by his chronic alcoholism, entered psychotherapy after a previous psychoanalysis twenty years earlier. He described an early history of intense envy of his older brother, whose aggressiveness and creativity
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had stood in contrast to his own sense of having been a compliant, good boy. Paradigmatic of his experience was the story told by his mother that when she had caught him masturbating at age three and had told him to stop, he had done so immediately, in contrast to his brother. Characteristic, too, was his experience, as a child, of letting other children painfully bend back his fingers without defending himself.
In his analysis with a woman analyst, he never revealed the extent of his angry, critical feelings toward her. When she became aware that he drank heavily, he reported that she told him to stop drinking; he did so immediately, but the transference meaning of this was never addressed. After the analysis, he resumed drinking. His drinking was secretive in general. He attempted to conceal it from his wife, drinking in his car or when she was away or asleep. These attempts were never ultimately successful, and his wife was quite aware of his heavy drinking and experienced it as anger directed at her. (This is characteristic of the accurate perception by others of the addict's underlying affect, though, of course, without a real understanding of its basis.) His secretiveness was expressed as well in the current therapy, in which he again did not at first reveal his critical or angry feelings, but, it later came out, had a number of devaluing fantasies about my professional ability and my sexuality. His inhibitions were reflected in several ways. As a child he had slept with his mother after having nightmares, until he was twelve years old, and recalled seeing his mother naked in silhouette once, when she stood in her nightgown in front of a light. Later, he developed an inhibition in regard to looking. His analyst had discussed with him his failure to notice her habitual knitting while she sat in analysis. In the current therapy he failed to notice my analytic couch in the room; and while sitting a few feet away at a concert by chance, he failed to notice me. His inhibition of aggression, as in his allowing his fingers to be bent back, expressed itself in adult life, among other ways, through involvement with a con man whom he permitted to steal from him.
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When he began therapy, he was still drinking. Strikingly, he recognized that he was an alcoholic, paid lip service to the need to stop, and described himself as feeling guilty about his drinking, yet had no guilty affect at all. When this was pointed out in an exploratory, nonjudgmental way, he began to speak of a feeling that no one was going to stop him in his drinking, that in fact there were many complaints he had about how he was being treated in a variety of contexts, and that in general he lived with an angry feeling that he had put up with enough. On one occasion early in the treatment when he drank, he said he had the thought, "the hell with it," and added he felt "entitled … I deserved it." When he was questioned about this entitlement, he associated to an occasion when he had bought the wrong item at a store at age seven and his mother had unfairly scolded him. He said he had always thought he had felt guilty then, but in retrospect he saw that he had been very angry and had had the secret thought that he was right in his rage: he was entitled to be treated better and to be enraged, though it had to be kept secret.
On another occasion when he drank, he spoke of feeling that he had been let down. It became clear that one area in which he felt this was with me—after I had challenged his intellectual acceptance of his alcoholism. His association on this occasion was to an incident when he was four years old and had visited his father's business. He had called out proudly to his father, who was leading a meeting. His father had been angry and afterward had spanked the boy. His father's puncturing of Mr. C's exhibitionistic narcissism, and of his wish to join with his father whom he idealized, was an empathic failure which had been re-experienced when I challenged his offer of his prized intellectual understanding. His subsequent drinking was a response to this narcissistic deflation and reflected his rage and reassertion of his potency. Mr. C's final drinking episode in his therapy occurred when he had felt devalued and powerless in response to a combination of my informing him of my vacation, his wife's leaving on a trip, and criticism of his prowess by a
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colleague at work. He associated to a man confined to a wheelchair who had been ignored as unimportant by Mr. C's older brother. It was possible at this time to clarify with him his rage at feeling that he had been placed in a powerless, helpless position, and the value of his drinking as seizing power over his experience, while also defying those (his wife and me) he felt were devaluing him.
Some time later, he reported masturbating, then cutting his finger and dreaming of his collarbone being broken. Subsequently, he associated the experience of drinking without knowing a drinking bout was coming on, with wetting his pants as a child without having been aware he was about to do that. The theme of his castration anxiety and his need to find a secret expression of his phallic wishes became clearer, as did the meaning of drinking as a masturbation equivalent. He said finally, "Masturbation is the ultimate secret activity." He added that it was now clear to him that his "drinking is so crazily involved with 'getting away with it' … thumbing your nose at authority."
While the functions of this man's drinking are complex, characteristic of the complexity of his neurosis, his drinking was fundamentally a (secret) reassertion of his potency, driven by his rage at feelings of powerlessness and helplessness.
Case 3
Mr. G, a professional man in his mid-twenties, was a cocaine abuser and an alcoholic. He had been troubled for most of his life by feelings of weakness and inadequacy, associated with his relationship with his alcoholic father, a tyrannical man who often frightened and humiliated him. He had been abstinent of all substances since beginning once weekly psychotherapy five months before, until I had to reschedule two weeks of appointment hours, shortly before my upcoming vacation. Mr. G then used both cocaine and alcohol, and over the next three weeks
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spoke of feeling deprived and angry. His thought about using drugs was that he wanted to "fuck everyone."
Five months later, again shortly before my vacation and just after Mr. G's girlfriend broke up with him, he reported walking into a bar to buy cocaine (although he did not buy it). He said: "I had a sense of rebellion; I wasn't always going to be a helpless, crying hulk." His associations linked drug use to masturbating with a fantasy of women finding him highly desirable, i.e., a fantasy in which his impotent self-image was reversed. Mr. G continued substance-free for another six months, before using cocaine again in this context: he reluctantly dated a woman, feeling helpless to avoid this because he thought it was a political necessity in his work, and he felt degraded by the experience. After the date, he realized that for several months his great efforts at work had been unconsciously motivated by a wish to advance in order to impress his former girlfriend and win her back. Like his feeling of powerlessness in his recent date, he had the feeling that, during this time, he had been out of control and under the sway of his former girlfriend. He then had the thought, "Fuck them all, I'll make myself feel good," whereupon he sought out, bought, and used three grams of cocaine.
Mr. G used drugs in response to feeling helpless, impotent, and devalued. He made an angry effort to reassert his power—"Fuck them all," he was going to make himself feel good—and his means of expressing this enraged reassertion of his potency was via his drug use.
DEGREE OF NARCISSISTIC IMPAIRMENT
The importance of a sense of helplessness in addicts may arise from any level of psychological development. For some, who describe chronic states of feeling disempowered, or experience dysphoric states when faced with external successes which arouse frightening aspects of a sadistic grandiose self, there is
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clearly a significant degree of general narcissistic fragility, up to and including narcissistic personality disorders. But most addicts are not narcissistic characters. The shame that may be associated with anal and separation-individuation/autonomy issues, or narcissistic injuries associated with oedipal impotence, guilt, and inhibitions, may all provide the underlying basis for a vulnerability to feeling overwhelmed and helpless that is great enough for helplessness to be experienced as a traumatic narcissistic blow. Put another way, since narcissistic injuries occur at all psychosexual levels without resulting in a character that is dominantly narcissistic, the sensitivity to feelings of impotence or powerlessness, which I suggest is important in addiction, may occur in a wide variety of character structures. The narcissistic disturbance I am suggesting as a predisposition to addiction is, in fact, narrower than that in narcissistic personality disorder. (Khantzian and Mack [1987] also described alcoholics as suffering with "sectors" of narcissistic vulnerability.) As a result, addicted individuals have a rather wide range of general emotional health, and the engagement of narcissistic libido in addiction, which I am suggesting, need not be at primitive levels.
CORRELATION WITH OTHER PERSPECTIVES
In the perspective for viewing addiction that I am proposing, drug use is both id derivative and ego defense. It expresses an aggressive drive to be in control of one's narcissistic core self, while also reasserting that control, maintaining potency in the face of threatened helplessness. Correspondingly, the importance of aggression and even rage for maintaining a sense of inner stability and control was noted by Stolorow (1986), who wrote of the utility of "rage and vengefulness in the wake of injuries … [to] serve the purpose of revitalizing a crumbling but urgently needed sense of power and impactfulness" (p. 395). And Krystal (1978) spoke of the defensive value of even "affective storms" for avoiding states of psychic helplessness.
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The function of drug use I am describing might also be viewed as akin to the "ego instincts" of survival, since this use performs a central self-maintenance action. Khantzian and Mack (1983) wrote of the self-soothing and self-preservative functions of the ego and their consecutive development in childhood, the former preceding the latter. While addicts notoriously fail to self-preserve adequately, they clearly self-soothe in their behavior. This self-soothing function is related to the taking over of control (or self-regulation) of one's own affective state which I am describing.
Many of the formulations of drug use cited earlier may also be correlated with the perspective presented here. For instance, in the self-medication hypothesis of drug use (Khantzian, 1985), the choice of substance abused is made on the basis of its ability to alleviate the addict's most intolerable affective state. Put another way, such an overwhelming or intolerable affect threatens to create a feeling of powerlessness, since the affective flooding of the ego (psychic trauma), which is implied by the notion of intolerable affect, is a blow to the core of one's sense of mastery of oneself. Making the choice of a particular drug because it is the best antidote to this most intolerable affect is equivalent to doing one's best to restore internal equilibrium and potency.
McDougall (1984) observed that some patients, whom she called "dis-affected," immediately disperse all emotional arousal in action. She referred specifically to use of alcohol and drugs, as well as other addictive behavior as examples of such dispersion, saying "these all represent compulsive ways of avoiding affective flooding … due to unsuspected psychotic anxieties or extreme narcissistic fragility" (p. 389). She also noted, as I have, that such affective flooding could occur with exciting or positive affects as well as with painful ones. She felt that this condition arose from a relationship between mother and child in which the mother was simultaneously "out of touch with the infant's emotional needs, yet at the same time has controlled her baby's thoughts, feelings, and spontaneous gestures in a sort of archaic
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'double-bind' situation" (p. 391), which results ultimately in "an enraged child who is struggling, with whatever means he has at his disposal, for the right to exist" (p. 406).
While McDougall's description refers principally to psychologically more primitive addicts, I find her observation of an enraged struggle for "the right to exist" in these patients to be in a general way consistent with the view I am suggesting. Though she sees the addictive behavior only as a way to avoid the anxieties associated with experiencing affect, I would emphasize that it is also a direct expression of this urgent insistence upon a "right to exist," and a corrective response. That is, the addictive behavior represents the repeated fighting and (transient) winning of the struggle for the kind of autonomy to which she refers.
Krystal's (1982) observations about alexithymia are also relevant. In speaking of addicts and psychosomatic patients, both groups which he describes as having alexithymia, he wrote that there is "inhibition in regard to assuming the care for one's own self" (p. 361) because such activity is reserved for the mother and is proscribed to the child: "'taking-over' of these maternal functions is forbidden and very dangerous" (p. 361). Further, he said there is a distortion in self-representation, with "all vital and affect functions … experienced as part of the object represenation" (p. 361). Krystal's view that addicts feel they cannot "take over" certain of their own internal affective functions appears consistent with my view of a need to struggle for internal power and control in these patients. I would differ, however, with Krystal's conclusion that addicts in their substance use are only seeking an external agent which will soothe them. In my view, this underestimates the active, though unconscious, struggle to retake that control. An example of the difference in approach this entails may be taken from Krystal's paper. He presented a case vignette in which the patient experienced somatic distress in place of an affective reaction, in the transference. Krystal described the patient as saying that "when he gets in these states of [somatic] distress, he is completely helpless. It
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is not possible for him to help or relieve this distress, except with the use of some external agent such as food or drugs" (p. 362). The therapist in the case interpreted the patient's difficulty to him in these terms: "not only was he unable to soothe or comfort himself, but … such activities were prohibited for him, as was the acquisition of any such skill" (p. 363).
It would be useful, I believe, to also offer an additional interpretation. The key to the patient's feelings appears to be in his statement that when he gets in these states of distress, he is completely helpless. That is, somatic distress is not the final (nor I would say precipitating) affective state which he experiences before using food or drugs—rather, it is his helplessness. I would suggest it is his helplessness that his addictive behavior serves to relieve. I would ask him to consider that while he feels proscribed from acting, he repeatedly acts via his addictive behavior. That is, his feelings of helplessness ential other feelings—of being overwhelmed, disempowered, and enraged—and he regularly acts upon these feelings. (His denial of the active nature of addictive behavior is a commonly seen defense, often expressed by addicts in the externalization that the drug has power "over" them.) In pursuing this understanding with the patient, I would then be interested in exploring with him the history of his feelings of helplessness, and his solutions to them.
Krystal's observations also point to the object role of drugs. Drugs may certainly in part represent a longed-for object, particularly one over which individuals have complete control, and one which can also supply the omnipotence they seek. Analogously, I have described the search for omnipotent objects or omnipotent transitional objects in alcoholics' transferences to Alcoholics Anonymous and to its "higher power" (Dodes, 1988). The use of drugs to overcome traumatic helplessness and to re-establish internal omnipotence through a relationship with an omnipotent object represents an object relations perspective on the view I am describing.
From a different standopint, Wurmser (1984) emphasized
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the use of drugs to relieve pressure from an archaic superego, saying such use was a defiance against the superego and a way of supporting an identity free of its tyranny. This identity, he said, would allow denial and suppression of anxiety, shame, disillusionment, and guilt. I agree with Wurmser that the demands of a punitive superego are commonly a source of difficulty in addicts. When addictive behavior is induced by the superego, it most often appears, in my experience, as a restitutive response to the inhibiting function of the superego. That is, there has been an inhibition of an aggressive action (because it is unacceptable) by the addict in response to some injury or limitation. The drug use then serves, as Wurmser said, as a breaking out of a sense of constraint, or as a coup d'état against the superego. Put another way, the superego creates in the ego a sense of powerlessness as it induces internally a flood of shame or guilt, and externally an inhibition of action. What I would add to Wurmser's view is that the subsequent drug use is then not only to achieve a state which is free of unpleasant superego-induced affects, but also to re-establish the ego's autonomous power, free of imposed dysphoria and helplessness.
Finally, there is the question of the pharmacology of the substances chosen as a factor in addiction vulnerability. While there is clearly some psychic determinism in the selection of drugs, the fact that most addicts readily and often change the drugs they use, and use multiple drugs of entirely different pharmacological effects simultaneously and consecutively, argues against a primary role for the specific drug pharmacology in addiction (a point also made by Wurmser [1974]). The physical property of "addictiveness" of drugs also appears to be only a minor etiological factor in initiation or relapse of addiction (though there is a role of anxiety over physiological withdrawal in maintenance drug use). The minor role of pharmacological "addictiveness" is suggested by the everyday experience of controlled use of addictive drugs by non-vulnerable individuals (e.g., alcohol), and the demonstrated capacity of many addicts to remain abstinent from even the most addictive substances. In
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addition, there is the evidence of heroin-using returned Vietnam veterans. Over 90% of these individuals gave up heroin when they returned to the United States (Zinberg, 1975); once away from the extraordinary setting, their lack of intrinsic addiction-vulnerability readily overcame any physiologic pull to continued use.
ADDICTION AND NARCISSISTIC RAGE
I have described a drive, in addiction, to ward off a sense of helplessness and re-establish a sense of internal power. The drive is clearly aggressive and in the service of narcissistic equilibrium, i.e., to restore a threatened central aspect of "safety and reliability" in Spruiell's (1975) terms. The drive to re-establish the power to which one feels entitled has long been known for its intensity in narcissistically impaired individuals. Murray (1964) described the "massive rage and defiant determination to preserve … at any cost" (p. 493) that to which his narcissistically impaired patient felt entitled, and this man's sense of his right "to destroy … through anger and aggressive fantasies or anally devaluing attitudes" anyone who interfered with his view of his world (p. 494).
This drive may be called "narcissistic rage," though this term requires some clarification. As Nason (1985) has pointed out, the adjectives "primitive," "narcissistic," and "borderline" are frequently applied to rage in psychoanalytic literature, with somewhat differing connotations but perhaps describing a fundamentally unitary entity. A value of the term "narcissistic rage" is its indication of the origin of the affect in narcissistic vulnerability, and it is in this sense that I use it, without implying by this term either a Kohutian metapsychology or a link between this affect and pathological fear and envy (Kernberg, 1975). My focus is on a relatively specific area of "narcissistic expectation," to use Murray's (1964) term, namely, that of control of affective experience.
Nonetheless, Kohut's (1972) description of narcissistic rage provides a particularly clear clinical picture in considering
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the important role of narcissistic rage in addiction. He noted that narcissistic rage is set apart from other forms of aggression by its "deeply anchored, unrelenting compulsion" (p. 380), its "utter disregard for reasonable limitations" (p. 382), and its "boundless" qualities (p. 382). These characteristics are virtually identical to those that describe addiction. Indeed, the most striking aspect of addiction is its compulsive, insistent quality, as Wurmser (1974) emphasized. In addition, it is well known that the most common countertransference responses to addictive behavior are helplessness, frustration, and rage (or the manifestation of these feelings through defensive maneuvers designed to avoid them, such as rescue fantasies and withdrawal). These countertransferences, too, suggest that there is an irrational, unrelenting aggression in the addictive behavior.
There is also a characteristic loss of ego autonomy in both narcissistic rage and addiction. (This loss coexists with the active functioning of unconscious elements of the ego which I have been describing. It is the coexistence of elements of function and loss of function which results in the paradox referred to earlier of simultaneously seeking control while being out of control.) Kohut pointed out that "narcissistic rage enslaves the ego and allows it to function only as its tool and rationalizer" (1972, p. 387), and that in chronic narcissistic rage "conscious and preconscious ideation, in particular as it concerns the aims and goals of the personality, becomes more and more subservient to the pervasive rage" (p. 396). Substituting "addiction" for "narcissistic rage" in these statements creates a perfect description of the acute and chronic addicted state.
From another perspective, Stolorow (1984) described intense, primitive hostility (rage) in the psychoanalytic situation as serving "a restitutive function in restoring an urgently required feeling of omnipotence" (p. 650). Nason (1985) likewise pointed to the affirmative and valuable aspects of rage as an active position which "may be essential for many people in their struggle to survive" (p. 187), and cited George Klein's "principle of active reversal of passive experience" (p. 187). This mechanism of turning passive into active, in narcissistic rage-prone individuals
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(also noted by Kohut [1972], is consonant with the use of substances that I am suggesting, namely, the active remedying of an intense state of helplessness.
Finally, the permanent nature of the risk of resumed substance abuse even in a treated, abstinent abuser, is an almost universally recognized fact of addiction. For instance, it is central to the operation of Alcoholics Anonymous, which speaks of the need for the alcoholic to develop a permanent lifestly, and prescribes a treatment that has no provision for termination (Rosen, 1981). While I do not agree that the need for treatment must be permanent, there is no question that addicts have a permanent regressive potential (Dodes, 1988). This fact is another way in which addiction corresponds to narcissistic rage, as Kohut described: "… it must be admitted that … at the end of a generally successful analysis of a narcissistic personality disturbance … the patient should face openly the fact that there exists in him a residual propensity to be temporarily under the sway of narcissistic rage when his archaic narcissistic expectations are frustrated" (1972, p. 393).
It may be concluded that there is a striking overlap between the characteristics of addiction and those of narcissistic rage. In my view, this is because a central aspect of addiction is its function as response to a narcissistic sensitivity to powerlessness, in which the addiction is both a restorative defense against powerlessness and an expression of the narcissistic rage it produces. The role of narcissistic rage as the drive behind regaining a sense of internal power is a major cause of the "unrelenting compulsion," "utter disregard for reasonable limitations" (Kohut, 1972), and loss of ego autonomy which are characteristic of addiction. Each of the case vignettes described earlier illustrated the role of rage in addictive behavior.
TREATMENT
In keeping with these thoughts, one would expect that elements of narcissistic transferences would be important in the treatment
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of addictive disorders. I have previously noted (Dodes, 1988) that the use of Alcoholics Anonymous and its central concept of a "higher power" may be understood as examples of a search for an idealized object and an omnipotent transitional object, whose powers are utilized in exchange for the loss of power entailed in giving up the drug. Likewise, the therapist or analyst may also be quickly created or perceived to be such an idealized narcissistic object, leading to rapid achievement of drug abstinence. In these cases, the restoration of control, which had been achieved through drug use, is achieved instead via a merger with the idealized object that will provide assurance of power and control. This use of an object, however, is a capacity which is not universally present in addicts, or people in general, and as I have discussed elsewhere, the presence of such a capacity may distinguish those patients who rapidly abstain from those who do not (Dodes, 1984). (And some addicts will abstain from drugs but will be unable to internalize the function of the idealized object, therefore requiring its permanent presence, as via permanent use of AA [Dodes, 1984].) These transference phenomena may serve as the basis for a transference "cure" with early abstention from substance use. But in continued analytic or analytically-oriented treatment, the goals of insight and structural growth, as well as of a less brittle substance-free state, will require interpretation of the unconscious processes underlying the addiction.
A full discussion of treatment is beyond the focus of this paper. However, the illustrations contained in Cases 1 and 2 and in the discussion of Krystal's (1982) case will, I hope, suggest how exploration of the role of narcissistic traumatization around powerlessness, and its resulting rage, may help to understand the addictive process.
SUMMARY
In this paper, I have presented the view that addictive behavior serves to ward off a sense of helplessness or powerlessness and
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to re-establish a sense of internal power, via controlling and regulating one's affective state. The question of powerlessness is inherently an aspect of narcissism and is an area in which addicts appear to have a specific vulnerability. Several brief clinical illustrations were provided.
It was suggested that this narcissistic vulnerability in addiction is narrower than that seen in narcissistic personalities, and may arise from any psychosexual developmental level, consistent with the fact that addicts have a rather wide range of general emotional health. Correlations of this view were made with other psychoanalytic formulations and relevant theoretical perspectives, including those on the role of rage in maintaining internal cohesion; the self-care functions of the ego; the role in addiction of underlying affective disturbances, and of superego pathology; and the self-medication hypothesis.
The importance of narcissistic rage in addiction was discussed. This follows from the aggressive nature of the drive in addiction to restore a sense of power to which one feels entitled. I described the role of narcissistic rage in contributing to the "unrelenting compulsion," "disregard for reasonable limitations" (Kohut, 1972), and loss of ego autonomy which are characteristic of addiction.
Finally, treatment issues were briefly considered. Several illustrations applying the ideas I have suggested were provided in the case vignettes and in discussion of a case of Krystal's.
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