psychodynamic approach to research in drug addiction

Some ideas about my research project.

For the past year I have been attending Narcotic Anonymous and a Substance Abuse ministry at the Morning Star church to study the effect spirituality and religion has on sobriety. I had to abandon observation of Substance Abuse ministry due to a very small size, inconsistent participation and high drop-out rate. I was hoping to make a comparative study of Narcotic Anonymous and faith-based recovery model. Now, I am concentrating on studying Narcotic Anonymous and how NA/AA model may help the process of recovery from addiction. I feel that I may have identified one component crucial to the recovery effort at least in relation to the minority clients at Narcotic Anonymous.

The core issue identified is that of shame. Although addicts rarely use the term shame, it is nonetheless spoken of in disguised form. There is a shame talking about shame, thus, other terms are used to express shame. The overwhelming majority of the addicts at the AA/NA meeting are men. The overwhelming majority at the observation site are also African-Americans and Hispanics.

The majority of the addicts appear to come from inner-city neighborhood with problems ranging from high unemployment rate, unstable family structure and violence. I use attachment theory in order to understand attachment patterns of addicts. Attachment theory is often utilized to explain mother-infant relation or to some other significant figure to the infant. I am extending attachment theory application to family and social structure.

My main argument in explaining addiction is the following: affects and impulses are contained and discharged not only in the dyadic relationship between an infant and its care-taker but also by the family and social institutions. Family structure and social structure help to adequately contain anxiety. However, when all these layers, i.e. dyadic containment of impulse, family containment of impulse and social containment of impulse fail, an individual may become prone to use external means of containing anxiety. In our society drugs happen to be the most widely used method of containing anxiety. However, despite the prevalence of drug abuse, especially in some quarters, there is a great deal of stigma and ostracism of the addict.

Obtaining and using drugs becomes the focal point of the addict in terms of expenditure of energy. Often and especially in the inner-city, the addict may resort to all manner of socially disapproved ways to obtain drugs. I would argue that shame becomes especially clear when the addict’s social status is increasingly lowered. Low social status means decreased social capital both in terms of financial resources, attachment figures and a sense of one’s appraisal, perception or feelings about its social standing. Decreasing social status leads to narcissistic injury and further intensifying the cycle of shame. There is also a close relationship between shame and rage which I will elaborate in the future.

What mechanism(s) explain sobriety in AA/NA? AA/NA provides a safe space where emotion around shame is intensified and processed. The 12 stapes in AA/NA are a blueprint in the ritual processing of shame. Addicts’ testimonies are primarily around shameful acts of betrayal, deceit and hurt of loved ones. The 12-step is a practical spiritual tool of primarily shame metabolism. Shame metabolism is an arduous process involving the surrender of oneself to a spiritual practice by acknowledging that one is not only an addict but can not maintain recovery by sheer self-will.

Initially there is a resistance followed by ambivalence and culminating in sobriety. The theory I am proposing is that intense affect of shame is catharted in personal narrative. AA/NA encourages sharing as a way of constructing and reconstructing personal narrative as it relates to shame. Spirituality aids in interpreting personal narratives. Spirituality may also foster internal phantasy. I am still in the process of thinking about how a rich internal phantasy helps to stimulate the imagination and the expectancy of recovery.

But how do we measure emotional intensity in relation to shame metabolism which presumably leads to a recovery? There is no objective measure of subjective emotional intensity but my hypothesis is that personal narrative of an addict at different stages of the recovery process should be different in terms of its emotional valence. Therefore, on average sober individuals should have a narrative rich and colorful in how they construct and interpret spirituality in the context of their own life experiences compare to addicts who are still using drugs and alcohol? However, I feel that a valid comparison may be the narrative of one individual over time than comparing the narratives of different individuals since each individual may interpret differently what has been helpful in the recovery effort.

To summarize, addiction may be the result of an attempt to contain anxiety by external means of drugs/alcohol because of a lack of or inadequate containment in the addict’s family dynamic and social institutions. In the inner-city shame may be is a result of lowered social status often due to decreased social capital. AA/NA provides safe space as well as containment and a safe controlled, purposeful discharge of affects. Sobriety is the result of a successful metabolism of shame. Shame metabolism occurs as a result of intense emotion cathercted into personal narrative. Life experience of the addict is continually constructed and reconstructed in light of spiritual practice. Spirituality helps to foster internal phantasy and expectancy of recovery to the addict.

Participating in a group of people with similar social status and addiction help to increase emotional attunement and decrease resistance. The 12 step method helps to intensify emotion around shame. The ability to tolerate intense affect (shame) may improve overtime. The ability and willingness to tolerate shame affect is in effect the process of shame metabolism. AA/NA focuses in the here-and-now; while past pain is acknowledged, the focus is how to overcome current obstacles to a successful recovery.

Areas needing elaboration

· How internal phantasy is increased with spirituality.

· Language and solidarity; how do slang, figure of speech and culture specific gestures promote or hinder solidarity affecting emotional attunement?

· Internal phantasy and outer image. How to overcome the enormous and powerful reminders of images related to drug use, i.e. neon lights, prostitution, clubs, nights, back alleys, basements and certain people who stand to continually and visually evoke craving.

· The relationship between shame and rage. Alcohol/drugs as a way of containing rage due to perceived humiliation.

· Is recovery primarily the construction and reconstruction of personal narratives in the form of a language or image or both?

· Image precedes verbal language and is preoedipal; is spirituality in AA/NA perceived by the addicts primarily in the form of an image? Is regression necessary to magical thinking in order to meet the addict at its developmental stage? Is the goal to help the addict transition from magical thinking to maybe mentalization?

The most difficult challenge is how to conduct a study at AA/NA where people are resistant or even hostile to be a subject of study.

Child psychoanalysis

In the past decade the concept of metallization came to be a major contribution to come out of clinical psychoanalysis and seems to affect almost all aspects of clinical work in including grief and mourning. Metallization refers to the child’s capacity to understand what appears to be an objective experience as a personal experience (Seligman, 2007). The child in normal development comes to understand his or her mind apart from other and the child also develops the capacity to appreciate other people have separate minds. Furthermore, the child’s capacity to see itself from the perspective of another and at the same time having the awareness that the other has a separate mind, is a developmental milestone (Seligman, 2007).

A concept that is related to metallization is reflective functioning which is an ability to reflect accurately about one’s thoughts and feelings vis a vis the other. Reflective functioning is important because it helps to make sense of events in the world and also help provide the feelings of safety and security (Seligman, 2007). When the reflective functioning is compromised then the person becomes prone to paranoid projection, idealization and some internal malignancies (Seligman, 2007). Research shows that the capacity for reflective functioning to be crucial for psychological security and the inability to mentalize appears to be at the core of numerous psychological difficulties. Metallization and reflective functioning are psychological insights that emerge in the context of a relationship. The child’s ability to gradually transform from a narcissistic mode of existence to object relations comes as a result of metallization occurring in a secure space.

Social neuroscience and addiction

The long lasting effect of childhood trauma has now been substantiated. The amygdale responsible for fight, flight or freeze response is fully formed at birth suggesting that even children are capable of experiencing high level stress (Dayton, 2005). However, Adam (2004) states that the hippocampus which interprets sensory input and the prefrontal cortex are not fully functional until approximately ages 5 and 11 respectively. Therefore, early assault on the child’s psyche is bound to be interpreted in a very personal way owing to the child’s tendency of egocentricity. Moreover, because the neo cortex is not fully functional before around age 11, the child may suffer a full-blown assault on the psych due to the lack of modulating effect found in the higher brain (Dayton, 2005).

Research shows that on average addicts are raised in a chaotic environment lacking the care and nurturance from primary care giver or the environment compared with the average population. If the primary stressor is found within the family, the child’s sense of self and it’s interpersonal world may be compromised and the child’s ability to interpret threat level and the capacity to regulate and sooth itself may also be diminished (Dayton, 2005).

Psychodynamic perspectives on mourning

The role of mourning in Narcotic Anonymous

The mechanism by which sobriety is achieved in narcotic anonymous may rely on affective hermeneutics. The addict may not be able to reach the affective core to verbalize feelings in a way connecting both the conscious and unconscious apparatus. Rather, the narrative of the addict is first hampered by narcissistic defense as a result of past trauma which interferes with narrative imbued with affective charge. The addict may willingly engage in a seemingly revelatory exercise of narrative sharing purely on a cognitive level disconnected from unconscious processes. Such an addict functioning on a cognitive level is referred by Bucci operating on a symbolic level. The addict whose mode of communication is expressed somatically without the ability to articulate feeling states in a meaningful way is said to operate on a sub symbolic way. Some addicts use image as the best mode of communicating feelings on a symbolic level in distinction from those who verbalize affect. Thus, addicts do not have a uniform way by which they express affect and the mode of expression regarding affect reflect defenses surrounding painful experiences.

Multiple code theory states that all information including emotional information is represented in three major forms; the sub-symbolic nonverbal processing which includes somatic and sensory systems, the symbolic nonverbal system of imagery and the symbolic verbal system of language. These three systems are connected by the referential process which links all types of nonverbal representations to one another and to words. The capacity to express all manner of nonverbal experience, particularly emotional experience, in verbal form has been termed referential activity. In treatment the emotion schemas are important and the goal of treatment is to integrate these systems that have been dissociated.

In narcotic anonymous, any component that is activated has the potential to activate other elements, so that language and imagery may activate traces of sensory or visceral experience or action, or the converse may occur. The new participant in narcotic anonymous may just feel sensation without the ability to express subjective feelings into words. The sub-symbolic system dominated by somatic and sensory feelings is what may be initially activated. The addict may experience all manner of bodily sensations without the capacity for explaining them into words.

Activation is often a function of the interaction with other addicts in a group. The group is responsible in activating the symbolic or sub-symbolic system when sharing personal narratives that the new addict in the group start may identify reflecting one’s own experience. When a negative emotion schema is activated by any of its elements, the affective core and the behavioral response associated with the schema will be aroused. For the addict, the intensity of emotional activation relates to the extent he or she relates to the narrative being shared. What is often aroused in a setting like Narcotic Anonymous is painful emotion emerging from the mourning process. Often, the addict attempts to control or regulate the symbol related to the painful emotion by attacking the objects, images, sounds and words that are linked with the schema. The operation of dissociation or de-symbolization, in which the connection between the sub-symbolic and symbolic components is cut, works as the converse of the process of organizing the schema.

It appears that what occurs at a narcotic anonymous meeting is to activate affect using each person’s personal narrative of mourning as a way to linking the symbolic and sub-symbolic system. The theoretical assumptions is that affect needs to be activated first in order to label and interpret such an experience using spirituality as a referential activity The spiritually based interpretation in this case means an imaginative exercise of ordering one’s internal experience by finding a narrative that is useful for the individual. A successful narrative comprises both sub-symbolic and symbolic system harmonized by a spiritual narrative functioning as a referential activity.

Drive theory and mourning

Freud (1917/1957) described the mourner as one who suffers because of the loss of internal attachment to the deceased person and the goal of mourning is to separate the libidinal investment from the lost object (Baker, 2001). The mourner who has not relinquished the libidinal tie with the deceased may endure suffering. Although Freud’s view is by in large endorsed in psychoanalysis, later psychoanalysts disagreed with his theoretical formulations with regard to mourning. Bowlby (1980) concluded from his extensive research on attachment and loss that many healthy individuals maintain a libidinal tie with the deceased without a pathological effect (Baker, 2001). Increasing research appears to lend credence to the notion that some kind of relationship to the image of the deceased continue to remain with the

mourner. Thus, some researchers support the need to re-conceptualize some of Freud’s views on mourning.

psychodynamic perspectives on addiction

Fundamentally, spirituality has the capacity to transform the addicts from self centeredness to object love. During the process, the influence of the higher power functions as a self- object on the way to achieving object love. Kurtz and Ficher (2002) contend that AA provides a mirroring where members have the chance to influence each other and perceive each other as who they really are. Additionally, idealization of the higher power serves as a source of strength for an addict that strives to incorporate spiritual values in his lifestyle. Morrison (1989) highlighted the detrimental effects of shame or humiliation on an addict by bolstering a narcissistic defense. Thus self centeredness, pride and grandiosity can be directly attributed to a narcissistic defense. Seemingly, these are the core issues that Alcohol Anonymous strives to address during its meetings.

Morrison (1989) maintains that shame has various negative implications on the well-being of a person. In particular, it perpetuates feelings of inferiority alienation, transgression and defeat. It is a major component of the state of addiction and is often experienced interpersonally. However, over time, studies indicate that it can be easily activated by external parties. It is the internalizing process of shame that eventually shapes the identity by spreading throughout a person’s self.

The Feelings of shame is often a very bitter experience that the addict goes through and is often characterized by feelings of inadequacy. Of great reference in this regard is the shameful feeling that culminates from humiliation by other people (Bollas, 1985). The addict usually feels overly exposed and hence becomes self conscious. As a result, the feelings of inefficiency and ultimate inferiority are heightened and the addict feels unable to perform anything. Seemingly, this has the capacity to significantly reduce the productivity of the addict, which is already at stake. In order to counter these feeling, the addict opts for employment of drugs, other addictive substances as well as defective behaviors. Bollas (1985) indicates that the secondary reaction to shame includes fear, rage or distress.

In his study, Lipschizt (1987) states that, the inability to effectively regulate the feelings of shame and rage and other emotions leads to a fragmented self in future. The capacity to effectively control these feelings is a very complex process that involves employment of the inner resources and in ways that are adaptive to the person. The persons that lack adequate inner resources to effectively deal with these feelings are the ones that resort to external objects to function in lieu of what they lack in themselves.

In Narcotic Anonymous, addicts are encouraged to express these feelings freely and slowly and progressively transform the feelings of false pride, grandiosity and inflated ego that are often employed by the addict as a defense to the feelings of shame and inferiority. As such, NA provides a sustainable safety net in the capacity of an effective internal object by providing the necessary holding environment.

Vaillant (2002) indicates that a holding environment is very instrumental in enhancing viable nurturance that then counters the destructive impulses. Management of impulses is important because it enables the addict to incorporate internal object representation. At this juncture, Flores (2004) perceives all forms of addiction as having a sole purpose of misguided self regulation. Further, inadequate psychic structure and lack of self care also affect interpersonal relations. Addiction appears to have a double edge sword in that early deprivation may lead to a vulnerable self prone to addiction or simply erodes the individual’s psychic structure and the capacity for self care with increasing use of substance use even when the individual does not appear to have suffered any early deprivation.

The psychodynamic conception of the drive and the object relations theory is closely linked. Studies show that addiction is a social disorder that is influenced by either the internal drive or object relations. This implies that placing strong emphasis on one theory at the expense of the other can fail to effectively bring out the concept of addiction in the field of psychology. The internal objects are initially generated between the mother and the infant but over time, they are internalized by the infant. The good enough mother is charged with the responsibility of managing the projection of the infant and modifying the object in line with the internalization of the infant. As the psychic structure of the infant develops, it incorporates the functions that were initially only undertaken by the mother. This suggests that the process of nurturance is a lifelong and very important in development.

Mental model

Internal Working Models are a mental representation of repeated interactions of children with significant other as described by Bowlby (1973). The interactions are around meeting attachment needs and emotional regulation. Attachment needs include the maintenance of proximity with the primary caregiver who is nurturing to the child. Thus, the nature of the child’s relationship with the primary caregiver including emotional availability and responsiveness is in effect the building blocks of the Internal Working Model (Fletcher & Clark, 2003). The Internal Working Model refers to self and significant other; the child’s sense of feeling worthy for loving care and the caretakers timely responsiveness as well as emotional availability determines the nature of the working model of the child.

The Internal working model is similar concept to what psychologist call schemas, scripts and prototype (Fletcher & Clark, 2003) . The major difference is that the internal working model is multidimensional and complex. Working models are created in an attachment system reflecting past history of experiences regarding beliefs. Therefore, the beliefs about self and other serve as a template to all future relationships. A good working model is one that accurately reflects social reality as experienced by the child.

Internal Working Model (IWM) is a primarily unconscious process whereby a person’s psychic structure is organized. Internal working model is a mental representation of a relationship starting from infancy (Fletcher & Clark, 2003). Internal Working Model is formed early on as a result of repeated interaction with other people - often the primary care giver. Hence, overtime there is a schema built around emotional memory.