The role of attachment theory in addiction

Abstract

Attachment is a complex set of behavioral adaptation that increases survival of a species by having parents take care of infants in their early and vulnerable years. The infant is provided with “mental representation” which guides the infant in relationship to others and affects regulation. Secure infant are free to explore and attach to others in a manner helpful to meeting their own emotional needs. Infants who have not had healthy attachment, often due to early maternal neglect, are prone to be anxious and may develop later psychopathologies. Anxiety is central to affect disregulation due to lack of early attachment. The propensity of substance abuse may be high in those lacking early maternal attachment. Drug use alleviates anxiety by stimulating similar biochemical mechanisms used in healthy attachment. Oxytocin and vasopressin are biological substrates thought to be involved in attachment.

Introduction

Attachment theory is formulated by John Bowlby and later improved by Mary Ainsworth, an astute and meticulous experimentalist (Panksepp, 1998). Bowlby sought to update Freud’s theory of attachment anchoring it on the science of his day. According to Freudian theory, an infant’s attachment derives from love of sensuous oral gratification. Bowlby thought that feeding habit did not adequately explained attachment of an infant to the mother. Attachment in his new understanding was tied more to biology where the growth of brain occurs in critical periods and stages influenced by the environment. The social environment changes over the stages of infancy and induces the reorganization of brain structure.

This new reformulation of attachment is a radical departure from psychoanalytic thinking since it ascribes profound influence mothers’ have over their infants’ behavior, in contrast to psychoanalysis, where internal psychic structure of the infant only determines the level of attachment Thus, this new theory of attachment is less psychically determined compared to psychoanalysis because it takes environmental influence into consideration. However, it should be noted that the influence the mother holds on her infant was appreciated by later school of psychoanalysts, especially object relation theorist, who diverged from classical Freudians. This paper will explore the neurobiology of attachment especially as it relates to drug addiction. The neuropeptides oxytocin and vasopressin have long been implicated in attachment and will also be reviewed in the paper.

I am interested in studying drug addiction in relation to attachment theory. My interest grew out of my work as a therapist where most of the clients I see are addicted to drugs. Since there is a great deal of time and money spent going through the ritual of acquiring drugs and using drugs, I started to think of addiction as a form of attachment or bonding. The addict is soothed and gratified by taking a substance knowing perfectly well that in the long run this behavior is often met with detrimental end. Hence, my hypothesis is that those who have not been able to attach as infants’ to their caregiver may be prone to addiction since the preferred substance used takes place as a “surrogate mother” offering a semblance of love and security to the addict.

Neurobiological Basis of Attachment

An infant’s attachment to a caregiver results in innumerable befits as a result of optimal adaptation to an environment. Hence, insecure-attachment may have clinical relevance since psychopathology is often an inability to form proper attachment and bonding. Maturation occurs as a result of timed neurodevelopment processes with an intricately coordinated series of contacts between the maternal-social environments (Panksepp, 1998). Hence, the caregiver plays a pivotal role in responding to the need of the infant with careful mediating functions such as soothing, validating, conforming and stimulating – sequential interventions necessary for neural development.

Infancy is an important period of neuronal development and the development is affected not only by internal biological factors but also social mediation. Therefore, the fact that the infant is born with the potential for wiring with outside environmental stimulation is a testament for appreciating the gene-environment interaction. However, this does not necessarily mean that the infant is born, as it were, with a “clean slate”; rather, the infant is born with some pre-wired connections and other postnatal neural connection to occur at later critical stages of neurodevelopment. It is important that postnatal neural connections occur, among other things, from environmental input with appropriate environmental stimuli at appropriate stage of development to determine attachment.

Literature Review

Numerous studies have been conducted to determine the chemistry of pair bonding in animal model. Insel (1997) reviews experiments using voles to study the effect of oxytocin and vasopressin on pair bond formation. Prairie voles were selected because of highly developed social behavior observed in the field and also because they showed similar affiliative response in the laboratory. Prairie voles are also monogamous. In comparison, montane voles of related specie, sharing similar nonsocial behavior with the paiere voles, nonetheless were observed showing little social contact and not having been monogamous.

To test partner preference, researchers placed three cages attached to each other with openings on the side of the cages for a female vole to roam around. The female was placed in the middle cage while two male voles were tethered in their respective cages. The purpose of this experiment is to observe if the female vole would spend time alone or, with her original partner or, a novel stranger. The female was placed in the cage for 24-hours. In a 3-hour preference test, parier voles spent more time in partner’s cage. A similar experiment with a montane vole demonstrated that the female vole spent more time in her cage without any preference to either of the two males.

Continuing the partner preference test, females were separated from their mates for 7 days and were placed in the cage with access to the male cage. As a pretest an intruder was also placed inside the cage of the experimental male. Following 24-hour mating, the experimental male receives yet another intruder male placed in his cage. In the highly affilitive parier vole, aggression was minimal before mating but increased 40-folds within 24 hours and the increase was sustained for several months. In contrast, the same experiment with the montane vole did not show an increase in aggression toward the intruder male.

The experiment Insel (1997) reviews in A Neurobiological Basis of Attachment is elegant but does not prove that oxytocin and vasopressin are attachment neuropeptides per se. For instance, finding ways to index the neuropeptides using whole blood analysis or measuring metabolites of oxytocin and vasopressin in CSF would help in comparing neuropeptide levels (Mofitt, et. al, 1998). For instance, it is an important finding if measured oxytocin correlates with high level of pair bonding across species to determine if oxytocin is a robust indicator for attachment.

Previous behavioral studies have assessed the degree of serotonergic activity in response to a fenfluramine challenge. Brain serotonin and aggression are the best-correlated studies to date. In the study researchers infused serotonin agonist fenflurimine into subjects veins and the fenflurimine would bind to receptors in the hypothalamus and cause the release of the hormone prolactin from the pituitary gland into circulation (Pine et. Al, 1997). This study has shown inverse relationship between fenflurimine induced prolactin and behavioral aggression. Thus, if oxytocin or vasopressin is found to be related to attachment like serotonin and aggressive behavior, then the finding would be considered robust.

Whole blood serotonin rates have been related to violent behavior in men but not in women (Moffitt, et al 1998). The hormone oxytocin has been associated in several medical conditions and can easily be measured in a specific enzyme immunoassay (EIA) ( Alfven, 2004 ). Since it is my hope to demonstrate an association with either oxytocin or Vasopressin and how these neurochemicals relate to attachment in the prairie vole population, it is helpful that there is also a test in which oxytocin EIA can be performed on microtitre plates coated with a rabbit polyclonal antibody which does not significantly cross react with vasopressin.

Assays such as the one available for oxytocin are also available for vasopressin in which a polyclonal antibody to vasopressin is used to competitively bind and demonstrate, in an inversely proportional manner, the concentration of vasopressin in the sample. A variable in this project may be that rodents and humans both release vasopressin in response to physical and emotional stress, and therefore the degree of stress of the sampling on the final numbers must be integrated into the study methodology. .

By observing prairie vole populations for issues of attachment within different animal models, and subsequently measuring for levels of both oxytocin and vasopressin, it is my hope that I will be able to correlate which neurochemical is more closely associated with stronger or lesser attachment on a statistically significant basis. This research then will be a precursor for the study of the neurochemical basis of attachment in human beings.

Preference for a certain original male for mating may not be an entirely accurate measurement for attachment. For instance, the female montain vole does not appear to have a particular preference for the two males she has access to in an experimental setting. It may be the case that she can form attachment to either male but chooses to spend more time in her cage to avoid inciting aggression in a closed perimeter where she can also become a victim. In other words, oxytocin level may have little in the way the montain vole expresses an attachment behavior since behavior is a function of an evolutionarily adaptive strategy.

Perhaps the study would have been more reveling on attachment if it also included mother-infant voles. A montain vole that shows no preference for male in the experimental setting may show preference to her infant compare to a male vole or even of another infant of a different mother. Hence, unlike the prairie vole, attachment may be limited between a mother and an infant in montane vole.

Neuropeptide level may also fluctuate for a reason. Thus, quality of attachment may vary across species because of different evolutionary adaptive functions. For instance the prairie and mountain voles differ in bonding preference because monogamous relationship in the parier vole may decrease aggression thus maximizing survival by cooperative child rearing. Whereas the montain vole had to adapt in an environment that polygamous mating behavior is a successful mating strategy for increasing survival of the specie.

Bales & Carter (2003) investigated postnatal oxytocin by manipulating neonatal parieri vole male. In the experiment neonatal vole males received either an injection of Oxytocin (OT), and injection of Oxytocin antagonist (OTA), Saline or just handling. These male voles were tested for partner preference as adults after 1-hour cohabitation with a nonestrous female.

The researchers report in their result, with the exception of those voles treated with saline, they did not find a significant difference in social contact with the rest of the experimental group. However, when they studied side-to-side contact in minutes, voles injected with OT were found to have preference for a familiar female vole than a stranger during a 3-hour test. There may be at least two explanations for the observed phenomenon. The male vole may have a better chance copulating with the familiar female than a stranger since the male vole has had prior contact and presumably had invested courtship time; or the female may recognize the scent of the male and as a result emit pheromones to attract the male vole to come to her. Thus, in this scenario the role of oxytocin may be incidental.

An experiment with two familiar voles to a particular male may shed light to the question of partner preference vis a vie oxytocin. What would be the male preference of two familiar females where one of the female had social relations and the other sexual relations with the male vole? If the preference is strongly inclined to the female with past copulation history, then oxytocin may be suspected to have a role specific to sexual pair bond formation as supposed to familiarity or kinship pair bond formation.

The handled group also showed a similar preference, (but statistically nonsignificant) for familiar female partner. However, there are a number of issues to consider in this research. For instance, despite injecting a group of male voles with oxytocin antagonist, there social contacts were not different from the group of voles injected with oxytocin. Had the OTA group been social isolates, the role oxytocin plays in pair bond formation would have been significant. However, the social contact of the OTA group is just as extensive as those with OT injection. This experimental observation suggests that there maybe other mechanisms for pair pond formation in addition to oxytocin.

One way of studying the role Oxytocin plays in pair bond formation is by having two separate groups of pairer voles, one experimental group having numerous parair voles interacting in a social setting and, another group of voles isolated individually for a period of time. Then, compare oxytocin level between these two groups. Then reverse the experiment where the socially interacting voles are removed and placed in isolation. And those isolated are placed in a social setting. Again, measure the oxytocin level to determine differences on oxytocin level.

If the result is high oxytocin level with high pair bonding and low oxytocin level with low pair bonding, and if the result is statistically significant; then oxytocin level maybe said to correlate with pair bonding for that particular specie under study. If the result can be replicated with other species, oxytocin maybe sine qua non attachment neuropeptide. It is probably the case that since behavior is a complex social sand biological phenomenon, the underlying biological substrates may also be complex.

An important experiment may also involve placing a newborn parier vole in isolation for a period of time and compare the level of oxytocin between the isolated prairie voles with a controlled praier infant vole nurtured by its mother. If oxytocin is involved in attachment and pair bond formation, what is the effect on attachment removing an infant parier vole at critical stages of growth? Can the infant parier vole resume healthy attachment if joined back with the mother? Are there differences in the level or quality of attachment depending on, when, or how long, a parier infant vole is isolated (separated) from the caregiver or from the community parir voles?

There may be confounding factors such as fluctuating oxytocin level due to circadian rhythm, fluctuating oxytocin during, for instance, mating season or after having given birth. Oxytocin level might also be affected by stress, unfamiliar social environment, and lack of movement, all of which are difficult to control in an experimental setting. Could it be that attachment or pair bonding has different mechanisms in male and female. A male parier vole may be monogamous because of high level of testosterone whereby monogamy allows continual access to a certain female. Thus, oxytocin maybe correlated with testosterone or testosterone may affect the level of oxytocin. Thus, testosterone may also be important is determining in pair bonding.

Addiction and Attachment

Bonding is a dialectical experience whereby shared needs are best met between two people, initially between a caregiver and an infant. As the infant grows, attachment to the father and siblings also become pronounced and later, attachment would include peers and other people as well. The binary response of gratification and distress of an infant would give way to complex interaction over time. It is in the context of attachment that the infant then, the child learns to mediate the whole gamut of affective response.

Human survival very much follows a utilitarian philosophy of minimizing pain and maximizing pleasure. Thus, early childhood emotional neglect or abuse may cause the person as a teenager or as an adult problems forming healthy attachment. Inability to attach is manifested by numerous failures and hardship an addict encounters over time. To live a successful life the addict would have to abide by the rules of the society and help stave off ostracism and punishment for using drugs. For the addict inability to attach means inability to calm or soothes himself under stress. Inability to attach is an inability to self-regulate emotion learned in early infancy. Thus, the addict would resort to drugs as a way of soothing self from uncomfortable feelings even when the larger society highly disapproves of such behavior.

A drug is an inanimate substance and does not interact with the addict the same way a mother interacts with her infant, even though, the addict is also attached to the drug. Healthy attachment has to be interactive with another person. Thus, the addict’s attachment is that of an inferior kind or, at best artificial.

Anxiety plays a pivotal role in lack of attachment. Children whose parents do not consistently respond to their signals and emotional needs may lead to distrust that others will be there for them; as a result of this mistrust, some children may isolate themselves while others become extremely dependent.

Attachment theory does not conclusively explain drug addiction. It is at best a working hypothesis, which requires a great deal of research in this area. Sociological reasons for addiction vis a vie environmental influence and access to drugs poses a serious challenge in distilling addictive behavior best explained just by attachment theory. Moreover, individual variability in terms of affect tolerance and affect discharge may also play a role regardless of psychosocial factors.

The most notable way of measuring attachment is using Adult Attachment Interview. The premise in this psychological instrument is to assess adult’s internal working. During the interview parents are asked to describe and evaluate their childhood memories of attachment experiences and important relationships. The instrument is thought to be valid because studies had shown that attachment is highly stable over the first two years of life (Owen, et al, 1984).

The shortcoming of the assumption is that attachment is stable over the first two years of life and the fact that attachment stability has been standardized observing infants in a middle class environment. It is conceivable that environmental factors such as divorce in the family or the birth of other siblings may affect attachment behavior. In addition, this instrument needs to be tested in longitudinal studies of not only infants born in different social classes, but also in different cultures. The varying cultural practices of child rearing may affect attachment styles. Hence, the instrument may only be valid at best to a middle class family.

Conclusion

There maybe a sound evolutionary reason for attachment as an optimal survival mechanism. In order to have emotional and physical needs met, an individual would need to be able to reciprocate in kind. These are subtle negotiations that have been perfected over an animals’ evolutionary history since cooperative behavior increases the chance of survival and continuation of a species. It is in the context of attachment to another person first, and to other people later, that an individual learns moral proscriptions of the tribe. An individual also learns suitable methods of affect regulation such as shame and aggression. What is morally sanctioned behavior are often attributes that the tribe finds desirable because it helps to protect the integrity of the tribe as a group. In evolutionary terms, behaviors that may compromise the integrity of the tribe, i.e. maladaptive for survival, brings forth certain punishment to the rule- breaker. Adaptive behaviors are passed on over the generation as part of the cultural milieu.

Attachment theory makes strong argument for the important role relationship in infancy and childhood has in later life. This makes sense because during infancy and childhood neural connections are made much faster and the brain seems to have greater plasticity. However, there are situations where early neglect has not made a negative impact on a person judging from observable maladaptive behavior. Not all infants who lacked early attachment suffer from psychopathologies.

Individual variability also plays a role on how much infants seek or need attachment. There are also degrees to attachment. For instance, what is the minimum level of attachment needed to prevent the propensity for drug abuse? Attachment is definitely needed for proper growth and adaptation, but can attachment be quantified? Do all infant need the same level of attachment? It is not very likely that attachment, as a complex behavior would be explained entirely by oxytocin. Attachment behavior is probably a result of environmental, biological and sociological factors.

Bibliography

Alven, Gosta. (2004) Plasma Oxytocin in children with recurrent abdominal pain. Journal of Pediatric Gastroenterology & Nutrition. 38(5):513-517, May 2004.

Bales, K. L. & Carter, C. S. (2003). Developmental Exposure to Oxytocin Facilitates Partner Preferences In Male Prairie Voles. Behavioral Neuroscience, 4: 854-859.

Insel, T. R. (1997). A Neurobiological Basis of Social Attachment. American Journal of Psychiatry, 154: 726-735.

Moffitt, E. T., Brammer, G. L., Caspi, A., Fawcett, J. P., Raleigh, M., Yuwiler, A., & Silva, P. (1998). Society of Biological Psychiatry, 43: 446-457.

Owen, M. T., Easterbrooks, M.A., Chase, L., & Goldberg, W.A. (1984). The relation between maternal employment status and the stability of attachment to mother and father. Child Development, 55, 1894-1901.

Panksepp, J. (1998). Affective Neuroscience. Oxford University Press, NY.

Pine, D.S., J.D. Coplan, et al (1997). Neuroendocrine response to fenfluramine challenge in boys. Archives of General Psychiatry 54: 839-846

Neuroscience perspective on addiction

- Multiple Code Theory

Multiple Code Theory is a psychoanalytic model of mental states that attempts to reconcile current cognitive neuroscience of information processing system with psychoanalysis (Bucci, 1997). Multiple Code Theory posits three major domains of how emotion can be processed. The symbolic system refers to an image or language. Symbols are used in semiotic sense to refer to something outside of itself. Language or image can be combined to generate infinite varieties of words or images. In the symbolic system language is presented in chunks thus its meaning can be discriminated since words are combined in many different ways to generate endless varieties of phrases. Similarly, images can also be combined to generate more complex images. Image is different from language in that auditory, olfactory or tactual modalities are employed. The symbolic system operates in the sphere of the conscious (p.174).

In contrast, the Subsymbolic system processes information in a continuous manner where information is assessed for patterns or similarities and not for discreet categorized chunks. Thus, the information in the subsymbolic system tends to be intuitive, and not well suited to be fully captured in language alone. Somatic states are primarily communicated via the subsymbolic system. The subsymbolic system mode of operation is primarily in the unconscious (p.175).

Furthermore, Multiple Code theory states that the Referential process connects the three domains; an image is especially strong in its connection potential. Image maybe connected to the subsymbolic process using its discreet and generative nature of its feature (p.178). In Multiple Code Theory, emotion schema refers to how a person is affected by interacting with other people. The term schema is meant to convey the active nature of memory and perception. Emotion schema is a type of memory formed through repeated interaction with others. Hence, repeated interaction with others, personal desires or fantasy and the response from the environment contribute the formation of emotion schema. Emotion schema is thought to transverse the domains of the symbolic and subsymbolic systems (p.195).

Emotion schema is closely associated with the Affective core that includes the bodily, sensory, visceral and motoric modes of response. Therefore, the activation of the emotion schema leads to the activation of the affective core. A person’s emotion schema can be activated in an interpersonal context and by an image or fantasy. However, it is an image that has a strong valence for activating emotion schema. For instance, a fear schema activates the affective core resulting in increased breathing, flight and change in homeostatic balance induced by an emotional factor (p.201).

Emotion schema follows a normal trajectory in development. In empathic environment, the child is able sooth itself to modulate the activation of an affective core and utilize the incorporated parental representation for comfort, safety and self-regulation. However, repeated fear schema in non-validating environment, the child’s capacity to modulate fear through the incorporation of parental representation is diminished and the result is the child’s capacity for self-care and soothing maybe compromised.

As mentioned before, the emotion schema cuts through the three domains of information processing systems. However, the emotion schema maybe disconnected from each domain due to trauma in the form of dissociation. A child may use the mechanism of dissociation in an environment of abuse from a caretaker.

The pain associated with dissociation is the result of an attempt to repair such an overwhelming affect without knowing the source of the distress. The various attempts to repair distressful affect using somatization, addiction and even psychosis are efforts to manage activated arousal level. In an effort to diminish activated affective core, the person may resort to such things like addiction which may introduce yet another level of complexity in the layer of existing pathology (p.203).

Emotion schema is anchored on contemporary neuroscience understanding. LeDoux (1998) maintains that stimulus in the brain may pass through the direct route (low road) or the cortical loop (high road). In the direct route, fear stimulus, for instance, travel the sensory thalamus through the triggering site of the amygdala and the prefrontal cortex to the emotion execution sites. The direct route initiates automatic or instinctual response of fight or freeze. The cascade of fear based information trigger motoric, visceral and somatic response (affective core) to affect changes in breathing rate, blood pressure, body chemistry as well as register changes in hand movement, vocalization and expressive functions in the face,

Fear stimulus traveling the cortical loop passes through the thalamus but bypass through the cortical association and hippocampus. This particular venue allows information to be modulated, evaluated, regulated, delayed or redirected immediate affective response. The cortical loop using the hyppocampal and related systems represent stimulus in episodic memory, which is oriented in time and space, as opposed to a general or semantic memory. Therefore, the episodic memory oriented in space and time can be processed in multiple channels including, visceral and actions (p.164) However, when the hyppocampal and related systems are compromised due to high stress, it interferes with the registration and retrieval of episodic memory such as patients with Post Traumatic Stress Disorder. Patients diagnosed with PTSD fail to remember specific source of information like a person involved, or a place or event about the trauma; their knowledge is based on narratives lacking context and detail. It should be noted, however, moderate level of stress actually enhances episodic memory (Bucci, 1997)

The referential process connects the three domains partially or to varying degrees. Therefore, therapeutic change in multiple code theory functions to transform emotion in such a way that it is integrated functionally with both symbolic and subsymbolic system (p.215).

Multiple Code Theory may elucidate the mechanisms necessary for a recovery in Narcotic Anonymous. Emotion schema activation is often precipitated by the interaction with other addicts. Interaction in the group helps to activate the affective core when individuals share personal stories. The level of activation seems to be a function of how an addict’s personal experience may resonate with others. Often painful emotion is activated at NA in the emerging mourning process.

It appears that what occurs at NA meeting is to activate affective core using each other’s personal narratives as a way of linking the symbolic and subsymbolic processes in the process of mourning. The assumption is that affect needs to be repeatedly activated in order to process and interpret painful feelings using spirituality as a referential activity. The spiritually based interpretation is an imaginative exercise of symbolizing the addict’s internal experience. Referential activity refers to the symbolizing effort of subsymbolic processes. Spirituality may help the budding symbolization effort primarily by creating a safe space in the form of acceptance and encouragement of the addict, to allow a gradual expression of affect. Subsymbolic experience may then be expressed in the form of memories, fantasies or images. Repeated attempts to symbolize help strengthen and elaborate memories, fantasies or images to the verbal system. Once these symbols become sufficiently strong, they can be discerned enough to be labeled by the addict. The addict may then verbalize feeling shamed or angered. Hence, spirituality may help in the symbolizing effort first and also helps to contextualize what is symbolized in the reflection phase. Thus, the most important function of spirituality is as a referential process perhaps in allowing the addict to find a suitable and adaptive narrative for the evoked feelings. Of course, the narrative itself is dynamic and is continually being constructed or reconstructed to reflect current needs of the addict.

sociological perspective on addiction

Addition recovery is a difficult and resource-intensive process for addicts and recovery workers alike. Addictive behaviors, especially those resulting from psychoactive substances, are “one of the most intractable therapeutic problems” (Zafiridis, 2001; 22). Addicts who require recovery services typically manifest emotional, psychological, and physiological needs. Recovery workers who assist addicts in the recovery process strive to develop recovery strategies that meet these needs in a manner that reduces stress and promotes equilibrium, as the goal of recovery is to help patients recognize the influences of addiction and give them the tools necessary to overcome them. Unfortunately, research on recovery services suggests that these are often ineffective, as former patients experience a high rate of recidivism and relapse back to established behaviors, often resuming the same habits that led them to addiction.

Recent research has been done on the effects of spirituality in treating addiction. Chen (2006) explored the personal and emotional status of inmates with a history of addictive behaviors and who had received recovery treatment supplemented with an emphasis on spirituality. The inmates who participated in this program demonstrated “a higher sense of coherence and meaning in life and a gradual reduction in the intensity of negative emotions (anxiety, depression, and hostility)” than those inmates who did not participate (p. 306). Similarly, Arnold et al. (2002) found that addicts who participated in an opiate recovery program and who were encouraged to develop their spiritual backgrounds as part of the program improved their hopefulness and their willingness to continue ongoing recovery work. These and other studies suggest a correlation between spirituality and an addict’s improved chances to not only complete a recovery program but to preserve the message of the program and resist recidivism.

Additional research is required to clarify the influence of spirituality in addiction recovery programs. The proposed research study is designed to isolate the effects of spirituality on persons working to overcome addiction in a local Narcotics Anonymous program. The selection of Narcotics Anonymous (NA) was done on the basis of a strong spiritual theme that is found in the program. However, NA emphasizes that addicts develop a “triangle of self-obsession” towards their addiction, and through moving past their anger the addict can recognize that they have lost their emotional, psychological, and physiological connection to the addictive substance of their choice. The benefits of this self-obsession are questioned in the literature, as is the influence of spirituality throughout the program. The proposed research study strives to identify how the spiritual component of NA affects addicts and influences the outcome of their participations. A qualitative case study of 15 persons participating in a local Narcotics Anonymous program will be conducted to identify how spirituality may serve in helping to construct an integrated self as measured by Referential activity.

Background

In the original handbook issued by Narcotics Anonymous World Services (1983) it was argued that the single greatest challenge for addicts was to overcome the emotional, psychological, and physiological dependence that addictive substances create in addicts. The addict tends to demonstrate childish tendencies, especially those that represent “the self-centeredness of the child” (p. 1). Addicts cannot break from challenges that reduce their sense of importance, and:

We never seem to find the self-sufficiency that others do. We continue to depend on the world around us and refuse to accept that we will not be given everything. We become self-obsessed; our wants and needs become demands. We reach a point where contentment and fulfillment are impossible. People, places, and things cannot possibly fill the emptiness inside of us, and we react to them with resentment, anger, and fear (p. 1).

According to the handbook, addicts who are overwhelmed by these negative emotions cannot break away from them without help. Indeed, they are looking for help; the addict turns to substance abuse because he wants to feel good about himself and the illusion of power and stability attained through drugs and alcohol is the closest he can come to achieving this elusive goal. Serious problems emerge when the addict can no longer obtain the feelings he craves and has to increase both the amount of substances he requires and the frequency of intake. As time progresses, it becomes more difficult to sustain the illusion of power and stability, and the addict finds that the negative emotions that he is working to suppress begin to dominate his life.

In the NA philosophy, addicts who enter the recovery program find themselves caught between these negative emotions and their dependence on addictive substances. These two separate influences combine and these further reduce the addicts’ internal equilibrium, as “resentment, anger, and fear make up the triangle of self-obsession. All of our defects of character are forms of these three reactions. Self-obsession is at the heart of our insanity” (p. 1). When these three reactions combine, the outcome can be devastating:

Resentment is the way most of us react to our past. It is the reliving of past experiences, again and again in our minds. Anger is the way most of us deal with the present. It is our reaction to and denial of reality. Fear is what we feel when we think about the future. It is our response to the unknown; a fantasy in reverse. All three of these things are expressions of our self-obsession. They are the way that we react when people, places, and things (past, present, and future) do not live up to our demands (p. 1).

The NA philosophy refers to addicts and how addicts differ from developed persons who demonstrate a stable emotional, psychological, and physiological equilibrium. To overcome these negative emotions and eliminate self-obsession, NA emphasizes the transition between an addict’s past life, the present, and opportunities found in the future:

In Narcotics Anonymous, we are given a new way of life and a new set of tools. These are the Twelve Steps, and we work them to the best of our ability. If we stay clean, and can learn to practice these principles in all our affairs, a miracle happens. We find freedom – from drugs, from our addiction, and from our self-obsession. Resentment is replaced with acceptance; anger is replaced with love; and fear is replaced with faith” (p. 1).

The scientific literature on Narcotics Anonymous, as with its sister program, Alcoholics Anonymous (AA), shows that researchers have challenged these principles on the grounds that recovery programs that rely on spirituality and religious faith are unlikely to succeed (Goldfarb et al, 1996). There are multiple reasons cited for failure, such as lack of medical care (Goldfarb et al, 1996), emphasis on an unseen spiritual connection instead of a tangible relationship developed with a significant relationship, and the need for the addict to rely on spirituality throughout all stages of treatment and recovery and accepting that their failures are their own (Goldfarb et al, 1996; Zafiridis, 2001). Goldfarb et al. (1996) studied the relationship between spirituality and addiction recovery and found that programs such as Narcotics Anonymous failed to emphasize the medical requirements of recovering drug addicts. The researchers hypothesized that the failure of these programs could be attributed to a lack of medical attention during critical periods, such as in withdrawal when opiates were gradually processed by the body and caused significant physical pain. It has been argued that the theoretical basis for NA and AA is fallacious, and that the programs constructed on this background fail to consider the causes of addiction as the “inadequacy of the therapeutic programs known today becomes even more obvious when the therapeutic approach aims at: a) complete abstinence from all legal or illegal substances, b) vocational rehabilitation and, c) termination of illegal activity” (Zafiridis, 2001; 22). These procedures fail to address the causes of addiction or the lifestyle choices made by addicts, and propose reform strategies that force addicts to sever all past connections and to rebuild themselves anew, effectively devaluing their past and their personalities.

While researchers have historically challenged the theoretical foundation of self-help programs such as AA and NA, one of the foremost arguments in favor of these programs is that persons who participate in these programs demonstrate the desire to overcome addiction. Zafiridis (2001) noted that “participation in such groups requires positive motivation that a significant percentage of addicts don’t maintain” and that addicts who demonstrate willingness to make positive change differentiate themselves from those addicts who have accepted their condition (p. 23). Indeed, a central tenant of the AA and NA philosophies is that admitting that a problem exists is the first step towards recovery. Yet researchers have historically emphasized that a second tenant of the program, faith in a higher power, is incompatible with the idea of self-help as it removes personal responsibility from the equation (Zafridis, 2001; Brown et al, 2002).

Recent literature provides evidence that there might be other ways of exploring the Narcotics Anonymous and Alcoholics Anonymous programs. In a research study conducted by Chen (2006), a comparison between NA programs demonstrated that those programs that incorporated spirituality were more likely to have a positive influence on addicts than the NA programs that did not have a spiritual component. The focus of Chen’s research was the “12 Step” strategy that has long been used as an optional component of both NA and AA rehabilitation program. Avants, Beitel, and Margolin (2005) found that recovery programs that incorporate a “spiritual self-schema” that help addicts imagine themselves as they would like to be helps cultivate feelings of self-reliance and reduces the likelihood that addicts will engage in high-risk behaviors. Brown et al. (2002) suggested that the success of these programs could be attributed to format, particularly the requirement that all participants attend meetings on a frequent and regular basis.

Significance of the Problem

Substance addiction in the United States is a significant problem. In the most recent data released by the Bureau of Justice Statistics (2009), it was found that “114 million Americans age 12 or older (46% of the population) reported illicit drug use at least once in their lifetime” (para 16). Additionally, “14% reported use of a drug within the past year” and “8% reported use of a drug within the past month” (para 16). Substance abuse causes serious consequences for addicts, their families, and their communities, and creates socio-economic, political, and economic repercussions. For example, in 2006 it was estimated that “that 1.7 million emergency visits (ED) were nationwide were associated with drug misuse or abuse” (Bureau of Justice Statistics, 2009; para 18). Of these visits, cocaine is the drug most likely to put the user at risk, as:

• Cocaine was involved in 548,608 ED visits.
• Marijuana was involved in 290,563 ED visits.
• Heroin was involved in 189,780 ED visits.
• Stimulants, including amphetamines and methamphetamine, were involved in 107,575 ED visits.
• Other illicit drugs, such as PCP, Ecstacy, and GHB, were much less frequent than any of the above (Bureau of Justice Statistics, 2009; para 19).

The physiological effects of cocaine are severe and place abnormal stress on the body through acting as a nervous system stimulant. Crack cocaine exacerbates these health hazards and creates additional threats for the user as “Evidence suggests that users who smoke or inject cocaine may be at even greater risk of causing harm to themselves than those who snort the substance. For example, cocaine smokers also suffer from acute respiratory problems including coughing, shortness of breath, and severe chest pains with lung trauma and bleeding” (Office of National Drug Control Policy, 2009; para 14). Additionally, “a user who injects cocaine is at risk of transmitting or acquiring diseases if needles or other injection equipment are shared” (Office of National Drug Control Policy, 2009; para 14). The risk of addiction with crack cocaine is high, and dependency on the drug is quick to develop.

Research indicates that minorities are more likely to suffer the negative effects of crack cocaine use than are whites; not only is crack cocaine more likely to be available in minority communities, the economic conditions found therein are conducive to the creation of cocaine-centered economies (Fryer et al, 2006). In a cocaine-centered economy, residents are affected by conditions in which education and job opportunities are limited, which fosters dependence on substance abuse. Professionals in the drug trade are likely to be the wealthiest persons in such communities and hold influence over the other community members (Fryer et al, 2006). In such communities, addiction is pervasive and, while not accepted, is generally tolerated as a fact of life. Rehabilitation programs designed to help these persons are likely to face resistance from some community members and be perceived as an intrusion (Fryer et al, 2006). Religion and spirituality have long played an important role among minorities, especially in African-American communities (Brome et al, 2000; Arnold et al, 2002; Hill et al, 2003). Researchers who explore the relationship between spirituality and substance abuse programs have found that incorporating spirituality into these programs has had positive effects among African-American drug addicts (Brome et al, 2000; Hill et al, 2003; Fowler et al, 2004). The significance of religion and spirituality as a component of recovery among African-American former drug addicts has caused some researchers to perceive spirituality and religion as “culturally relevant” tools that can promote therapy and recovery (Fowler et al, 2004; 1267). Other researchers have defined spirituality and religion in the context of the therapy process for African-American addicts as “an essential aspect of psychiatric care” (Carter, 2002; 372). It is possible that spirituality can be beneficial to members of other racial, cultural, and ethnic backgrounds, but this area of inquiry has not been explored to the same extent as that of African-Americans. Additionally, the receptiveness of different racial, cultural, and ethnic groups to spiritual and religious therapy suggests that certain groups are more likely to resist spiritual therapies and be more receptive to psychological or psycho-social therapies (Carter, 2002). However, the extent of these disparities remains unknown.

Purpose of the Study

The purpose of the study is to explore the effects of a Narcotics Anonymous program that utilizes the 12-step program and encourages participants to explore the negative emotions of resentment, anger, and fear and determine how spiritual practice may help in processing these emotions in such a way that purpose and meaning can be derived from the experience. A governing principle of the 12-step program is that an addict must put his or her faith in a higher power to make effective personal change. The effectiveness of the 12-step program can be improved if its influence on addicts is explored and the theoretical background of the program isolated. Outcomes of the research can be applied to future addiction recovery programs where addicts from different backgrounds can receive therapy that reflects their personality and socio-cultural background. Tailoring the nature of therapy to the participant’s personality might improve the effectiveness of the therapy and reduce recidivism.

Problem Statement

The problem statement that governs the study is stated as follows:

Past research suggests that religion and spirituality can increase the effectiveness of drug rehabilitation programs and reduce recidivism among addicts, but it is not known whether the emphasis on resentment, anger, and fear as endorsed by Narcotics Anonymous should be classified as a component of spiritual rehabilitation.

Research Questions

The following research questions are used to direct the study:

R1: How does the 12-Step program as described by Narcotics Anonymous affect drug users?

R2: How is the concept of a Higher Power being used, what function is it serving in the various phases of the referential process?

R3: How does spirituality influence the stages of recovery?

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.