Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

460 V. TREATMENTS FOR ADDICTIONSPSYCHODYNAMIC BASIS FOR PSYCHOTHERAPYOF ADDICTED PATIENTSThere have been a number of major contributions to understanding the psychologyof the addictions, particularly over the past 25 years (Khantzian et al.,2005). The most frequently described function of substance use is the managementof intolerable or overwhelming affects. The idea that certain substancesare preferentially chosen on the basis of their specific ability to address (ameliorate,express) certain affective states is termed the “self-medication hypothesis”(Khantzian, 1985b, 1997). Various authors described connections between certainaffects and the use of alcohol or particular drugs, for example, use of narcoticsto manage rage or loneliness, and use of cocaine and other stimulants tomanage depression, boredom, and emptiness, or to provide a sense of grandeur(Khantzian, 1985b; Milkman & Frosch, 1973; Wurmser, 1974). In a more generalway, Krystal and Raskin (1970) spoke of a “defective stimulus barrier” inaddicts, causing them to be susceptible to flooding with intolerable affectivestates that are traumatic. They described a normal process of affective developmentin which affects are differentiated, desomatized, and verbalized, andpointed to defects in this development in (some) addicted individuals. Thesedefects leave some addicts with the inability to use affects as signals, a criticalcapacity for managing them. Without this signal capacity, drugs may be used toward off affective flooding. Others have noted the quality of addicts’ relatednessto their alcohol or drugs as akin to human object relationships. The chemicalbecomes a substitute for a longed-for or needed figure—one that has omnipotentproperties or is completely controllable and available (Krystal & Raskin,1970; Wieder & Kaplan, 1969; Wurmser, 1974).Related to these views are observations about the narcissistic pathology ofaddicts. Wurmser (1974) described a “narcissistic crisis” in addicts. He notedthat for some addicts, collapse of a grandiose self or of an idealized object providesthe impetus for substance use in an effort to resolve feelings of narcissisticfrustration, shame, and rage. Kohut (1971) also referred to the narcissistic functionof alcohol or drugs in addiction as a replacement for defective psychologicalstructure, particularly that arising from an inadequate idealized self-object.From another perspective, Khantzian (1978, 1995, 1999b) and Khantzianand Mack (1983) described defective self-care functions in addicts—the groupof ego functions involved with anticipation of danger, appropriate modulatedresponse to protect oneself, and sufficient positive self-esteem to care aboutoneself. These defective self-care functions may be seen in many substanceabusers who characteristically place themselves in danger or fail to protect theirhealth and well-being. In turn, this problem may be related to inadequateattention to the protection of the child by his or her parent, resulting in thefailure to internalize self-care functions.