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

21. Individual Psychodynamic Psychotherapy 461In addition to this ego deficit psychology, several investigators describeda generally defective capacity to be aware of affective states in certainaddicts. Some addicts appear to be “alexithymic,” that is, unable to name ordescribe emotions in words. Krystal (1982) described substance use in some ofthese patients as a search for an external agent to soothe them, associatedwith their lack of sense of ability to soothe themselves. McDougall (1984)described patients whose use of words and ideas is without affective meaning,and who use alcohol or drugs to disperse emotional arousal and thus avoidaffective flooding. Although the final appearance of this affective intolerancehas the quality of an ego deficit, its underlying basis is understood to be adefensive avoidance of intolerable feelings. Krystal (1982) described thisdefense as arising secondary to psychological trauma in either childhood oradult life.Khantzian (1999a) wrote about the preverbal origins of distress foundamong some substance abusers. He described a case in which early experiencethat remained out of conscious awareness created a nameless pain that recurredin response to a current stimulus (a film), leading to an alcoholic relapse. Ofequal importance, when the early experience of abandonment again recurred inthe setting of a group therapy, it could be clearly interpreted, understood, andborne rather than managed through substance abuse. Along similar lines,Walant (1995) stressed infantile origins of problems with interpersonal contactand interdependence that could predispose to addictive adaptations. Alongsimilar lines, more recently, Flores (2004) has elaborated on addictions as anattachment disorder for some patients.Finally, addiction may play a central role in seeking restoration of innercontrol of one’s affective state (Dodes, 1990, 1996, 2002). This need for controlin addicts involves a narcissistic vulnerability to being traumatized by the experienceof helplessness or powerlessness. The use of substances is seen as a way tocorrect the experience of helplessness; that is, by taking an action (using alcoholor drugs) that can alter their internal affective state, addicts may reassertthe power to control their inner experience, undoing and reversing the feelingof powerlessness. Because a sense of control of inner experience is a centralaspect of narcissism, the intense aggressive drive to achieve this control when itis felt to be threatened may appropriately be considered narcissistic rage.According to this view, narcissistic rage arising from feelings of powerlessnessgives addiction its most defining characteristics, namely, its insistent, compulsive,unrelenting quality and its relative unresponsiveness to realistic factors.This also offers an explanation for why, like narcissistic rage in general, theaddictive drive may well overwhelm other aspects of the personality (Dodes,1990).More recently, Dodes (1996) expanded this view to place addictions withinthe category of those psychological problems currently and historically