Commentary on “Understanding Addictive Vulnerability”

Psychodynamics or neuro-psychoanalysis?

Dr. Khantzian has done a masterful job of summarizing the psychodynamic literature on addiction. Khantzian states, “With some notable exception, it is surprising and unfortunate that since the 1970s there have been so few contributions from psychoanalysts addressing the dynamics of SUDs [substance use disorders].” If we add the statistics from McGinnis and Foege (1993) that drug addiction is responsible for 25% of all deaths in the United States (nicotine 19%, alcohol 5%, illegal drugs 1%) and obesity (food addiction) is responsible for another 14% of U.S. deaths, it becomes obvious that addiction is a pressing issue for psychoanalysis. Either many patients undergoing psychoanalytic therapy have active addictive issues and their therapists lack a good theoretical basis for understanding their issues and consequently ignore them, or these extremely common patients are being systematically turned away from psychoanalytic therapy because we lack a good theoretical basis for understanding their issues. I suspect both are true.

Since there is a major biological component to addiction, an important difficulty involved in using psychodynamics alone is that the biological nature of the addictive process becomes indistinct rather than standing clearly as one side of a dialectical process between psychology and biology. Neuropsychoanalysis dwells in the margin of psychoanalysis and biology from which Dr. Khantzian indicates synthetic models may be formulated.

I will use the definition of neuropsychoanalysis provided by Kaplan-Solms and Solms (2000, p. 62). Neuropsychoanalysis links mind and brain “to dissect the internal psychological structure of the various changes in personality, motivation, and complex emotion that occur following damage to different cerebral structures. Thereafter, the multiple underlying factors producing these symptoms and syndromes can be identified and each correlated wi