New Psychoanalytic Understanding of Addiction

For many years psychoanalysts have avoided offering psychoanalysis to patients with addictions because of a series of misunderstandings. These include early psychoanalytic views that people with addictions are too ill to participate in an analytic process, an unjustified reliance on the therapeutic reputation of 12-step programs (they are effective for only 5-10 percent of people who attend), and an overvaluation of neurobiological findings that have mistakenly suggested that addiction is a “brain disease”—a view based largely on findings with rats, which has been repeatedly demonstrated to be inapplicable to addictions in humans.

Addictions can, in fact, be shown to be primarily psychological symptoms, a subset of psychological compulsions generally, and as suitable for psychoanalysis or psychoanalytic therapy as other compulsions. As with other compulsions, people with addictions run the gamut of mental health. Their analyzability depends not upon their addictive symptom but upon their overall level of psychological function.

Three Major Elements: Helplessness, Rage, and Displacement

First, every addictive act is preceded by a feeling of overwhelming helplessness or powerlessness. The issues that precipitate such overwhelmed states are unique to each person, and a reason that individual psychodynamic therapy is frequently the most appropriate treatment for people with addictions. Addictive behavior functions to repair this helplessness. It is able to do this because taking the addictive action (or, significantly, even deciding to take this action) creates a sense of being empowered, of regaining control over one's emotional experience and one's life. Drugs are particularly apt for this purpose because they possess the capacity to alter and, thereby, reclaim control of one's emotional state. However, non-drug addictions (for example, gambling, exercising, compulsive use of the Internet) can be shown to work in exactly the same way, since it is the ability to intentionally do something that will alter and control one's affective state that is important, not a physiological drug action. This reversal of helplessness may be described as the psychological function of addiction.

Second, states of overwhelming helplessness inevitably produce a particular sense of rage in response to the narcissistic injury of loss of control over oneself. As a reaction to narcissistic injury this feeling may be properly termed narcissistic rage. Narcissistic rage is well known for its powerful compulsive qualities, its capacity to overwhelm one's judgment while in the throes of the rage, and its deep intensity. These characteristics are identical to those that describe addiction. Indeed, it is the presence of narcissistic rage (at helplessness) that gives addiction its most defining characteristics, and it is narcissistic rage at helplessness that provides the drive behind addiction.

The final element in addiction is understanding why it takes the forms it does. These forms are a consequence of the fact that all addictive behaviors are displacements. For example, if a man were flooded with feelings of intolerable helplessness when he was unfairly criticized by his superior (because the criticism touched on specific unresolved issues) and he regularly dealt with such circumstances by drinking, his behavior could be understood to be a (temporarily successful) effort to reverse his helplessness via this displaced act. And this act would be intensely driven by the rage associated with his need to overcome his intolerably powerless state. We call such repetitively driven behaviors addictions. On the other hand, if when he was criticized he had instead charged into his boss's office furiously complaining, he would have reversed his helplessness by this direct act. It is very unlikely that he would have had a drink. Addictions exist only when there is a displacement. Indeed, we name addictions by the displacement. This man had alcoholism, but if he shifted to reverse his helplessness by driving to a casino we would change his diagnosis to “compulsive gambling.”

The well-known ability of people to shift from one addiction to the other is due to the fact that these changes are simply shifts in the displacement they are utilizing.

Treatment Implications

When patients understand the psychology of their addiction, including the kinds of issues that lead to their repeated experiences of intolerable helplessness, two things follow. They are able to anticipate when their addictive drive will occur, sometimes far in advance and long before the addictive urge is upon them. And, knowing the specific issues that lead to their helpless feelings, they can (with some practice) discover more direct actions rather than their displaced, addictive ones to deal more precisely with them. Consequently, patients can often bring their addictive behavior under good control well before they have fully worked out the issues behind it. Conversely, analyzing the precipitants to each occasion in which they have an addictive thought enables patients to more quickly identify their central emotional issues, since it is always these central issues that lead to intolerable feelings of helplessness. For this reason, analysis of the precipitants to addictive behavior can be, like dreams, another royal road to the unconscious.

Referring our patients with addictions to others, even with the idea of a concurrent “addiction treatment,” has serious disadvantages beyond the loss of opportunity to better treat them. It informs patients that their therapist does not feel competent to understand or deal with their problem (and, by extension, is not able to understand them); that they are essentially different from other people; and that their addiction is somehow separate from the rest of their psychology and cannot be integrated with it.

As analysts, we need to know the psychology of addiction and its corollaries: We are often the best treatment option for patients with addictive symptomatology, and we have something extraordinarily useful to teach the wider addiction treatment community about this very common and important problem.