PSYCHOANALYSIS AND ADDICTION:
INTEGRATING CONTEMPORARY THEORY AND TRADITIONAL TREATMENT MODELS
Lisa Director, Ph.D.
Introduction / Overview
Class 1
Alcohol and substance abuse are among the most common of problems, inevitably arising in the professional life of any therapist.
This course addresses contemporary currents in relational theory that enable psychoanalysis to better understand chronic substance use and its accompanying dynamics. A grounding in existing analytic views of addiction, and in the perspectives afforded by other models, informs a grasp of today’s theoretical innovations. Overall, the goal of the course is to impart a working knowledge of addiction, and the leading constructs that explain it, with an emphasis on recent relational trends.
Long considered ill-matched to the risky nature of their behavior and their raw emotional needs, the psychoanalytic framework now has much to offer substance users. Recent perspectives on dissociation, and enactment as a medium of unsymbolized experience, shed light on the dynamics of substance users. Interest in trauma, and its sequelae in affective disturbance (Krystal, 1988), offers insight into drug abuse as a disorder of self-regulation (Khantzian, 1995). And, the idea of the
“relational matrix” (Mitchell, 1988), as constitutive of the psyche and its disorders, offers a new schema for conceptualizing drug abuse.
Additionally, as a disorder of the body and behavior, as well as of the mind, drug abuse uniquely sits at the “crossroads” (Wurmser, 1977) of several disciplines. We will consider developments in neuroscience and cognitive-behavioral advances that influence addiction treatment today.
The course has three parts. Part I, Theoretical Foundations
(Classes 1-8), surveys existing analytic and other theoretical perspectives. Part II, Substance Use: Variable Forms, Specific
Components (Classes 9-10), familiarizes students with the many forms of substance use, and with other components unique to symptomatic drug use.
In Part III, An Integrative Treatment Model (Classes 11-15), familiarity with addiction and existing theory is combined, together with consideration of recent relational trends, to create an integrative model for the treatment of chronic substance use.
I. Part I: Theoretical Foundations
What is drug abuse? Controversy accompanies the study of addiction, with differences among those who view it as a “symptom” of underlying pathology, those who view it darkly as a “disease,” and those who normalize it as “maladaptive behavior.” Familiarity with diverse viewpoints informs a strong, working knowledge of addiction, and its
“overdetermined” (Levin & Weiss, 1994) nature.

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Class 2: Classical and Contemporary Freudian Perspectives
Reading
Otto Fenichel (1945). Dynamics of addiction. In: Levin & Weiss
(Eds.), The dynamics and treatment of alcoholism:Essential papers
(1994), pp. 98-103. Northvale, NJ: Aronson.
Leon Wurmser (1977). Psychodynamics in compulsive drug use.
In Levin & Weiss, pp. 176-204.
Optional
Freud, letter to Fliess (1897): masturbation as a “primary
addiction.” In: Levin & Weiss, pp.51-52.
Though Freud himself did not write a major paper about drug addiction, his early followers did address the topic. Fenichel, as an example, viewed alcohol and drug abuse in terms of instinctual gratification.
Leon Wurmser departs from the early classical emphasis on pleasure, but is faithful to the Freudian tradition in seeing addiction in terms of intrapsychic conflict. In particular, Wurmser focuses on the superego’s role.
Class 3: Trauma and its Effects - Use of Drugs to Ward Off a Return
Reading
Henry Krystal (1988). Integration and self-healing: Affect,
trauma, alexithymia. Hillsdale, NJ: Analytic Press.
Ch. 9, “Trauma and affect,” pp. 142-153; 166-169.
Henry Krystal & Herbert Raskin (1970). Affect tolerance. In:
Levin & Weiss, pp. 160-170.
Krystal, Integration and self-healing. Ch. 13, “Alexithymia,”
pp. 242-249.
Like Wurmser, Henry Krystal (1977, 1988) believes that the histories of drug-dependent people often contain early experiences of psychic trauma, involving states of overwhelming affect and their disorganizing effects. The cognitive dimension of feelings is also undeveloped, resulting in a syndrome that Krystal and others have called alexithymia.
Class 4: Drug use as Adaptation: Ego Psychological Views
Reading
Edward Khantzian (1995). Self-regulation vulnerabilities in
substance abusers: Treatment implications. In: S. Dowling (Ed.),
The psychology and treatment of addictive behavior,
Madison, CT: International Universities Press, pp. 17-41.
Herbert Wieder & Eugene Kaplan (1969). Drug use in adolescents:
Psychodynamic meaning and pharmacogenic effect, Psychoanalytic
Study of the Child, 24, 399-406 (pp 1-4).

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Given the affective disturbance that is a universal among drug users, some see them as making an adaptive effort at self-cure.
Khantzian coined the “self-medication hypothesis” to capture addicts’ pursuit of particular drugs to soothe problematic feelings.
Wieder and Kaplan offer an earlier, related set of views.
Class 5: Drug use and Disorders of the Self
Reading
Jerome Levin (1991). Alcoholism and regression / fixation to
pathological narcissism. In Levin & Weiss, pp. 370-385.
Herbert Rosenfeld (1987). Destructive narcissism and the death
instinct. In: Impasse and Interpretation, London: Routledge,
pp. 105-125.
Optional
Kohut (1977). Preface. In: Psychodynamics of Drug Dependence,
NIDA Research Monograph No. M12, pp. vii-ix.
The fragility of these patients, and their reliance on drugs, can be viewed in terms of narcissistic need - for affirmation in some cases, and for destructive power, in others.
Class 6: Drug Use and Disturbances in Object Relations
Reading
Henry Krystal (1977). Self- and object- representation in
alcoholism and other drug dependence: Implications for therapy.
In: Levin & Weiss, pp. 300-309.
Christopher Bollas (1987). Chap. 1 of The shadow of the object:
Psychoanalysis of the unthought known, NY: Columbia University
Press, pp. 14-29.
Drug dependency entails a fundamental disturbance in object relations. What is it? Here are two views of object relations phenomena that have applicability to substance users.
Class 7: Perspectives from Neuroscience: Updating the “Disease”
Model of Addiction, with Research on the Brain
Reading
Eric Nestler & Robert Malenka (2004, March). The addicted brain,
Scientific American, pp. 80-85.
Allan Schore (2003). Affect dysregulation and disorders of the
Self, NY: W.W. Norton. Ch. 7, “The effects of relational trauma on right-brain development, affect regulation, and infant mental health,” pp. 178-212, 229-233.
One view of addiction as a biological “sickness” has taken on new meaning, as advances in neurochemistry shed light on addiction’s mechanisms in the brain.

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Nestler and Malenka, who study the molecular basis of addiction, report drugs’ effects on dopamine, and the workings of reward, tolerance, and sensitization.
Schore’s (1994, 2003) emphasis is developmental, as he maps out how differing infant-caregiver interactions may optimize or handicap the maturation of right-brain systems responsible for social and emotional functioning.
Here, Schore singles out the disorganized (“type D”) attachment pattern - found in abused and neglected infants - as a source of
“relational trauma” on the infant brain, altering development of various response capacities. Schore’s theories about type-D failures in brain development are relevant to substance users, because, Schore believes, many are likely to carry type-D histories.
Class 8: Cognitive-Behavioral Perspectives
Reading
Alan Marlatt & Judith Gordon (1985). NY: Guilford.
Relapse prevention: Theoretical rationale and overview of the model.
Ch. 1, Relapse prevention: Maintenance strategies in the treatment of addictive behaviors, pp. 3-37.
Optional
Peter Fonagy (1999). The process of change and the change of
processes: What can change in a ‘good’ analysis. Div. 39
keynote address, pp. 1-21.
Marlatt and Gordon normalized relapse (drug use), moving it from the outskirts of treatment to its center stage, and giving therapists practical strategies to grasp it.
They outline the principles of conditioning that underlie addictive behavior. Their focus on a “microanalysis” of the relapse process is standard in institutional approaches to addictive behavior today.
Their approaches are conducive to psychoanalytic thinking. For example, Marlatt and Gordon believe in building drug users’ skills to note their own behavior. The ability to note one’s behavior is a step towards noting one’s “self” as a subject, a process central to Fonagy’s work on mentalization.
II. Part II: Substance Use: Variable Forms, Specific Components
Theoretical consideration of addiction must be matched by practical familiarity with the phenomenon of drug use itself, and its diverse forms. An essential complement to a working knowledge of addiction is a grasp of programmatic models of treatment, which include biobehavioral approaches and other components unique to addiction.
Classes 9 & 10: Forms and Components
Reading
For Class 9
Instructor’s handouts in class - concepts and characteristics,

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use-abuse-addiction
Caroline Knapp (1996). NY: Dell. Drinking: A love story,
pp. 1-27, 56-62. Personal account, whose author depicts the evolution of the addictive process.
Optional
Marlatt & Gordon, pp. 37-55. Continued walkthrough of their
“microanalytic” approach to working with substance uses.
For Class 10
Excerpts from the American Psychiatric Association’s
“Practice Guidelines for the Treatment of Patients with Substance
Use Disorders,” 2 nd edition, pp. 303-324.
This is Amer. Psychiatric Assoc’s official criteria for designated treatment approaches for substance use disorders,
published in 2006.
(Complete version also published as a Supplement to the American
Journal of Psychiatry, and issued in August 2006.
Lance Dodes (1998). The psychology of combining dynamic
psychotherapy and Alcoholics Anonymous. Bulletin of the
Menninger Clinic, 52, 283-293.
Optional
David Sheff (2008). Beautiful boy: A father’s journey through his
son’s addiction (NY: Houghton Mifflin), pp. 117-121. Treatment
options, as recounted by an author facing them.
A comprehensive grasp of the variability of substance use is a prerequisite to accurate assessment and dynamic understanding of the problem. Subjects include properties of classes of drugs; differing drug effects and domains of these effects; distinctions among use-abuseaddiction.
Specialized treatment approaches, designed for drug use, are discussed to provide familiarity with the prevailing programmatic models, and to consider their dynamic implications. Residential treatment models and adjunctive medications are addressed; 12-step fellowship is explored as a therapeutic model itself.
III. Part III:
An Integrative Treatment Model: Applications and Advances
What does contemporary psychoanalysis have to offer that would be especially therapeutic to substance-using patients?
This question is the focus of these classes. Treatment models and theories are combined, together with consideration of new trends in relational thinking, to inform the design of an integrative model for treating drug use and other addictive disorder.
Class 11: Changing Views and Role of Enactment
Reading

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Philip Bromberg (1998). “Speak! That I may see you.” In: Standing
in the Spaces, pp. 241-261.
Lisa Director (2005). Encounters with omnipotence in the
psychoanalysis of substance users. Dialogues, 15(4), 567-584.
Optional
David Lozell Martin (2008), Chap. 7, “I wish I had drunk more gin.”
Excerpt from his autobiography Losing everything (NY: Simon &
Schuster), pp. 73-78, 81-83. Author is son of a mill-working
father and mentally unstable mother, who grew up to become a
novelist and recounts his development.
Recent attention to enactment as an inevitable development in the transference and, in particular, a vehicle for the expression of unsymbolized experience has special relevance to substance users, who are prone to action and often organized by dissociation.
Enactment holds promise as the means by which a substance user may reproduce an unresolved relational dynamic in therapeutic form.
Class 12: Perspectives on Conflict, and its Achievement
Reading
Donnel Stern (2004). The eye sees itself: A theory of
dissociation, conflict and enactment. Contemporary
Psychoanalysis, 40: 209-221; 228-231.
Jody Davies (2004). On the nature of unconscious conflict and
fantasy in relational psychoanalysis (unpublished manuscript,
pp. 1-10).
Interest in multiplicity as a model of mind has given rise to new perspectives on conflict and its place in mental health.
Davies & Stern write that the process of expanding the patient’s awareness of self-organizations that were previously incompatible - i.e. tolerance of conflict - becomes a basis for health.
Class 13: Countertransference Considerations
Reading
Howard Shaffer (1994). “Denial, ambivalence, and
countertransferential hate.” In: Levin & Weiss, pp 421-435.
Leon Wurmser (1978). Excerpts from Ch. 16, “Intensive
psychotherapy,” of The hidden dimension: Psychodynamics of
compulsive drug use, Northvale, NJ: Aronson, pp. 467-473.
Optional
Linda Hopkins (2001). “Masud Khan’s descent into alcoholism.”
In J. Petrucelli & C. Stuart (Eds.), Hungers and compulsions:
The psychodynamic treament of eating disorders and addictions,
Northvale, NJ: Aronson, pp. 321-345.
Class 14: Harm Reduction: A New Paradigm in Addiction Treatment
Reading

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Andrew Tatarsky (2002). Harm reduction psychotherapy. Ch. 1, in:
Harm reduction psychotherapy: A new treatment for drug and
alcohol problems, (A. Tatarsky, Ed.) Northvale, NJ: Aronson,
pp. 16-48.
From a different discipline (the field of public health), and region (Europe), a new set of ideas has invigorated the treatment of addiction. “Harm reduction” offers an alternative to abstinence-only approaches.
We will explore the ways in which the tenets of harm reduction are compatible with psychoanalytic beliefs, and make possible earlier engagement with substance-using patients.
Class 15: Synthesis - and its Merits
This class allows for the synthesis of preceding questions, and for consideration of the value of the process of synthesis itself.
Can an integrative model for treating addiction, that draws on other disciplines and tools to enhance effectiveness, be considered
“psychoanalytic”?
Final attention is also given to a question that runs throughout the course: what insights and approaches from the psychoanalytic consideration of substance users have wider application to all patients?