Psychoanalysis Is Addiction Treatment's Missing Piece
Sobriety doesn't guarantee a good life. By focusing on the whole person—not just the drug or drug use—psychoanalysis can help addicts grow in ways that go beyond recovery.
Many people who suffer from addiction are told that psychoanalysis is the last treatment they should ever try. Psychoanalysis, which is psychotherapy that focuses on helping clients become aware of how their behavior can be motivated by factors often out of their awareness, can seem beside the point to people who are in crisis because of substance misuse. In addition, psychoanalysis historically involved several sessions per week for a period of years, incurring great costs of money and time; this reputation persists despite the fact that that is not how most psychoanalysts practice today. Because of this, and the fact that contemporary psychoanalytic approaches are not well known, the general public has many misconceptions and even mistrust of the process.
The situation is often not much better among addiction experts. There is an unfortunate history of analysts asking alcoholics and addicts to lie on the couch and free-associate while their disease only progresses. Therefore, the negative reactions are not surprising. However, the truth is that psychoanalysis has always had enormous benefits to offer, and it can greatly enhance the chance for success in recovering from addiction. Yet because of mistakes by some analysts, the valuable contributions many others make are often neglected by treatment professionals.
As far back as Freudian times, psychoanalysis has been on the leading edge of enlightened, nonjudgmental approaches—the “analytic attitude”—to mental illness and, more recently, substance use disorders. Psychoanalytic theories about addiction date back to the 1930s, when addicts were blamed for their own fate; it was assumed that using substances was a “regression” to immaturity and all about indulgence or self-destruction.
Foreshadowing what good clinicians believe today, psychoanalyst Sandor Rado, MD, wrote that “the study of the problem of addiction begins with the recognition of the fact that it is not the toxic agent, but the impulse to use it, that makes an addict of a given individual.” Accordingly, much of the addiction field now acknowledges that the object of study should be the individual rather than the substance. Certain substances are addictive for certain people (often due to their unique combination of biology, psychology and social circumstance).
Edward Glover, MD, another 1930s psychoanalyst, was the first clinician to propose that people use substances in an effort to soothe or escape emotional pain. He said that drug addiction is not a regression but a “progression that performs a protective function” and that it is “frequently a successful maneuver.” This belief underlies today’s psychoanalytic understanding of addictive disorders, captured by the phrase “Self-Medication," which was coined by Edward Khantzian, MD, in a classic 1985 paper, “The Self-Medication Hypothesis of Addictive Disorders.” In this paradigm, addiction is removed of its stigma and those who are addicted are treated as individuals who use for their own reasons that need to be understood and addressed. It is acknowledged that often the addictive substance works (or once worked) in the short term to provide relief or enable a skill, and that it can be terrifying to give up. Analysts start from these premises in their work with substance use disorders.
Curiosity is a hallmark of psychoanalytic treatment: Analysts want to understand their clients as deeply as possible, and one goal of the process is to encourage the client’s curiosity about themselves. Treatment professionals often tell addicts that they suffer from “terminal uniqueness.” This is an attempt to help them understand that they are not alone, but also “not so special”—a message that can help some people step down from a narcissistic sense of difference from others and engage with others in the process of recovery. But it can also obscure a very important truth in treatment, and one that analysts are trained to be sensitive to: Each person is unique, and has a unique history and a unique set of needs, desires, fears, etc. If treatment is to be truly and lastingly successful, all of these aspects of their personality must be understood and addressed.
Addicts might be labeled “liars” less often if it was understood that one aspect of their personality does not always know what the other is doing.
This concept fits well with the “meet the patient where the patient is at” principle of Harm Reduction Therapy. In fact, there are many ways that harm reduction psychotherapy overlaps with psychoanalysis, especially Relational Psychoanalysis, which focuses on the importance of interaction with others in the development of personality and on the therapeutic relationship as the mechanism for cure. Both approaches recognize that treatment is not a one-sided affair but a relationship between two people to which both contribute. Goals are discussed, collaboration takes place, plans are made with mutual input. The clinician offers professional expertise but does not pretend to know the client, or what is good for the client, better than the clients know themselves.
This “two person” model of treatment emphasizes the importance of the therapeutic relationship. It is not just the content of sessions that matters, but also the feel and the process. In other words, it does matter how the therapist and the client relate. Harm Reduction therapists often talk about the importance of respecting the client and trust as a foundation of treatment. Similarly, Relational analysts assume that what goes on in the session is part of the treatment. Being respected by the therapist, involved in treatment decisions and negotiating differences supports the growth of more mature, stronger aspects of the self.
By paying attention to the feel and the process, analysts can learn what their patients are unable to tell them directly. Many people who use substances have lost the ability to know, and communicate in words, what they feel. So, for example, if a patient suddenly starts missing sessions, they may be angry at or disappointed in the therapist. In this model, the therapist will do everything possible to make it safe to talk about.
There are many ways that motivations that remain outside awareness can be discovered through a relational dynamic. For example, I had a client who could not take ownership of her desire to stop drinking. She kept telling me that she was getting sober because I would discharge her from therapy if she didn’t. I kept reminding her that wasn’t true. Then she said that it was only because her husband would leave her. That wasn’t really the case, either. Next she said that the only reason she didn’t drink was because she was on antabuse. I reminded her that she chose to take it.
My patient could not talk about her lifelong sense of lacking agency and empowerment, but it came out in this process between us. Once I pointed it out, we could talk about it. The feeling that she had no control over anything in her life had of course contributed to her alcoholism, but she had never put words to it before. Now she was able to start dealing with it, and once she did that, she was able to start developing a conscious choice to stop drinking—and a stronger sense of self in general.
Many people who misuse substances have suffered trauma in their lives, and also many suffer trauma due to the stigma and hardships of being addicted. One hallmark of trauma is dissociation, or splitting and compartmentalizing various aspects of self. This psychological process has a very important implication for therapy: A different aspect (or “part”) of the person may be present in the therapist’s office than the part that emerges in a bar or at home or with friends. When the therapist and client make plans for the client to contain their substance use, the “part” who actually uses (often the hurting, scared or lonely part) may not be present and participating. The plans are being made, but only with the part that feels safe with the therapist and is motivated to change.
Analysts make a great effort to invite all parts of a person into the therapeutic process. If more therapists recognized the powerful effects of dissociation and the importance of integrating all aspects of a person in treatment planning, failures to comply with the plans might occur less often and be less baffling when they do occur. Addicts might be labeled “liars” less often if it were widely understood that one aspect of their personality does not always know what the other is doing.
By promoting the many insights and advantages of psychoanalysis in the treatment of addiction, I am not suggesting that we stop teaching tools for sobriety, coaching behavioral change, engaging spirituality or referring to self-help groups. No good psychoanalyst today would treat an addict or alcoholic without using cognitive-behavioral, medical-biological, social support, and other techniques. But at the same time, psychoanalysis should not be rejected because of past failures. It has much to contribute that will increase substance use treatment’s chance of success.
When the focus is not specifically on the substance or even the substance use, but on the full individual, treatment can help nurture and support a sense of self as a strong, competent individual able to withstand challenges and live a happier life. Managing substance use is one—but not the only—very important part of this achievement.
Debra Rothschild, PhD, is a psychologist and psychoanalyst in New York City. She is also a credentialed alcoholism and substance abuse counselor, a clinical associate professor at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis, and a clinical supervisor at City College, Yeshiva University and Long Island University clinical psychology programs. She is on the executive board of the New York State Psychological Association Division on Addictions. She publishes and lectures widely on the integration of psychoanalytic thought with harm reduction psychotherapy and substance use treatment.