The International Journal of Psychosocial Rehabilitation

An Overview of Substance Dependency

Norman Jay Gersabeck, M.D.
Senior Editor - IJPR
 

ADDITIONAL  INFORMATION  ON  SDIP: www.rust.net/~norman/

Citation:
Gersabeck, N.J.  (2001)  An overview of substance dependency.
 International Journal of Psychosocial Rehabilitation. 5, 61-76


The general issue of substance dependency is best exemplified by the problem of alcoholism. There is actually still some controversy as to whether it should be considered as a disease or not. I strongly believe that it is a disease- but just not the usual type. It canít be diagnosed by a physical exam, imaging techniques, or any blood tests. But it ruins lives and kills people. Most psychiatrists and psychologists see alcoholism as mainly a genetic/biochemical type of disease. Then there are those who consider it as only a irresponsible behavior. My understanding of alcoholism agrees with neither of these positions. Both of them fail to look at the great importance of the functioning of the unconscious mind in dependencies. (Specific insight about this involvement for any given individual is usually not needed. What is needed for significant change in the unconscious mind regarding the dependency to somehow occur.) The idea of all substance dependencies as basically being of a "straightforward" genetic/biological nature can be comfortable for many substance dependent individuals and support groups. But regardless of what the understanding of the basic nature of a dependency is- there is still always the need for afflicted persons to take personal responsibility for their dependencies, and for making basic changes in themselves and their behavior.

Substance (or chemical) dependency is what is commonly thought of when "addiction" is mentioned. Unfortunately, it has lost much of its association with the more general concept of addiction. It also includes non-substance addictive practices- or dry addictions." For example, there is a frequent association between alcoholism and compulsive gambling. Not only are they found frequently in the same person, but the alcoholic person may occasionally switch completely from alcohol to compulsive gambling- or visa versa. Both substance dependency and compulsive gambling are addictive practices. The former just happens to also involve the ingestion of addictive substances. Of course, the psychopharmacological properties of the addictive substance are important- but substance dependency is much more than the sum of these effects. At one time, cocaine addiction wasnít thought to really exist, because there werenít any pronounced withdrawal effects upon cessation of its regular use. Substance dependency represents a group of very complex behavioral disorders. The addictive process in all addictions is mainly a learning one. It follows that the value of animal experimentation to better understand human substance dependency is very limited. A rat who is experimentally addicted to alcohol and then withdrawn from it won't later get depressed, obsess about it, crave it, perhaps develop panic reactions, etc. The difference is that, unlike persons, rats don't have complex and symbolizing minds

It has recently reported that cigarette dependencies can occur very quickly in people (largely referring to teenagers) and that even several smoking occasions over a period of a couple weeks can sometimes suffice. Cigarette smoking is extremely addictive, and anybody who gives himself half a chance will soon become addicted- even if it is the personís first dependency. The important message that this finding strongly suggests is that, theoretically, anybody is capable of becoming addicted to any addictive drug. There are many diverse factors, including a few genetic ones, that determine if any particular person will ever be exposed to any particular addictive substance to start with- and then what further exposure would be needed for a dependency to develop. The rapidity and ease of the cigarette addictive process is involved with more than just nicotine alone. Iím quite sure that studies would find that it takes longer for most people to get addicted to chewing tobacco. A very recent finding indicates that teenage cigarette smokers are four times more likely than their nonsmoking counterparts to develop depression.

The particular substance involved in a dependency plays a strong role in its potential psychopathological effects and consequences- which often can be quite subtle. Nicotine is quite low in this regard, and alcohol is on the high side. One woman was a long time smoker and was divorcing her husband for obscure reasons. They were still getting along well, and shortly before they separated, they were planning to see a movie together. Just before leaving, she impulsively went back in the house to make sure that her cigarette was completely out in the ashtray. It was out, and without any animals or children in the house, it wouldnít have mattered if it werenít. She changed her mind about the divorce a few months later. I was then able to explain to her that her unusual behavior regarding the cigarette had been an unconscious expression of concern about the divorce action. Her cigarette addiction both symbolized and facilitated the more neurotic and immature part of her personality that wanted the divorce. Her checking on the cigarette had expressed her concern about her dependencyís potential destructive ("inflammatory") effects on that part of herself- including the risk of its gaining a dangerous degree of power within herself.

There is a great deal of ignorance about substance dependency by even mental health professionals. Additionally, the current and predominant "biological psychiatric" thinking operates as an effective obstacle to its better understanding. (I use quotation marks here because of the misuse of the legitimate term "biological," as defined in the dictionary.) Unfortunately, many psychiatric training programs have dropped any training in psychotherapy, due to the influence of "biological psychiatry." It is a sad irony that "biological psychiatry," in its efforts to make psychiatry more scientific, has actually succeeded in some ways of making it less so. There is a long-known and somewhat "tongue in cheek" "Four, Two, and Zero Rule" in the field of substance dependency- and it still has much truth to it. It concerns the matter of substance dependency education in medical schools and refers, respectively, to the number of years of medical school, the number of hours of lecture on the subject, and finally- the amount learned. Psychiatric training programs are little better in this area.

Only the very obvious psychiatric organic diseases like Alzheimer's and Huntington's fit the traditional (biomedical) disease model fairly well. That model is based on infectious diseases like tuberculosis where the cause is obviously the tubercle bacillus. It has been criticized because disease effects are often being confused with disease origins- with neglect of the latter. "Disease effects" refer to symptom-producing physiological mechanisms ("chemical imbalances"), as for example, acute anxiety in response to unconscious emotional conflict in panic reactions. Psychiatric diagnostic entities, in particular, don't fit this model very well, and substance dependency probably fits worst of all. There have been many "Procrustean Bed" (in Greek mythology, a bed for which, if necessary for a good fit, a person's legs would be partially cut off) efforts made to have substance dependency appear to fit the traditional disease model. There is a book by Stanford neuroscientist Robert Sapolski by the amusing title of "The Trouble With Testosterone." The "trouble" is for "biological psychiatric ideology-" that assumes the reverse of the finding of an animal experiment dealing with animal aggressiveness. It found that animals first showed signs of increased aggressiveness- and only then developed a higher level of testosterone.

In the relatively recent book, "Understanding Alcohol," its councilor authors were obviously writing from their knowledge of the general understanding of substance dependency at most substance dependency treatment centers. In their chapter on psychiatric illnesses, they state: "Alcoholics do have psychiatric illnesses in approximately the same proportion as the nonalcoholic population." This is an obviously incorrect statement. I think there is a strong, but hidden wish here not to acknowledge any strong associations between substance dependency and other psychiatric disorders. Psychiatrist Mark Gold of the University of Florida cited a 37% incidence for such an association- and I think it is a bit higher than that. These disorders are depression, anxiety states, panic reactions, manic-like disorders, obsessive states, post-traumatic stress disorders and functional psychoses. .

A "biological understanding" of substance dependency requires that many important aspects of it be largely ignored- like placebo effect. The great importance of the placebo-affecting "set and setting" in addictive drug use is well exemplified by the case of the proverbial alcoholic man who responds so differently at times to the same amount of alcohol in regard to different situations. He may be: somnolent in a library; tearful at a sentimental movie; belligerent at a bar; the life of a party; sexually passionate in the back seat of a car. The general (collective) concept of substance dependency is critically important to understanding any individual substance dependency. A basic tenet of the concept is that one dependency can, and often does completely substitute for another. The use of multiple substances in dependencies is very common, and they tend to be a greater problem than single ones. A cocaine addict can switch completely to alcohol- or visa versa. Yet these two substances are in completely different chemical classes- with alcohol being a depressant type drug- and cocaine a stimulant. It is a fairly well-known fact that developing a first dependency facilitates the addition of additional substance dependencies. The most common example of this is that the large majority of alcoholic persons were first addicted to cigarettes- and many of them would have not become alcoholic without that facilitation. The influence of "biological psychiatry" has kept this risk of cigarette smoking from being used in the battle against smoking. From a "biological theorizing standpoint," substance dependency is actually rather messy!

It is the development of the irrational and narcissistically-driven overvaluation of the substance by the dependent which is really the "heart and soul" of the addictive process. I once made a "hypothetical offer" to an alcoholic man who had to attend an outpatient substance abuse treatment program because of a couple of DWI offenses. He was in denial for his alcoholism, and wanted to convince me that he wasnít alcoholic. I asked him to imagine I was an eccentric millionaire who was offering him in good faith the sum of $50,000 for his right or opportunity to ever drink any more alcohol- no matter what. His very interesting response was an immediate refusal of the offer, and the comment that accepting it would be "like selling my soul." He was smart enough to know that the best "denial answer" would be to accept the money- whether or not he really felt that way. In effect, this option was overruled by his strong unconscious need "not to deny alcohol." I then knew beyond any doubt that he was alcoholic.

There has been a general trend in the field of substance dependency to get away from the early emphasis on the importance of withdrawal symptoms and signs, and to look more for the "benefits" of substance use. Because something is very obvious about a problem doesnít necessarily mean that it is given adequate scrutiny. The irrational degree of overvaluation by the alcoholic person for alcohol is a given- and this is no less the case with other substance dependencies. I am convinced that it is vital to look for the "likely mechanisms" for this importance. It is fairly easy to adequately explain the nature of an organic psychosis like Huntingtonís disease as being due to straightforward biochemical/genetic factors. But it would be very difficult, if not impossible, to attribute the irrational and great importance that the substance dependent person has developed for the addictive substance to these factors.

From a logical standpoint, it is hard to explain substance dependency as being other than chiefly a learned sort of behavior- since the addiction itself is irreversible. Only its practice is reversible. Before I really knew much about addiction, I treated a man in his early fifties who had started to show (non-psychotic) paranoid thinking. I didnít use any medication, and weekly outpatient therapy for about 10 months was successful. It wasnít until after therapy was over that I belatedly realized that his paranoia was related to his approaching 25 year anniversary of recovery from alcoholism. He denied any temptation to drink, and I think he was being honest with me. His paranoia was symptomatic of- but also a defense of sorts against an unconscious rationalization that, after 25 years of sobriety, it should be okay to have a drink or two.

In his presidential address to the Society For Biological Psychiatry, Wagner Bridger went so far as to declare that personality is in no way affected by childhood. In a report in the July 1989 "Clinical Psychiatry News" he declared, "There seems to be no relationship between early experience and adult outcome in the human life cycle." He then added: "Even a horrible parentless or institutionalized childhood has 'no effect on later personality development. All that matter is genetic predisposition and current life influences." Apparently he believes that the past isn't prologue; rather it is nothing! Let me invite the reader to read the essay by psychiatrist David Kaiser that is critical of "biological psychiatry," which is also on this web site. It is entitled: "Not By Chemicals Alone: A Hard Look At Psychiatric Medicine." I am not at all against the use of psychoactive medications. I just donít believe that there is now, or ever will be a pill or pills to fully treat every, or even most psychiatric problems.

There was a psychological experiment carried out on volunteer alcoholic persons who were recent dropouts from treatment programs. They were truthfully told that (a randomly chosen) half of their group would receive a placebo beverage, and the other half would receive a alcoholic one. The placebo drink was pure tonic water, and the experimental one contained tonic water and vodka at a ratio of five parts to one. Essentially, the two beverages looked, smelled and tasted the same. Each group were given subtle, but misleading clues as to which beverage they were actually receiving. Each person was given an amount of beverage, which if it were the alcoholic one, would yield a blood alcohol level of 0.10%. After drinking the beverages, the volunteers were then subjected to some relatively minor provocative behavior of a negative type. The individual responses could be objectively evaluated and the results were very interesting. They showed that "typical alcoholic behavior" was elicited much more by what the person thought he or she was receiving- as opposed to what actually was received.

There was another experiment in which three heroin addicts in a hospital treatment program for the dependency were falsely told (on the quiet) that they alone among a group of other actively addicted persons would not receive gradual withdrawal from heroin. They were to serve as a "control" among the group who would receive at least daily injections at an unknown schedule of a decreasing amount of heroin.The subjects would receive the same amount of liquid injection until the withdrawal was completed. None of the group experienced withdrawal symptoms. Then the three subjects were finally told the truth- that they had also been withdrawn from heroin. They then suddenly exhibited signs and symptoms, which were typical of acute heroin withdrawal. Though their withdrawal was no doubt less severe and protracted than a "true withdrawal," they were certainly not "play-acting."

Psychiatrist Robert DuPont is a former White Chief of Drugs and author of the excellent book entitled "Getting Tough on Gateway Drugs." He wrote that "getting addicted to drugs is a lot like falling in love." He has also had some very interesting things to say about social drinking. He feels it isnít definable scientifically, and that the majority of persons thought of as "true social drinkers" are actually "only a short step or two from active alcoholism." Some of them will inevitably eventually take those steps, and some of the others will just be potential victims of fate. He cited the matter of consumption and problem curves of drinkers not being bimodal. This means that they describe just one population of drinkers, not one healthy and the other of sick alcoholics. In practice, the person considered to be "just a problem drinker" is almost always alcoholic. Along the same line of thinking, in their book "Alcoholism And Substance Abuse," Bratter and Forrest always referred jointly to "substance abusers/dependents." It is an interesting finding that, not infrequently, some persons, who are properly diagnosed as "alcohol abusers" (by current official diagnostic criteria), are actually more strongly addicted than some other persons who are diagnosed as "alcohol dependents."

There are many good reasons to advocate complete abstinence in the treatment of any substance dependency. Although, for example, there are certainly some alcoholics who manage to control their drinking and its consequences quite well, this always represents a somewhat unstable situation. Though most alcoholics will experience progression of their disease- this is not always the case. There is the recent and tragic example of Audrey Kishline, the woman who championed "moderation management" for "problem drinkers." She was responsible for the death of two people in an auto accident she caused, and was found to have had a high alcohol blood level. Even when she was managing to drink a moderate amount of alcohol, her drinking couldnít be considered as "truly moderate," or normal, as the "true social drinker" doesnít overvalue alcohol as she obviously did. She had acknowledged that her program wasnít for alcoholics- but only for "problem drinkers," like herself. (She now admits that she is and was alcoholic.) There is a recent book by psychologist Jeffrey Schaler by the title of "Addiction Is A Choice." He feels that few people who use addictive drugs get addicted, and those who do use them heavily will "mature out of it" in time and without any treatment- which is a waste of time." In his book (written before her accident), he was critical of her view that there even was such a disease as alcoholism- and mentioned that he had withdrawn from the Board of Directors of Moderation Management.

The mention of "love" in connection with any conceptualization of the nature of substance dependency must create shivers among "biological psychiatrists-" but there is no shortage of such mentions. Peele and Brodsky are the psychologist authors of the classic book on addiction entitled "Love and Addiction." In a more recent book they developed a list of five attributes of any addiction (substance or not):

"1) It organizes, structures, and fills time: without it your day is formless and barren.

2) It provides regular rewards: the activity is the major reward in your day.

3) It makes you feel accepted, worthwhile: your sense of yourself depends upon the activity or the habit.

4) It erases negative moods such as anxiety, depression, boredom: It makes you forget, 'gets you through the night,' creates a soothing oblivion.

5) It extracts, as a cost of the rewards it provides, penalties that make the person more dependent on it;"

The authors don't think alcohol or drug dependency should be considered as a disease- but rather an unfortunate, disordered behavior. I strongly disagree with them about substance dependency not representing a true disease. Nonetheless, I think that they made some very good points in their two books.

The psychologist husband and wife team of the McAuliffes operated a training center for substance dependency councilors in Minneapolis for many years. Their book, "The Essentials of Chemical Dependency" stated at the very beginning that chemical (substance) dependency was "essentially

a pathological or sick relationship of a person with a mood-altering chemical substance, a psychoactive substance, in expectation of a rewarding experience." They developed this understanding on an intuitive basis in their work with substance dependent persons- and were "innocent" of any psychoanalytic understanding or background. They helped to found the American Chemical Dependency Society whose motto is "Love Heals."

The alcoholicís essential error is poetically, but still well stated in a revealing statement by psychologist Charles Hampden-Turner in his book "Maps of The Mind:"

"Much as wine symbolizes communion, the alcoholic has taken the symbol for the reality and uses

drinking as a substitute for the relaxation, fusion, surrender and security of deep personal relationships."

In Smokey Robinsonís lyrics to a song, it is unclear whether he was referring to a woman or an addictive

drug. Most likely, he was consciously referring to both:

"I donít like you but I love you, Seems Iím always thinking of you, Though you treat me badly, I love

you madly, You really have a hold on me."

I am a firm supporter of substance dependency treatment programs- even though their results often donít look that encouraging. There are no easy answers to treating substance dependency, and likely there never will be. Prevention, of course, is the best treatment- but that isnít easy either. Twelve-step programs such as AA and NA can be very valuable. Biologically-oriented psychiatrists give lip service to their importance. But they certainly are not aware that, for some of their members, these organizations are capable of giving more than simple supportive treatment. Their altruistic-oriented and structured programs can actually give specific treatment that is aimed at the excessive narcissism of the addictions (which is not synonymous with the dependent person being narcissistic) .

There is a place for the individual psychotherapy of some substance dependency patients. I treated a middle-aged successful business man for depression with psychotherapy alone. At the first meeting I surprised him by telling him he was very likely alcoholic. He had been a six beer a day drinker before undergoing neurosurgery for a cerebral aneurysm. (His wife didnít even think he had a drinking problem.) Though the surgery was successful, and there was no residual impairment or symptoms, he became depressed for the first time in his life. The onset was almost immediately post-operative, and I first saw him six months later. With his depression was an almost complete loss of desire for alcohol, and a decrease in intake to about one drink daily. I gradually managed to erode his denial for alcoholism by a variety of means. The Marty Mann Test is a functional test for alcoholism which calls for the person to drink from one to three standard drinks daily for 30 days. (I have added the proviso that the person also not experience any unusual emotional reaction to taking the test.) He twice flunked it in short order by going over the daily limit. As his denial weakened, his drinking increased and his depression lessened.

Despite there having been a good patient-doctor relationship, I wasnít surprised when he abruptly quit therapy after about five months. He was feeling good, and apparently didnít want his denial for his alcoholism weakened any further. A few months later, I called to see how he was doing and talked to his wife. I found out he was recovering from a broken leg suffered in a drunken auto accident- and she now wanted him to see me again. I never did see him again, or learned what happened to him. But I think the chances were good that he eventually got sober with the help of AA. I never had the chance to fully deal with his very interesting family history. His mother had become disabled from neurosyphilis at his age of two- though she lived for ten more years. He likely wouldnít have suffered a depression if he had developed some other serious medical problem. Unconsciously, his suffering from a "brain disorder," like his mother, had been a great stress for him. It seems likely that, in a "repetition of the past" manner, there had been a switch from a "good parent meaning" of alcohol for him to a "bad one" (like the "good mother" before she became disabled, and the "bad one" afterwards). This psychodynamic understanding correlated well with both his depression and the loss of desire for alcohol.

Placebo response is a phenomenon that is very basic to substance dependency. The term "placebo" derives from the Latin word meaning "to please"- though negative placebo response is always a good possibility too. Most people don't recognize the term- but are still somewhat familiar with the idea of the "fake sugar pill" and its ability to help some people some of the time. Most typically it is a pill, liquid or shot that enters the body and its effect is not (directly) related to any pharmacological properties- if present. A procedure, belief, situation, another person or a thing can also elicit placebo effect. In short, a placebo can be anything that invites the unconscious mind to react strongly in some manner. Placebo effect is always inherently unstable and unreliable. It wasn't until the turn of the century that there were literally more than a handful of drugs being used by physicians that possessed any intrinsic worth. Providing that neither the dose or the type of drug used was toxic (which unfortunately it often was), any therapeutic effect from the great majority of drugs used then could result only by eliciting a positive placebo effect. With the right placebo response, a sleeping pill can act like a stimulant- if a person is in the right "set and setting." The sedative effects are simply overwhelmed by the placebo response.

A man with advanced cancer was near death, but then enjoyed a "miraculous therapeutic response" to a worthless cancer drug which was being given a therapeutic trial at his hospital. This positive placebo response was possible via his emotion-sensitive immune systemís better functioning. It had been stimulated enough to do this simply by the hope he had associated with this new medication. He was continuing to improve until about three months later when he read in the newspaper that the AMA had gone on record in labeling this drug for what it was. All of his symptoms and signs quickly returned after learning of this negative evaluation, and in a few weeks he was dead. His problem, like that of many people, was in learning how to access his own self-healing potentialities.

Andrew Weil is the psychiatrist author of the "Natural Mind," in which he referred to all psychoactive drugs as being "active placebos." He meant by this that their pharmacological effects were more likely to elicit placebo effect than other drugs or medications. Addictive drugs are simply that class of psychoactive drugs whose pharamacological properties are such as to produce quite pleasurable effects in most people. This factor then invites additional pleasure from their use- secondary to frequently experienced positive placebo response. Learning to really enjoy an addictive drug is the same thing as becoming addicted to it. For example, marijuana, usually requires a fair amount of practice before a sufficiently strong positive placebo response results. Nicotinic acid is often added to inert placebo pills. It is a form of "B" vitamin and has the effect of causing slight flushing of the skin at a relatively low dosage. This addition has the subtle effect of inviting placebo effect because of this limited pharmacological property- as if the volunteer actually had gotten the real experimental drug. The reason for the use of this type of active placebo is to increase the reliability of double blind tests of new drugs. The only way to scientifically explain the results of acupuncture is to posit a positive placebo effect. Not surprisingly, variations on acupuncture using pressure seem to work as well.

70 years ago some medical investigators found that the same post-surgical patients who experienced a fairly good pain relief to a placebo "pain shot," also responded more strongly to actual injections of morphine. This was in contrast to non-placebo responders. Furthermore, on psychological testing and interviews, the placebo responders showed similar psychological test profiles to those of addicts. The strong placebo responders were described as being more anxious and more emotionally volatile, and had less control over the expression of their instinctual needs. They were also more dependent on outside stimulation than their own mental processes, which were not as mature as those of the non-responders. This study correlates well with the finding that substance dependent persons are invariably strong placebo responders- which can complicate the use of psychoactive medication for them.

Some recovering alcoholic persons will state that, in retrospect, they realized that they were alcoholic from the very first drink because they liked alcohol's effects so much. This type of statement has been incorrectly thought to support a strong genetic-biochemical nature for alcoholism. But these are actually persons who were already fully primed (for example, by having a parent or step-parent who drank a lot) to react to alcohol with a strong and positive placebo response. There is still some truth in what they say. The process of addiction always requires a time factor for the learning of the addiction to occur. But these persons have shown by their initial response that they are "fast learners." Therefore, barring unusual circumstances arising, an addiction develops rather quickly because the person is very likely to start drinking at a frequency and quantity that he or she will almost certainly shortly become alcoholic.

The psychologists Firestone and Catlett, in their excellent book "The Truth- an Approach to a Psychological Cure" use the metaphor of an "emotional bond." It is also an "attachment-behavioral bond," and can seem to be located in other persons, things and even some ideas. This is obviously the psychological phenomenon of "transference"- although they never did name it as such. Their treatment of the concept is particularly helpful in gaining an understanding of the crucial role of transference in substance dependency. They first defined their meaning of "emotional bonds" and then commented on what can be the problems of breaking one of these bonds:

"By taking in the rejecting attitudes of the parents and identifying with them through imitation and preserving them through the inner voice, the child forms a fantasy of being self-sufficient, of having everything he needs within himself. This is the first bond, so to speak, a kind of close tie with his parents within himself- in effect, a self-bond...A bond is an imaginary connection with another person and is used to allay pain and anxiety. When a bond is broken, the underlying pain surfaces. People from tremendous resistance to the truth to ward of the pain of breaking a bond. They will literally destroy themselves to hold on to their bonds, imagining that they are holding on to people."

The unconscious parental ties or meanings of the substance in a "substance dependency" are particularly meaningful in a linguistic sense because they automatically repeat, in a way, a personís experience of early "parental dependency." But transference developing toward a thing like alcohol is obviously much more irrational than that toward another person- which need not be at all pathological. In combination with splitting (into "good and bad aspects of the object"), it always represents the basic core of any addiction (substance or not), and is always ultimately at least a little harmful to the person. The addict always experiences a very strong need to highly repress his or her self-knowledge of this source of artificial self-love and illusory power from any conscious awareness- and for a number of reasons. And the obvious first line of defense against such knowledge is the denial of the addiction itself. There is an inevitable increase in narcissism that occurs in the origin and practicing of a substance dependency. This is intimately associated with the ego-regressive effects of a dependency.

The progression of a substance dependency with the increasing negative consequences of its practice sorely threatens the very important initial "good parent" symbolizing or labeling of alcohol for the alcoholic person- and thus also lessens the pleasure of drinking. To counter this, some alcoholic persons will "act out" this internalized splitting in a creative way by creating an outward denial/defensive "good alcohol/bad alcohol split." The person will maintain that he or she can handle beer or wine ("good alcohol") as well as ever. Its the "hard stuff," or liquor ("bad alcohol") that causes them all the trouble. This choice of beverages is made less because of the matter of its greater alcohol concentration, than stereotypes about it. But the person will always occasionally use the "bad alcohol" anyway. Seldom, if ever, is the person wrong in his or her negative expectations of its use. Inevitably, some negative (placebo) responses to the "good alcohol" also occur as the addiction progresses.

Dr. Weil also observed that the use of any consistent set of rules which apply to the times, occasions and amounts of addictive substance use has some protective effect against a dependency occurring. If one already exists, it limits its negative behavioral effects. The source of these rules could be anywhere, including the person himself- though they would have more force if socially imposed. He didnít explain how or why this effect should occur. I am convinced that the reason is the narcissistic-limiting effects of following any rules. Obviously, using the addictive substance whenever, and to whatever extent that the person feels like at the moment is a more narcissistic position to take. A businesswoman had a strict policy of having six drinks daily- two at lunch, dinner and in the evening. She often had the evening drinks in a bar, and one evening she gave into the temptation to have a third drink. The next morning, she was surprised and upset when she woke up in a strange bed with a strange man. This was the first time this had ever happened- but not the last!

An understanding of narcissism ("self-centeredness") is important to a good understanding of any type of addiction. Everybody has a narcissistic side to their personality. Hopefully, the more mature, adult, and altruistic side of a personís personality and character will be able to play the role of "good parent" to the vulnerable "inner child" to safely control its immature and narcissistic tendencies. Narcissistic satisfaction and power is the all-important common denominator in substance and non-substance addictions. One way to understand a strong and progressed substance dependency is to see that it both represents and fuels an unconscious, compulsive, and destructive quest for "unconditional love." For example, in an abusive marriage the desire for illusionary evidence of such may paradoxically be partially satisfied merely by the mistreated partner not leaving the mistreating partner. The person who later becomes an addict doesnít necessarily initially have a greater amount of narcissism than the average person. But the process of becoming an addict and, especially, the practice of an addiction always increases the personís narcissism, or potential for same. This doesnít mean the person necessarily becomes a "narcissistic person." Such implies that a personís narcissistic tendencies exceeds their altruistic ones. A recovering alcoholic person, for example, may become quite a mature and altruistic person. Cessation of the practice of the dependency is usually, but not always, associated with a decrease in a personís narcissism and a healthier adjustment in general.

It is fairly well-known fact that the use of heavy doses of opiate-type drugs for the relief of chronic and severe pain seldom results in an opiate addiction. I think the explanation for this phenomenon is inextricably linked to the issue of narcissism. The conditions of this strongly utilitarian use of opiates precludes enough narcissistic leeway for an addiction to develop. The psychologist Gary Forrest, in his book "Alcoholism, Narcissism, and Psychopathology," reported an interesting finding involving a relatively small number of alcoholics. They are true sociopaths, who fail to show any compulsion to drink. Should the results of their alcohol use become too painful, they simply stop drinking quite easily- at least for awhile. I think the reason for this is that, in these alcoholics (who are definitely not AA types), there is no inner conflict between the altruistic and narcissistic aspects of the self to fuel the compulsion to drink This is because the former is essentially absent. Therefore, unlike the case for most alcoholic persons, the personís narcissistic values arenít put at any risk by not drinking

The practice of any addiction is an exercise in narcissism. Dr. Aaron Stern, in his book about narcissism, made the wise comment that "all addictions were a narcissistic force." Psychological regression is intimately associated with sufficient narcissistic power. Regression, or the potential for same, is an integral part of any addiction. Sexual enjoyment has been characterized as a "regression in the service of the ego," and ideally, this will continue to be the case for any given person. But like the enjoyment of alcohol, the issue/practice of sex involves some finite risk of addiction. Substance dependency entails a greater risk of regression than for non-substance addictions. This is largely because there is the added pharmacological effect of the substance to stimulate narcissism. In turn, this invites unconscious and irrational fantasy related to its ingestion and, therefore, its becoming "part of the self." The psychological meaning of "regression" is that of a return to earlier and immature modes of thinking, feeling and functioning. The phenomenon of regression is very important to understanding substance dependency.

By definition, enough regression can result in a psychosis. This actually happens somewhat frequently in what I have termed "substance dependency-induced psychoses" (SDIP). It is a new diagnosis that I am working to establish. A university psychiatrist reported an association of the diagnosis of substance dependency in 80% of state hospital cases of schizophrenia. Unfortunately, he erroneously assumed that the mental illness comes first in these cases. His assumption wasnít based on the patient histories regarding the respective sequences of the dependencies and psychoses. Rather it was based on the "biological theory" that genetic factors cause both the mental illness and the dependency. But a substance dependency therapist on a dual diagnosis ward (schizophrenia and substance dependency) reported that, in over half of these cases, it was clear that the dependency came first. Its further investigation has been supported by the National Council on Alcohol and Drug Dependence. There is a link to an article on the diagnosis at the Mentalhealth.about.com web site on the menu list. Unlike this article which is aimed at general edification about substance dependency, it endeavors to help this very clinically important diagnosis to overcome its "political/biological incorrectness." This has caused academic psychiatry to almost unanimously "stonewall" the diagnosis, which has a critical need for a clinical trial to be organized by a medical school.

There is a substance abuse-related psychosis diagnosis which was established several years ago at the last revision of the DSM (the psychiatric diagnostic bible), which is entitled "substance-induced psychosis." Its ("very biological") criteria require that it be a "direct result of the physical effects of the substance-" which explains its two rather arbitrary 30 day time limits. It canít persist, or have its onset from the last use of the substance beyond that period of time. Although nearly all of the uses of the diagnosis involve addictive substances, its criteria completely ignore the issue of substance dependency. Its clinical value is minimal, except when non-addictive substances are involved.

Some years ago George Weinberg wrote a best-selling book entitled "Self-Creation," which was chiefly about making good habits and unmaking bad habits to better "create oneself." Is alcoholism a bad habit? It most certainly is- but it is no ordinary habit. Habits in general can be considered as usually having biological survival value for man and animals. The stronger the habit has become, the stronger is the sometimes irrational accompanying unconscious idea that it is dangerous not to practice the habit. In other words, the alcoholic person unconsciously (and often also consciously) has some fear of recovery. He writes

"The whole book is about habits because our convictions are not created by a single act. You have to reinforce them constantly by acting. The jealous person habitually reproduces his jealousy. The confident person makes confident choices and thereby regenerates confidence. We all repeat the same kinds of acts, and the underlying premise- jealousy or confidence, whatever- is reinforced in our minds. Every feeling, attitude, or belief that stays with you is being retained, reinforced, by strands that your choices weave. Choices you make constantly, habitually. This is the basic principle at work every day of your life behind the creation of your personality:
 

EVERY TIME YOU ACT, YOU ADD STRENGTH TO THE MOTIVATING IDEA BEHIND WHAT YOU HAVE DONEÖ ITíS AS THOUGH THE ACT RETYPES THE MOTIVATING MESSAGE IN YOUR MIND. WHEN ITíS ACTED ON, THE MESSAGE BECOMES BRIGHTER, LOUDER, RECHARGED, PROMPTING STILL MORE OF THE SAME ACTS."


The last sentence vividly depicts the nature of the risk of the "first drink" for an alcoholic after a period of recovery. It helps to make clear its importance- beyond the common sense fact that there can't be a second without a first and so on. The basic motivating idea (or world view) behind any substance dependency is that of narcissism- which is not the case with good habits: Richard Stiller in his book "Habits" wrote about habituation as a process by which an animal or person automatically continues to accept and practice a behavior- because of its being old, and thus also "safe. Therefore, it can be more or less ignored so as to be better able to concentrate upon that which is new and potentially dangerous. In substance dependency, the "logic of the habit" is, of course, very misleading.

It is falsely assumed by not only the general public, but also by the psychiatric profession, that alcoholism has a strong genetic or biological element. This understanding supports biological theorizing- because genes control the basic biochemical make-up of the organism. It also fosters hope that eventually a medication will be found to neutralize or eliminate the harmful effects of an alcohol dependency by getting at the inner-most source or workings of the disorder. But the reality is that no such possibility exists (like insulin for diabetes). Furthermore, David Lester, a prominent biological researcher recently concluded after a lengthy review of the pertinent literature that the evidence for genetic involvement in alcoholism was "weak at best." He explained that the popularity and persistence of the idea of a strong genetic factor had much to do with its "conformity to ideological norms." The famous Danish genetic study so often cited to prove a strong genetic element applied only to men (a sex-linked disease)?? This is despite the fact that women were also included in the study. Most importantly, the use of identical and fraternal twin comparison studies has never supported a genetic etiology for alcoholism. And such a study is the most reliable genetic investigating tool available. Psychiatrist George Vailant, in his acclaimed book, "The Natural History of Alcoholism" commented succinctly on the matter: "A person had as much chance of inheriting alcoholism as of inheriting the skill of being a good basketball player."

A particularly unfortunate, yet very common example of "biological psychiatric thinking" really having gone wrong is the use of lithium, or its equivalents, to "biologically treat" that which is too often only a bogus case of "bipolar illness." This happens much too often in the presence of a substance dependency- which may or may not also be diagnosed. The real diagnosis is usually one of a somewhat atypical substance dependency- with or without various psychiatric complications. It should be remembered that substance dependency doesn't usually respond well to medication as the main or only therapy. Some psychiatrists actually make a practice of diagnosing any substance dependent person who comes their way as also having the "more important" diagnosis of bipolar illness. But the majority of substance dependents don't need any medication- apart from detoxification therapy when needed. And the use of not-indicated medication in their treatment is at best a needless risk and a waste of money- and too often acts as a direct hindrance.

Very much contrary to current psychiatric understanding and practice, George Vailant wrote that bipolar illness is not more common in alcoholics than in the general population. (He also commented that there have been many "metabolic theories" proposed for alcoholism- but none have held up to scrutiny.) Once under-diagnosed, bipolar illness has become greatly over-diagnosed due to the subtle, but still seductive expectation of being able to effectively and easily treat it with medication. (It also enjoys good "P-R.") And biopsychiatrists do know that substance dependency isn't at all easy to treat "biologically." The major inpatient substance dependency treatment centers often initially discontinue medication used to treat this disorder- as not having been indicated to start with. Here we have a sorry situation where a non-existent disease is being treated- while the actual disease was likely largely being ignored. Probably the worst thing about this type of false diagnosis is that it offers substance dependents a dangerous, though subtle rationalization to de-emphasize their need for complete abstinence from the substance. For alcoholics, this tendency can be greatly aggravated if the person is told that his or her excessive drinking was "merely symptomatic" of their "bipolar illness." If the person does use the addictive substance, his or her condition usually deteriorates. And then the non-existent bipolar illness is simply considered to have gotten worse.

There obviously is no intrinsic reason why an interest in biochemistry has to result in the antipsychological, mechanistic, and overly simplistic thinking of mainstream psychiatry. A very positive example that biological psychiatry should learn from are the ideas of two biochemically-oriented psychologist authors who are interested in such "non-biological issues" as love, fantasy, self-identity, security, etc. Milkman and Sunderwirth are these authors, and they have recently written an excellent book entitled "Craving For Ecstasy" and subtitled "The Consciousness And Chemistry Of Escape." They demonstrate the necessary interrelatedness and interdependency between thoughts, feelings, behavior and biochemistry. In other words, they realize that these factors represent a "seamless whole." This is in stark contrast to biopsychiatrists who greatly emphasize biochemistry at the expense of the other three. (Nature [genetics/biochemistry] and nurture [the environment] donít represent a true dichotomy- and the mind and body donít represent separate worlds.) Their work has obvious relevance for substance dependency and SDIPs. They wrote that "love is the Ďpiece de resistanceí of addictions." This is because it manifests quite strongly the three ingredients of any type of addiction- which are arousal, satiation, and illusion. They write:

"Are criminals, cocaine users, sky divers, police, and lovers motivated by a similar adrenaline rush? Are comparable needs being met through alcoholism, overeating, and membership in a spiritually oriented group? The term 'addiction' was once reserved for dependence on drugs. Today it is applied to a range of compulsive behaviors as disparate as working too hard and eating too much chocolate. In fact, there are essential biological, psychological and social common denominators between drug use and other habitual behaviors. Whether your pleasure is meditation or mescaline, cocaine or cults, you are addicted if you cannot control when you start or stop an activity.

In this book we examine the age-old search for pleasure, finally from a new perspective. We transcend the inconclusive debate that surrounds substance abuse and focus instead on more basic issues of human compulsion and loss of control. The enslaving drive to feel good is inadequately explained as a function of a weakness of character, chemical imbalance, or spiritual defect...

From a psychological perspective, voluntary courtship of any drug or activity depends on how well it 'fits' with one's usual style of coping. The drug of choice is actually a pharmacological defense mechanism; it bolsters already established patterns for managing psychological threat. People do not become addicted to drugs or mood-altering behaviors as such, but rather to the sensations of pleasure that can be achieved through them. We repeatedly rely on three distinct types of experience to achieve feelings of well-being; relaxation, excitement, and fantasy; these are the underpinnings of human compulsion. As they say in show business, 'you've gotta feed em, shock 'em or amuse'em.'

Addiction: self-induced changes in neurotransmission that result in behavior problems. This new definition encompasses a multi-disciplinary understanding of compulsive problem behaviors that involves the concepts of personal responsibility (the behaviors are self-induced); biochemical effects (the body's neurotransmission changes); and social reactions (society absorbs the costs and consequences of problem behaviors)...

Given that we may voluntarily alter our neurotransmission to achieve a desired feeling, why do only some of us become compulsively involved in the pursuit? After all, most people can have a drink or occasionally rage at the race track without going off the deep end. Most addictionologists- even those who disagree about other matters of causation and treatment- agree that low self-regard is a crucial factor in all forms of addiction. The chronic absence of good feelings about oneself provokes a dependence on mood-changing activity. Manifest or masked, feelings of low self-worth are basic to most dysfunctional life-styles.

One way of coping with disquieting factors is to immerse oneself in an activity without serious self-evaluation. The climber, clinging to a mountain face with only a rope, pitons, and a tenuous foothold, has few moments to spare on self-derogation. The risk taker may figuratively bridge the crevasse of his or her sense of inadequacy by temporary surrender to something outside the self. A 32 year-old cocaine user reported a particularly vivid dream that illustrates this point: 'I recall seeing my personality as a huge concave surface. It looked like a great ceramic bowl with irregularly spaced craters on an otherwise smooth surface. Somehow I could patch the holes with an ultra fine paste made of cocaine. The new shimmering surface appeared nearly unmarred.'" This addict's dream imagery is a perfect visual metaphor, regarding the importance of cocaine in his inner and outer life

Biological psychiatrists consider dreams as neurological trash- meaningless. A better understanding is to compare dreams to "off-line computer time" where the person is unconsciously attempting to do problem solving in the form of trying to more fully integrate his experience. I think this man was correct about the meaning of his dream. One of the traits of many substance dependents is that of perfectionism. This is a reaction against feelings of low self-esteem- however, realistic or unrealistic these feelings may be. One writer referred to the "hero-zero split" of the perfectionist (and many alcoholics, in particular, are perfectionists). This metaphor says a lot. Obviously the "higher the zero," the "lower must also be the accompanying zero." Both images lie! Here is another view of the basic" good/bad" duality of any addiction. It also clearly indicates the plight of the addict. One recovering drug addict commented poetically about his personal growth in recovery from his addiction. He learned that: "Iím neither the giant of my dreams nor the midget of my fears."

From their chapter entitled 'Unreal Worlds':

"People frequently experience problems in living, and they may develop eccentric beliefs as highly personal and specialized coping devices. Clearly drug toxicity or internal biochemical imbalances are involved in much of the personality disorganization we describe as emotional disturbance. Yet the ability of many who have psychotic thoughts to function with great rationality stimulates a fascinating question. Are some 'crazy' people compulsively dependent on fantasy, as drug addicts may be to heroin or alcohol? Certainly there are some intriguing parallels, as the list of schizophrenics' characteristics reveals: DENIAL. Schizophrenics often deny that there is anything wrong with them or that their perceptions are inaccurate. COMPULSION. Schizophrenics often will choose not to take antipsychotic medications, which when properly administered, serve to reduce fantasy productions. LOSS OF CONTROL. Schizophrenics may suffer great damage to social, economic and health functions in relation to their uncompromising belief in the importance and authenticity of their delusions and hallucinations. RELAPSE RATES. For schizophrenics, drug addicts and alcoholics, recidivism is roughly the same, about 60-80% after 6-8 months of abstinence.."

Relative to this issue, one of my alcoholic patients had multiple and relatively brief SDIP episodes which ended only when he finally got serious about recovery from his alcoholism. On one occasion he made a very interesting and insightful observation: "One similarity about drinking alcohol or being psychotic is that either one is capable of making me feel powerful and important." That quote reminded me of the title of the book by psychologist Edward Podvol- "The Seduction of Madness." Certainly "feeling powerful and important" is seductive. He cited the four causes of functional psychoses as being schizophrenia, bipolar illness, personality disorders and substance abuse.



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