The International Journal of Psychosocial Rehabilitation
 

Self-experience from addiction to recovery: a qualitative study

Paraskevi Karakoula1
Sofia Triliva2

1Doctor of Clinical Psychology, Department of Psychology, University of Crete, Greece
evi_karakoula@yahoo.gr
2Professor of Clinical Psychology, Department of Psychology, University of Crete, Greece

 

Citation:
Karakoula P & Triliva S (2019)  SSelf-experience from addiction to recovery: a qualitative study..
International Journal of Psychosocial Rehabilitation. Vol 22 (2) 114-131



Abstract
Our aim in this qualitative study is to explore the self-experience of opioid addicted young adults from the perspective of Self Psychology. We conducted semi structured interviews with 22 men and women in the final phase of recovery and thematically analyzed the data in order to gain an in-depth understanding of the way opioid addicted adults experience their selves in relation to others, substances, and therapy. The findings elucidate ways in which narcissistic dynamics characterize the addicted individuals’ sense of self. The participants’ accounts converged into four core themes: (1) Developing camouflage in order to conceal the vulnerable and shameful self, (2) Seeking acceptance for a needy depleted self, (3) The disconnected self and its mechanistic abuse of drugs and significant others, and (4) Difficulties in regulating affect and containing aggression. Discussion focuses on implications for therapy, with an emphasis on the prominent role of shame.

Key words: Addiction, Self-experience, Vulnerability, Shame, Affect dys-regulation



 


Introduction:

This qualitative study focuses on the self-experience of opioid addicted individuals from a clinical psychoanalytic framework, namely Self Psychology (Kohut, 1971). From this perspective, addiction is understood as a symptom of a disturbance along the developmental line of self and narcissism, which burdens people with a constituent vulnerability to addiction (Kohut, 1977). Many qualitative studies on addiction are in social psychology and health psychology and focus either on drug abuse as a social phenomenon highlighting identity or on risk factors, rising trends, new substances, and public health implications (Neale, Allen & Coombes, 2005). Nevertheless, some of these studies address certain themes that touch on the phenomenology of narcissism, such as shame (Ehrmin, 2001; Hines, 2011; Neale, Sheard & Tompkins, 2007), self-esteem and boredom (Boys, Marsden, Fountain, Griffiths, Stillwell & Strang, 1999), aggressiveness (Roy & Jones, 1979). Larkin and Griffiths’ Interpretative Phenomenological Analysis study (2002) emphasized the concepts of self and identity as central themes in the addicted participants’ subjective experience and their findings cover a wide realm of what is clinically understood as the phenomenology of narcissism; ambiguity and uncertainty; rejection, abandonment and parentification; filling a void within the cycle of addiction; experiencing anger and shame that both lead to and result from drug abuse; concerns for the self-presentation as opposed to the authentic self and emotional experience; self-consciousness and self-loathing; and addiction as an identity and dependence on treatment. Using in-depth interview data, we explored the following questions: How do participants describe their selves and their relationships with significant others and drugs in different stages of their lives? How do they experience their self? What, if any, alternating self-states and experiences are described?

Methods:

Participants

The participants were 22 Caucasian adult substance dependent individuals, members of a public residential treatment program in Athens. All participants were in the final phase of the program, ‘the Social Reintegration’ stage. The program extends from Counseling/ Awareness (outpatient treatment, 1-4 months) through Main Therapy (residential treatment, 6 - 10 months) to Social Reintegration (outpatient treatment, 8-12 months). We chose to invite individuals from the last phase to participate in the study, under the premise that they would have not been using substances a long period of time, and they would have acquired enough insight so as to better appreciate and describe their self and their history more readily. Half of the participants were men and half women. Their age ranged from 26 to 43 years of age [M=31.6(SD=4)] and their mean age of drug abuse onset was 15 years, ranging from as early as 11 to 26 years. All participants were poly-drug users and heroin was the substance of preference for everyone.

Procedures

Semi-structured interviews were conducted by the first author with each participant individually and their duration ranged from 45 to 90 minutes. Interviews were recorded and transcribed verbatim. Nonverbal cues were also included in the final text. The questions posed were along four main lines: a. childhood experiences, b. history with drug use, addiction and rehabilitation, c. interpersonal relationships, and d. emotional experience.

Sampling was purposive since participants were chosen because of the stage in recovery and opioid addiction they were in.

Approval for the study was provided by the review board of the treatment program and all participants provided informed consent.

Analysis

Transcripts were analyzed using Thematic Analysis (Braun & Clarke, 2006) due to its flexibility to be used with realist/essentialist paradigms in psychology, like Self Psychology. The participants’ experience, their meaning-making processes and the way they experience and make sense of themselves, constitutes a reality of drug use, abuse, addiction, and recovery.

Data analysis was conducted in stages, separately by the two authors (researchers’ triangulation; Robson, 2007), and each stage of analysis was followed by a reflective discussion on the data.

Open (inductive/ bottom up) coding of data was adhered to, primarily because the research question had not been previously studied. Comparison of all the codes given to the dataset by the two authors showed a 75-80% percentage of agreement, thus we proceeded to search for themes based on those codes. After agreeing on most initial themes, we returned to our data to test their cohesiveness (Braun & Clarke, 2006). At this stage, we further merged some themes, dropped others that could not be satisfactorily supported by our data, and, finally, concluded in four main themes.

Findings and discussion:

The participants’ accounts converged into four core themes;

  1. Developing camouflage in order to conceal the vulnerable and shameful self;
  2. Seeking acceptance for a needy depleted self;
  3. The disconnected self and its mechanistic abuse of drugs and significant others;
  4. Difficulties in regulating affect and containing aggression.

In the analysis of each theme, we followed a developmental perspective, already inherent in both Self Psychology and the participants’ narratives. This allowed us to underline both stability and change in self-experience along each phase of the participants’ lives.

Developing camouflage in order to conceal the vulnerable and shameful self

Hiding profound feelings of shame and one’s global self-devaluation from the eyes of others in order to salvage one’s image was an experience that all participants shared. Most narratives highlighted feelings of shame and concealing aspects of self as two sides of the same coin; shame describes the emotional experience and concealment is a defensive behavior employed to cover up unpleasant aspects of experienced reality from others.

Participants felt intense shame and, consequently, shielded their true self since childhood to earn love and acceptance. Their need to hide pertained to the self in total and was connected to a constant self-observation and self-consciousness, a need to be invisible.

 “I try not to show what I feel or think in my facial expressions. I focus too much on showing something neutral. Not so much to smile as to not show it in my face. I am focused in not showing it [...] Ever since I was a kid, I channelled all my energy in hiding, that was my goal, to hide. Hide what I feel, do, hide from my mom, my dad, my friends.” (Irene, female, 26)

 The need to hide is tied to shame, continues throughout their course in life and takes a toll on interpersonal relationships. As the following extracts reveal, shame originates from a sense of weakness, which cannot be tolerated because it contradicts their ideal self-image. This is inexorably connected to their trouble in seeking help.

 “When I felt pressured at home, I felt shame ... for being weak, for letting out a tear. I felt it was a weakness.” (Jason, male, 26)

“I had learned to be like an oyster, not needing anyone, feeling ashamed to ask for help, not showing my needs.” (Chris, male, 32)

 The extracts above are in complete agreement with clinical understandings regarding the role of shame and hiding in pathological narcissism. Akhtar (2000) and Gabbard (1989) suggest that narcissistically vulnerable individuals are easily ashamed for their needs and limitations, and remarkably sensitive to being exposed or placed in the spotlight. The extracts also confirm Kohut’s (1972) understanding of shame as one of two (along with rage) possible reactions to narcissistic injury.

However, our participants related shame, not only to the exposure of need or weakness, but also with being admired or even noticed. Both Kohut (1966) and Gabbard (1989) attribute this aspect of shame to an underlying conflict between an exhibitionistic need and a profound sense of unworthiness.

“What was worse was when my mom took me somewhere and they all said, “you are so pretty and sweet”, it made me nauseous… eh, I was ashamed in front of my fellow students, when the teacher said nice things about me. I never wanted to stand out.” (Robin, female, 32)

Participants described feeling ashamed not only for themselves, but also for others who failed to live up to their expectations and disappointed them. They felt that other people’s shame and shortcomings reflected on them.

“But this is why I will be ashamed that he is my brother, since he is not good enough, if we are seen together.” (William, male, 28)

“I was ashamed because things were not normal in me and neither was my family normal. I was ashamed because I had no father to come and back me up. I was ashamed because nobody ever showed up at school to see how I was doing. […] I was ashamed because my folks had these views ... I was ashamed because they did not let me participate in whatever other kids did […] but I used to take it on me. I mean I was ashamed for myself.” (Chris, male, 32)

The participants’ tendency to hide and adjust to others’ attributions contributed to splitting and multiple self-experience. The extracts that follow clearly echo Winnicott’s (1965) concept of a false self that adjusts to the needs of others, while the real self remains hidden.

“I used to change faces and behaviors, I was defined by others, adjusted to them.” (Christen, female, 30)

 “When I became an adolescent, it was like I started having two personalities; one was the good kid, good student, D.’s daughter, and the other was what I really wanted to be, although I did not know what that was yet.” (Sue, female, 29)

Their encounter with psychotropic substances defines the course of shame and hiding. Drugs can relieve from shame, the fundamental affect arising from narcissistic frustrations that people try to soothe with drug use (Wurmser, 1974).

“[when I was intoxicated] I did not feel ashamed, I felt safe - of course it was an illusion - but I was not ashamed anymore or so insecure about my image.” (Robin, female, 32)

Shame has also been related to addiction and research findings suggest that people with addiction problems experience higher levels of shame than both the general population and people with psychological challenges (O’Connor, Berry, Inaba, Weiss & Morrison, 1994). More importantly, it has been empirically suggested that shame is not just related to addiction but comprises a risk factor for addiction. People who experience higher levels of shame are more prone to addiction (Cook, as cited in Wiechelt, 2007), and children at the age of 10-12 that are prone to shame are also more likely to use drugs at 18 years than their less ashamed peers (Tangney & Dearing, as cited in Wiechelt, 2007).

The participants descriptions of hiding in the years of drug use reveal that it functions to protect the self’s relationship with the substance, it safeguards a personal space, an identity, an important relationship.

 “The only thing that was mine, private, was drinking alcohol. Nobody knew at school, my friends, not even the closest ones … I brought bottles at school and nobody knew, it was just me and it.” (Mary, female, 29)

This function, as any positive psychotropic effect, is only temporary. The progression of drug misuse and, inevitably, addiction reinstates a sense of shame that, once again, needs to remain hidden from the eyes of others.

“It was too stressful, I had to keep up appearances, seeming ok and in control, while I was actually walking on a tight rope.” (Μartin, male, 34)

Shame, as a result of the tragicness of addiction, has been highlighted in two qualitative studies on the addiction experience. An ethnographic study of addicted women (Ehrmin, 2001) suggests that their unresolved feelings of shame and guilt are related to an experienced insufficiency in their role as mothers and, in turn, hinders their rehabilitation. Another study (Rhodes, Watts, Davies, Martin, Smith, Clark & Lyons, 2007) on the subjective experience of public intravenous drug use has highlighted both these addicted individuals’ need to avoid public exposure and their sense of shame and self-consciousness. Their constant exposure and negative associations with their drug use behaviors result in self-devaluation.

The studies mentioned above suggest a circular relationship between shame and addiction; shame enables and preserves addiction, as well as it results from it. Shame and concealment also accompany recovery efforts. The participants describe how they continue to conceal, protect their relationship to the drug, thereby sabotaging their treatment.

“I concluded the program with some relapses […] but I always knew I would use again […] I felt it all the time and I never expressed it or tried to figure out why. It took me 5 years to overcome this situation.” (Philip, male, 36)

Findings from two qualitative studies suggest that a non-judgmental and caring approach by addiction professionals would facilitate addicted individuals’ seeking help and their involvement in therapy (Hines, 2011; Neale et al., 2007). Also, it has been found that high sensitivity to humiliation comprises a risk factor for relapse (Salazar, Ripoll & Bobes, 2010), and a shame-focused intervention is related to reduced levels of shame, less days of drug use and better therapy attendance at follow-up (Luoma, Kohlenberg, Hayes & Fletcher, 2012).

Seeking acceptance for a needy depleted self

The second theme was the most prevalent in our data, both central in the participants’ narrations and with a special emotional importance to them. It concerns their deficient or defective self, where self-esteem is contingent upon others’ acceptance, confirmation, admiration or attention.

They describe a sense of inferiority, unworthiness, and emptiness, with concomitant desire to be accepted, that clearly points to the phenomenology of narcissistic vulnerability, as it has been theorized by Self Psychology (Kohut, 1971) and recently described and distinguished from narcissistic grandiosity (Cain, Pincus & Ansell, 2008). The empty self, inferior by comparison to others, with a constant need for affirmation due to a lack of an integrated self-image comprises the very essence of narcissistic vulnerability (Kohut & Wolf, 1978).

This sense was always present in our participants’ lives and connected in their stories regarding relatedness. Parental relations were all about unresolved acceptance needs and efforts to live up to parents’ expectations, who, in turn, used their children to fulfil their own narcissistic needs. The extracts below go along with Miller’s (1996) work on childhood experiences of being used as a narcissistic extension and the development of challenges, like addiction (Miller, 2006).

 “I had to show, to not break the image of the good kid, of the family, strange situation [...] it’s an inner voice that is not mine after all, the one that tells you to be perfect [...] live up to a family standard, you don’t choose if you want to be it or not.” (Sue, female, 29)

These deficiencies in self-experience accompanied our participants into their adulthood. They are related to low self-esteem, intolerance to criticism and are further fuelled by a constant comparison to others.

“I had a permanent sense about myself, that there is a genetic dysfunction in me, that I had to be something else in order to belong. But something had gone really wrong since the day I was born.” (Chris, male, 32)

“I always felt insecure, insecurity, I always carried that feeling. I never had the courage to express myself. Whatever I did, I did for others to accept me.” (Philip, male, 36)

The extracts above delineate the sense of unworthiness and contingent self-esteem described in the narcissistic vulnerability literature. A sense of psychological fragility, fear of disintegration as a result of criticism, and affirmation needs are central narcissistic vulnerability signs (McWilliams, 2011). Self-esteem has been historically linked to narcissism (Freud, 1957/1914; Horney, as cited in Ronningstam, 2005; Kernberg, 1975; Kohut, 1971; Reich, 1960), and low self-esteem, in particular, is hypothesized to characterize all people with narcissistic disturbances, although it is more explicit in the vulnerable types (Horney, as cited in Ronningstam, 2005; Reich, 1960). Recent research (Zeigler-Hill & Jordan, 2011) further explains the dynamics of self-esteem and narcissism suggesting that narcissistic personalities have high explicit self-esteem, which is fragile and labile, and in a deeper level they lack confidence and pride and are intensely self-critical.

Furthermore, self-esteem has been negatively related to narcissistic vulnerability in a group of addicted individuals (Ripoll, Salazar & Bobes, 2010). It was also found that it mediates a. childhood abuse and addiction in adulthood (Stein, Leslie & Nyamathi, 2002). b. the effect of insecure attachment in drug use (Kassel, Wardle & Roberts, 2007) and c. the relationship between family functionality and adolescent addiction (Jimenez, Musitu & Murgui, 2008).

Although the vulnerable self-state is the prominent, it is not the only self-state our participants report. They experience an alternation of opposite self-states regarding their self-esteem and sense of efficacy. The shift between self-states of vulnerability and grandiosity is rapid, dependent upon external cues and they are unable to satisfactorily regulate it.

“Yeah, and I am also absolute, I may feel absolutely special and the exact opposite in no time. At the opposite end, with just one word from you. I have always been like that; I balance between extremes. I may speak to you and be all confident and then I feel the burden of this relationship, that I won’t live up to it, and I collapse” (Philip, male, 36)

This dynamic is extensively discussed in the literature (Kohut & Wolf, 1978; Levy, 2012; McWilliams, 2011; Ronningstam, 2005) as alternating self-states in pathological narcissism. Ronningstam (2005) perceives this alternation - along with the unstable self-esteem, its external contingency and the accompanying affective instability - as the main defects with narcissistic personalities’ self-esteem regulation. Ronningstam (2005) suggests that a tendency towards grandiose self-experience is what makes some narcissistic individuals more vulnerable to addiction. Findings from Blatt’s research in addiction (Blatt, Berman et al., 1984; Blatt, Rousanville et al., 1984; Blatt, McDonald et al., 1984) support this view; he suggests that addicted individuals try to manage severe depression, which is organized around themes of self-judgment, guilt, shame and unworthiness, by withdrawing in self-induced experiences of omnipotent bliss and merger, since they cannot tolerate the stress accompanying interpersonal relations. Grandiose fantasies involving the self tend to focus on being different or exceptional (Ronningstam, 2005). Indeed, participants use fantasy to feel admired, superior or contented in an ideal or grandiose self-state.

“I fantasize I star in a play a lot … yeah, I have this fantasy […] that I am in the center of attention, I like that, I want that, I ask for that” (William, male, 28)

However, any state of grandiosity involves an ideal self. The participants’ experience of their real self consists in the deficit, the fragile self-esteem and the agony of what others think, which defines their self-image. According to their stories, psychotropic substances function as a patch for a gap in the self, that covers insecurities, (pseudo)integrates the defective self and relieves from burdening expectations. Their narratives echo Kohut’s (1977) understanding for the development of addiction in a context of narcissistic deficits. Kohut (1977) perceives psychotropic substances as a fake self-object, used as an extension of the self, covering the users’ deficits. Yet, as Ulman and Paul more recently (2006) suggested, substances have a harrowing quality, since they are not psychically internalized and constantly elude the users.

“I never felt full, even more so before ever using drugs [...] like a void that cannot be filled. Feeling unappeased, like you want something, don’t know what it could be, and you cannot fill it. Then the drug comes and fills it up just fine and you forget everything, and you don’t feel or think.” (Sue, female, 29)

Nonetheless, as addiction took hold, the idealized view of the drug dissipated. Drugs can not cover any deficits and result in intensifying them. They impede the development of the self by substituting the substance for healthy relationships and functions. Feelings of weakness and underestimation return more intensely, as new reasons for self-loathing have accrued.

“I had never imagined the abjection, depressed. Lying in bed waiting to die [...] I could not face my reality. I didn’t even know who I am, what I am doing, where I stand [...] I was completely lost, a void, it was like I could not think.” (Robin, female, 32)

In our participants’ stories, the tragedy of addiction is followed by a search for some magical solution that will function like another drug, an idealized omnipotent object (Kohut, 1971).

“I have made so many efforts, charlatan doctors promising incredible cures. I have been admitted twice for blood cleansing remedies, naltrexone fast-forward withdrawal, naltrexone patch, pill, gum [...] Buddhist convents, meditation centers. Every time, I grabbed at something thinking it was my salvation.” (Chris, male, 32)

Their incessant need for acceptance finds its way to the recovery program. The participants describe how they found there a chance to be seen as they really are, to be heard, understood and accepted for the first time. They felt contained by a more appropriate, yet still idealized, object and committed to changing their life.

“In the program, I feel well, I feel respected, I feel seen” (Irene, female, 26)

 “I found stability here, love, and understanding. Yes, there is also guidance, rules, [the notion] that what you did was wrong, and you must face the consequences, but in a more supportive way” (Martha, female, 43)

The changes in the participants’ self-image and self-esteem are consistent with research findings that confirm the role of unstable self-esteem in addiction and suggest that the duration of rehabilitation is related to gains in self-esteem (Carmichael, Linn, Pratt & Webb, 1977; Ucman & Prosan, 2007).

The disconnected self and its mechanistic abuse of drugs and significant others

A third central theme in our participants’ descriptions involves a non-human quality that characterizes both their sense of self and their relationships.

They describe an absent or detached self who mechanistically interacts with others. From a developmental perspective, this quality is present in their childhood relations with their parents, more accurately in the way their parents used them. They experienced themselves as being “used” and, in turn, “used” other people and substances in the same way. It should be noted that we use the term use and not relate following Ulman and Paul (2006) who introduced the concept of “use psychology”, as opposed to relational psychology, to describe a specific quality in drug dependent individuals’ interpersonal behavior.

The authors (Ulman & Paul, 2006) draw on their psychotherapeutic work with people dependent on various self-objects (drugs, food, sex, etc.) to brilliantly highlight the mechanistic or detached quality in the self-sense and use of others as non-human. In our participants’ accounts, this mechanistic quality both precedes and is expressed with the drug abuse, as the authors have also pointed out (Ulman & Paul, 2006).

Retracing their family lives, they described an absence of emotionally meaningful relations. Interactions are procedural and serve the maintenance of a good or normal image.

“We never talked about anything else, only what concerned the chores … Stuff like “how are you, how was your day at school?” was non-existent by both parents, so basically they never asked about me, how I am, feel, think, do.” (Gina, female, 33)

“In my family we have good relations, but not meaningful. They were there for practical and material things, but there was no meaningful communication.” (Sue, female, 29)

Their parents’ “use” of our participants as children ranged from emotional neglect through their use as non-human self-objects to cruel abuse.

“From a young age I felt I was the big sister that had the role of the protector, father, friend, very strange situation […] depending on the phase we were in I had to assume a different role [...] like an obligation, like I had to break in a thousand pieces and be everywhere […] then I could not handle it and started the drug use” (Sue, female, 29)

“Perhaps my relationship with my mother was a little dependent. I had to take care of her, taking her to the toilet, the doctor, her medicine[...] and you know what, she passed that without pressure, like “Oh, A., you are such a good boy taking care of me”, she made me want to be the good boy without me really wanting it” (Andrew, male, 34)

“She wanted to construct something, like she wanted to […] she tried that with violence, a lot of beating and oppression with no reason [...] she wanted total control over me.” (Philip, male, 36)

Growing up they internalize this “use” as their sense of self. They do not feel like autonomous, alive entities and experience themselves like machines - robots - or absent and detached from their inner and surrounding world.

 “I acted like a robot. Went anywhere, talked to anyone and could not understand or observe anything happening, it was all mechanistic […] I did not know myself, my characteristics […] things just happened” (Gina, female, 33)

This mechanistic quality extends to their adult interactions, even with those described as significant others, who perform specific functions and are not experienced as separate.

“Attempts to revise myself, that I have matured emotionally, like living with somebody, are not really important. Emotionally, the absence that characterizes me in my relationships was always there.” (Chris, male, 32)

“I have no relationship with my child […] I have not understood that I have a child, I thought of it like a teddy bear, “do this, do that, serve my needs” and nothing further.” (Maurice, male, 37)

 Blatt has also noted the self-object use of others described in these last extracts in his studies on the psychodynamics of addiction (Blatt, Berman et al., 1984; Blatt, McDonald et al., 1984; Blatt, Rousanville et al., 1984). He suggested that people with (heroin) addiction cannot perceive of others as separate and develop meaningful relationships.

The participants’ encounter with opioids is characterized by the same detachment discussed here. Interestingly, it coincides with their accounts of desirable effects of drug abuse and a problem in the continued abuse.

“I first took heroin in the army. Incredible feeling that I could leave and not even be there […] I found the absolute partner” (Martin, male, 34)

This short extract excellently portrays not only the positive experience of detachment, but also the investment in heroine as a human self-object, a “partner”. Indeed, according to Ulman and Paul (2006), the disturbance of self-object relations in addiction consists not only in using others as non-human self-objects, but also in investing in the substance like in a human self-object and attributing magical quality to it.

Relevant to the detachment experiences discussed here is the phenomenon of dissociation. Dissociation has been related to addiction by Ulman and Paul (2006), and also, some studies suggesting that adult victims of emotional abuse use drugs to induce dissociative experiences (Langeland, Draijer & van den Brink, 2002; Somer, Altus & Ginzburg, 2010). Furthermore, based on clinical observations, Burton (2005) suggests that addictions are consolidated in dissociated self-states. Ulman and Paul (2006) agree that dissociation is present in addiction, when individuals use substances to induce the numbness and detachment described by our participants above. However, they (Ulman & Paul, 2006) point out that it is not the substance of choice that is addictive, but the fantasy it helps induce. Empirical findings offer support for this hypothesis. It seems that childhood experiences of emotional abuse are related to dissociation, regardless the effect of later substance abuse (Schäfer, Reininghaus, Langeland, Voss, Zieger, Haasen & Karow, 2007).

Besides, Ulman and Paul (2006) do not suggest that dissociation is exclusively related to addiction. They perceive it as a defence that allows individuals to activate different self-states, achieve numbness, self-absorb in, often, grandiose and omnipotent fantasies, in the same way narcissistic personalities self-indulge in the same hypnotic-like states. This mechanism has been earlier described by Kohut as vertical dissociation (1971), in order to explain the alternation of self-states and how these may materialize in pathological narcissism. Consequently, dissociation, a rather broad clinical phenomenon, allows for a better understanding of the detachment experiences discussed here.

Detachment experiences gradually became dysphoric for our participants, as addiction took hold. It is unclear whether the substance cannot perform its role due to a physiological tolerance or they are now tired from this disconnection. Either way, they describe it as a problem. The extract below refers to the period right before abstinence.

“Somehow the good experience started to fade and … you know I felt like it moved - I went out and it was like I was in a bubble and everybody else was… moving parallel to me and I could not be in either side or anywhere else.” (Christen, female, 30)

The first detoxification efforts were also experienced mechanistically. The participants put their robot-body, disconnected from the self/subject that only observed, in the hands of, again, magical medical solutions, in the same psychodynamic modus they were operating in addiction. Sometimes they even ignored what was happening to them, they were unable to estimate the dangers, or they were detached from the body that received - sometimes - violent solutions. They describe it like they were not present or like they were robots to be repaired.

 “I was at some clinic for a month, they did something with the blood, I am not sure exactly what it was. It did not work out either” (Claire, female, 28)

“The naltrexone implant is illegal in Greece, the FDA has not approved it, and they stick it in here [pulls shirt up, shows where]. They make an incision, put it there and stitch you up.” (Chris, male, 32)

Finally, when they accepted the ineffectiveness of such methods and proceeded to therapeutic rehabilitation centers, they were still operating mechanistically and were detached from others. The detachment experienced at this time may be understood as a dissociative experience ensuing abstinence. A relevant study (Somer et al., 2010) suggests that dependent individuals mention a rise in automatic (as opposed to chemically induced) dissociative experiences, after the abuse has already stopped.

“I was shocked when I entered the program. It seemed like from another galaxy. I found it strange even seeing two people having a conversation … a different feeling, I was not in there nor thinking about using. Somewhere in the air [...] I did not know who I was, where I stand […] completely lost, a void, like I could not think…” (Robin, female, 32)

The last extract clearly depicts the automatic way our participants functioned and their difficulties in assuming agency. Their descriptions portray their tormenting struggle to leave the shadows that comprised their existence (Matsa, 2001).

Difficulties in regulating affect and containing aggression.

The fourth theme that reoccurs in our interviews is the difficulties our participants have in affect self-regulation, namely with expressing emotion, tolerating affect and regulating its intensity. Additionally, anger and aggression are central in their affective experience and related to the affect regulation difficulty.

These difficulties existed early in our participants’ lives in the context of their childhood parent-child relationships. They recount the way their parents pressured, rejected, abused or inhibited their emotional expression and did not allow for the development of affect regulation mechanisms.

“I was certainly afraid and scared to express my emotions, since [my mother] would censor it anyway, because it is wrong to externalize your feelings. So, when I entered adolescence, around 11-12, I had stopped expressing my emotions, I stopped talking about them” (Mary, female, 29)

Other participants describe that they can express their anger and aggression, but they are unable to moderate their intensity. They experience rage, that may even lead to physical aggression.

“My mother was overprotective with me ... eh… sometimes she was really violent, when I did not go along her ways […] when I reacted, I trashed the place” (Philip, male, 36)

Nevertheless, aggression was not directed exclusively to their parents. It traversed the participants’ experience, and, even before substance abuse, rage was central in their emotional experience, as a reaction to feeling deprived, ignored, criticized and devalued.

“I become angry with people that make fun of me, devalue me or do not respect me.” (Αndrew, male, 34)

“I have a soft spot for injustice, when I feel me or somebody else is the underdog. I react badly. I get angry, become violent and so on. I am still working on it.” (Stan, male, 34)

 The anger and aggression described above is what is referred to by psychoanalysts as narcissistic rage and it has been related to pathological narcissism. Kohut (1972) understands narcissistic rage as a reaction of narcissistically injured individuals to some frustration, often humiliation, injustice, devaluing or realizing one’s limitations, which threatens their fragile self-esteem. Kernberg (1975) has also suggested that angry reactions towards rejection characterize narcissism. Research confirms this hypothesis. It has been shown (Bushman & Baumeister, 1998; Rhodewalt & Morf, 1998) that narcissistic personalities are characterized by an intense affective reactivity toward the source of an insult when they feel their Ego and self-esteem is under threat. In such instances, they appear judgmental, react ragefully, become sadistic, and sometimes also present with more sophisticated expressions of their aggression.

As displayed below, this emotional reactivity ranges from being judgmental to physical violence.

“I can be a little ironic, sarcastic, pugnacious.” (Andrew, male, 34)

“I become ironic and hostile. I used to yell and ... act violently.” (Robin, female, 32)

“I go off so easily. I try to be patient, but I can’t. A moment may come that I will blow everything up.” (Hannah, female, 34)

“I could never manage my anger; I became aggressive and violent.” (Philip, male, 36)

 “In general, I have a thing with violence and anger. I could not express my emotions, and when I am moved emotionally, I externalize it as violence and anger.” (Pam, female, 27)

Aggression as a result of perceived threats to self-worth has been reported to be positively associated to narcissism (Bushman & Baumeister, 1998; Bushman, Baumeister, Thomaes, Begeer & West, 2009) and negatively to self-esteem (Donnellan, Trzesniewski, Robins, Moffitt & Caspi, 2005). Moreover, according to Okada (2010), vulnerable narcissistic personalities present cognitive and emotional elements of aggression, for instance, hostility and anger when rejected, whereas grandiose narcissistic personalities also engage in physical and verbal aggression when provoked. Findings of another study (Lobbestael, Baumeister, Fiebig & Eckel, 2014) suggest grandiose narcissism is related to externalized aggression and vulnerable narcissism to self-reports of aggression. However, in a series of studies on the nature and the origins of narcissistic rage, Krizan and Johar (2014) emphasize narcissistic vulnerability as the powerful motivating force for rage, hostility and aggressive behavior, which is triggered by distrustfulness, gloominess and angry rumination. Krizan and Johar (2014) conclude that narcissistic vulnerability explains narcissistic rage, without involving antagonism and exploitativeness, and supports clinical theories that involve defective self-esteem as an important drive for aggressive behavior.

Apart from threats to self-esteem, a sense of entitlement also results from feeling wronged and reacting with anger and aggression, according to our participants’ accounts. Their sense of entitlement contributes to their angry arousal when they are deprived of what they think is due to them (Reidy, Zeichner, Foster & Martinez, 2008; Witte, Callahan & Perez-Lopez, 2002). This is even more so when others enjoy what they think belongs to them, resulting in envy.

“Anger had to do with everything in my life […] things I saw others had and I didn’t. But unconsciously, I was not aware of that. I saw happiness around me and, because I was not happy, I became angry and reacted violently […] I was angry with myself and others, anger was an integral part of my life.” (Chris, male, 32)

Participants experienced difficulties in moderating the intensity of not only anger, but most emotions. They also often experience alternations between opposite and extreme emotions, that they cannot regulate.

“Any emotion I have is very very intense; joy, it will be so intense that I do not know what to do with it; sorrow, very intense, sadness, it will be intense, everything is so intense. When I feel something, it is intense. So much that I cannot moderate it, any emotion [..] Everything is so intense, what is it with that?” (Hannah, female, 34)

The psychoanalytic literature addresses this difficulty with affect regulation concerning both narcissism and addiction. Ronningstam (2005) suggests that the difficulties narcissistic personalities face with affect regulation consist of the presence of rather strong negative emotions, on the one hand, mainly shame, envy and anger, and in the low tolerance of their nature and intensity. Furthermore, she suggests (Ronningstam, 2005), as did Reich much earlier (1960), that the difficulty with regulating affect is dialectically related to the difficulty with self-esteem regulation. Ulman and Paul (2006) also discuss affective dys-regulation in narcissistic personalities and focus on the dialectic between affect and fantasy. Alternations and difficulty with self-regulation concern not only affect, but also self-esteem, and also implicate the role of fantasy in alternating affective and self-states.

Emotional dys-regulation is associated with the tendency to abuse substances to regulate and soothe the self and emotions. The self-medication hypotheses developed by Khantzian (1985; Khantzian & Mack, 1983), Krystal’s (Krystal, 1998) understanding of internalization and externalization problems that prohibit the practicing of self-regulating and self-soothing functions, along with McDougall’s (McDougall, 1984) views on alexithymia and hypo-symbolization describe the difficulties people with addictions experience. Krystal (1998) considers self-dysregulation inherent in narcissism, as well as in the addictions.

Empirical findings support the above theoretical considerations. Blatt (Blatt, Berman et al., 1984; Blatt, McDonald et al., 1984; Blatt, Rousanville et al., 1984) found that individuals addicted to opioids present with unstable affect. Anger, in particular, has been empirically related to addiction, as has the avoidance of difficulties. Eftekhari, Turner and Larimer (2004) found in a sample of incarcerated adolescents that anger, especially outward anger, and an avoidant style predict the development of addiction, and they suggest substance abuse is a way to regulate negative emotions or distract themselves from distress.

Participants describe the importance of substances in regulating affect and aggression. They turn to the substance in order to soothe negative emotions and undifferentiated affective tension.

“I couldn’t stand it and, instead of talking about it, I stashed it inside me and turned it into using. I took my anger out on using.” (Μaurice, male, 37)

“It helped freeze my emotion, like an armor, I’ve used it more like an armor than for pleasure.” (Martin, male, 34)

“I think using was my painkiller, my soother.” (Martha, female, 43)

However, some participants describe how the substances helped them experience emotions they otherwise could not due to their mechanistic use of self.

“I try to say something, be happy, because when you use you feel that. It may be an illusion, but you think it’s real and lasts. When you are sober, like I am for 318 days, what you live is kind of shallow. I don’t know if the heroin takes out emotions or is it an illusion, but you feel full of emotions. I mean now I cannot feel big joy or sadness” (Sue, female, 29)

Despite the soothing affects, aggression is still present when using, especially during withdrawal.

“At first, I had to take like 20 pills so as not to be on edge and do things I didn’t want to. I had hit my mother, stole, sent my brother to the hospital 3 times […] when we fought, I became really violent.” (Bob, male, 29)

“I had a fight with my step-father and burnt the house down. I wanted to burn them because he hit me. I was on cocaine withdrawal, it’s worse than heroin, it hits you at your emotions, your head. So, I dowsed the house in paraffin oil and set it on fire.” (Pam, female, 27)

Research findings, in line with these extracts, report increased aggression in people who abuse substances (De Moja & Spielberger, 1997), especially in withdrawal (Roy & Jones, 1979).

According to the participants, attending the rehabilitation program signifies abstinence from substances and also violence. They are encouraged to identify, tolerate and express their emotions, instead of using or act out violently.

“When I came here, my therapist - I try to remember what I was telling him at our first sessions. I spat out my raw pain, anger, I wonder how he could put them together […] suddenly, these people come and tell us “we would like to hear you, do it", and so I started trying to put my thoughts and feelings in order.” (Chris, male, 32)

Work on anger was for everyone an important part of their therapy, especially anger for their childhood experiences, which they connect with addiction.

“I have accepted it, after therapy […] I have talked about it, recognized it, I know why it happened. Whereas, when I first started talking about it, weird feelings of anger and sadness occurred. It is not like that anymore.” (Gina, female, 33)

“I mean, I don’t blame them anymore, before I came here, I was really angry with my parents.” (Claire, female, 28)

Empirical findings suggest that anger is alleviated in recovery therapy. It was found that hostility lessens in the first six months in recovery programs, whereas no change occurs with those who do not attend such programs (Small & Lewis, 2004). Another study (Bond, Ruaro & Wingrove, 2006) suggests that anger is moderated when people express their vulnerability to self-esteem threats that drives their anger (Bond et al., 2006), whereas no change occurs with the expression of anger alone.

Concl​usion:

The results from this qualitative study elucidate ways in which narcissistic dynamics characterize the addicted individuals’ sense of self. Participants experienced the core self as fundamentally ashamed and self-conscious with an incessant need for acceptance. This included interpersonal detachment or an absence or inability to self-regulate affect and contain aggression.

These findings are in accordance with the conclusions of Ronningstam (2005) pointing that what makes some individuals with narcissistic difficulties more prone to addiction are the severe forms of affect intolerance, the instability of self-esteem and the remarkable inclination towards grandiose self-experience. Our findings also echo her (Ronningstam, 2005) and Ulman and Paul’s (2006) point on the dialectic relation between affect, one the one hand, and self-esteem and fantasy, on the other.

Implications for therapy include that a focus on the difficulties with affect self-regulation, especially shame and anger, and on the instability of self-esteem, as it is expressed in the constant alternations between grandiose and vulnerable self-states may be fruitful. The prominent and intertemporal role of shame in addicted individuals self-experience has significant implications for treatment planning. O’Connor et al. (1994) suggest that confrontation may cause or maximize shame and relate to high drop-out rates. Moreover, distinguishing shame from guilt in therapy is of utmost importance. Misunderstanding shame for guilt, which is alleviated by confession and amends, further pushes ashamed individuals into hiding, since their overall sense of inferiority cannot be remedied by confession and remains unacknowledged (Kohut, 1977; McWilliams, 2011; Morrison, 1983). Lastly, those involved in treatment planning must collaborate with clinicians to identify and replace interventions that perpetuate shame. Additionally, clinicians should be trained in identifying shame in order to minimize its negative impacts and optimize treatment (Wiechelt, 2007).

Advantages, limitations and suggestions for further research.

The importance of this study lies in the in-depth understandings gained of opioid-addicted and in recovery individuals' sense of self and the self’s development, course through addiction, and efforts to change and (re)integrate. The study allowed for some insight into what the users of addiction recovery services experience as helpful, and hence therapeutic, rendering the findings clinically relevant and useful. Furthermore, our research underlines the necessity for recovery programs that restore a good enough sense of self as agent and promote the individuals’ social reintegration as independent persons.

Despite the pragmatic approach to reality we have adopted in this study, we acknowledge that dominant discourses influence people’s narratives. Therefore, it is important to acknowledge that our participants’ narratives have been co-constructed in various contexts, including the rehabilitation program and our interviews. This was a limitation that was difficult to surpass. What we tried to control was the “discovery” of preconceived theoretical categories in our data set. We used an open inductive coding to this end, and any theorizing was avoided until themes were derived from the data corpus.

Conducting more qualitative research in different phases of the life or the treatment of people with addictions, researching those who do not seek treatment, and those who experience narcissistic difficulties but do not develop addictions, may enlighten the relation between addiction and narcissism, and also the developmental course of vulnerable narcissism.

Acknowledgements:

The authors guarantee their sufficient participation in the planning, design, analysis, interpretation, writing, revising, and approval of the manuscript.

The authors declare no conflict of interest.

This research has been co-financed by the European Union (European Social Fund - ESF) and Greek national funds through the Operational Program “Education and Lifelong Learning” of the National Strategic Reference Framework (NSRF) - Research Funding Program: Heracleitus II. Investing in knowledge society through the European Social Fund.


References    

Akhtar, S. (2000). The shy narcissist. In: Changing ideas in a changing world: The revolution in psychoanalysis, eds. J. Sandler, R. Michels & P. Fonagy. London: Karnac Books, pp. 111-119.

Blatt, S. J., Berman, W., Bloom-Feshback, S., Sugarman, A., Wilber, C. & Kleber, H.D. (1984). Psychological assessment of psychopathology in opiate addicts. J. Nerv. Ment. Dis. 172:156-165.

Blatt, S. J., McDonald, C., Sugarman, A. & Wilber, C. (1984). Psychodynamic theories of opiate addiction: new directions for research. Clin. Psychol. Rev. 4:159-189.

Blatt, S. J., Rounsaville, B. J., Eyre, S., & Wilber, C. (1984). The psychodynamics of opiate addiction. J. Nerv. Ment. Dis. 172:342-353.

Bond, A. J., Ruaro, L. & Wingrove, J. (2006). Reducing anger induced by ego threat: Use of vulnerability expression and influence of trait characteristics. Pers. Individ. Dif. 40(6):1087-1097.

Boys, A., Marsden, J., Fountain, J., Griffiths, P., Stillwell, G. & Strang, J. (1999). What Influences Young People's Use of Drugs? A qualitative study of decision-making. Drug. Educ. Prev. Polic. 6(3):373-387.

Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qual. Res. Psychol. 3(2):77-101.

Burton, N. (2005). Finding the Lost Girls: Multiplicity and Dissociation in the Treatment of Addictions. Psychoanal. Dialogues, 15(4):587-612.

Bushman, B. J., & Baumeister, R. F. (1998). Threatened egotism, narcissism, self-esteem, and direct and displaced aggression: Does self-love or self-hate lead to violence? J. Pers. Soc. Psychol. 75:219-229.

Bushman, B. J., Baumeister, R. F., Thomaes, S., Begeer, S., & West, S. G. (2009). Looking again, and harder, for a link between low self-esteem and aggression. J. Pers. 77:427-446.

Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/personality psychology, and psychiatric diagnosis. Clin. Psychol. Rev. 28:638-656.

Carmichael, J. S., Linn, M. W., Pratt, T. & Webb, N. (1977). Self-concept and substance abuse treatment. Compr. Psychiatry 18(4):357-362.

De Moja, C. A. & Spielberger, C. D. (1997). Anger and drug addiction. Psychol. Rep. 81(1):152-154.

Donnellan, M. B., Trzesniewski, K. H., Robins, R. W., Moffitt, T. E., & Caspi, A. (2005). Low self-esteem is related to aggression, antisocial behavior, and delinquency. Psychol. Sci., 16:328-335.

Eftekhari, A., Turner, A. P. & Larimer, M. E. (2004). Anger expression, coping, and substance use in adolescent offenders. Addict. Behav. 29:1001-1008.

Ehrmin, J. T. (2001). Unresolved Feelings of Guilt and Shame in the Maternal Role with Substance-Dependent African American Women, J. Nurs. Scholarsh. 33:47-52.

Freud, S. (1914). On narcissism: An introduction. Standard Edition, 14. London: Hogarth Press, 1957.

Gabbard, G. (1989). Two subtypes of narcissistic personality disorder. Bull. Menninger Clin. 53:527-532.

Hines, L. (2011). The treatment views and recommendations of substance abusing women: A meta-synthesis. Qual. Soc. Work, 12(4):473-489.

Hopson, R. E. (1993). A thematic analysis of the addictive experience: Implications for psychotherapy. Psychother. Theor. Res. Pract. Train. 30(3):481-494.

Jimenez, T. I., Musitu, G. & Murgui, S. (2008). Family functioning and substance use in adolescents. The mediator role of self-esteem. [Funcionamiento familiar y consumo de sustancias en adolescentes: El rol mediador de la autoestima]. Int. J. Clin. Health Psychol. 8(1):139-151.

Kassel, J. D., Wardle, M. & Roberts, J. E. (2007). Adult attachment security and college student substance use. Addict. Behav. 32(6):1164-1176.

Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.

Khantzian, E.J. (1985). The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am. J. Psychiatry 142:1259-1264.

Khantzian, E. J. & Mack, J. E. (1983). Self-preservation and the care of the self: Ego instincts reconsidered. Psychoanal. Study Child 38:209-232.

Kohut, H. (1966). Forms and transformations of narcissism. J. Am. Psychoanal. Assoc. 14:243-272.

Kohut, H. (1971). The analysis of the self. New York: International Universities Press.

Kohut, H. (1972). Thoughts on Narcissism and Narcissistic Rage. Psychoanal. Study Child 27:360-400.

Kohut, H. (1977). Preface. In: Psychodynamics of drug dependence, eds. J. D. Blaine & D. A. Julius. Washington DC: U.S. Government Printing Office, pp. vii-ix.

Kohut, H. & Wolf, E. S. (1978). The disorders of the self and their treatment: an outline. Int. J. Psychoanal. 59:413-425.

Krizan, Z. & Johar, O. (2014). Narcissistic Rage Revisited. J. Pers. Soc. Psychol. 108(5):784-801.

Krystal, H. (1998). Affect regulation and narcissism: Trauma, alexithymia and psychosomatic illness in narcissistic patients. In: Disorders of narcissism: Diagnostic, clinical, and empirical implications, ed. E. F. Ronningstam. Washington DC: American Psychiatric Press, (pp. 299-325).

Langeland, W., Draijer, N. & van den Brink, W. (2002). Trauma and dissociation in treatment-seeking alcoholics: Towards a resolution of inconsistent findings. Compr. Psychiatry 43(3):195-203.

Larkin, M. & Griffiths, M. D. (2002). Experiences of addiction and recovery: the case for subjective accounts. Addict. Res. Theory 10(3):281-311.

Levy, K. N. (2012). Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder. J. Clin. Psychol.: In Session 68:886-897.

Lobbestael, J., Baumeister, R. F., Fiebig, T. & Eckel, L. A. (2014). The role of grandiose and vulnerable narcissism in self-reported and laboratory aggression and testosterone reactivity. Pers. Individ. Dif. 69:22-27.

Luoma, J. B., Kohlenberg, B. S., Hayes, S. C. & Fletcher, L. (2012). Slow and steady wins the race: A randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. J. Consult. Clin. Psychol. 80(1):43-53.

McDougall. J. (1984). The “dis-affected” patient: reflections on affect pathology. Psychoanal. Q. 53:386-409.

ΜcWilliams, N. (2011). Psychoanalytic diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. New York: Guilford Press.

Miller, A. (1996). The drama of the gifted child: the search for the true self (Revised Ed.). New York: Basic Books.

Miller, A. (2006). The body never lies: the lingering effects of hurtful parenting. New York: Norton & Company, Inc.

Morrison, A. P. (1983). Shame, ideal self, and narcissism. Contemp. Psychoanal. 19(2):295-318.

Neale, J., Allen, D. & Coombes, L. (2005). Qualitative research methods within the addictions. Addiction, 100:1584-1593.

Neale, J., Sheard, L. & Tompkins, C. (2007). Factors that help injecting drug users to access and benefit from services: A qualitative study. Subst. Abuse Treat. Prev. Policy 2(31).

O’Connor, L. E., Berry, J. W., Inaba, D., Weiss, J. & Morrison, A. (1994). Shame, guilt, and depression in men and women in recovery from addiction. J. Subst. Abuse Treat. 11(6):503-510.

Okada, R. (2010). The relationship between vulnerable narcissism and aggression in Japanese undergraduate students. Pers. Individ. Dif. 49:113-118.

Reich, A. (1960). Pathologic forms of self-esteem regulation. Psychoanal. Study Child 18:218-238.

Reidy, D. E., Zeichner, A., Foster, J. D. & Martinez. M. A. (2008). Effects of narcissistic entitlement and exploitativeness on human physical aggression. Pers. Individ. Dif. 44(4):865-875.

Rhodes, T., Watts, L., Davies, S., Martin, A., Smith, J., Clark, D., Craine, N. & Lyons, M. (2007). Risk, shame and the public injector: A qualitative study of drug injecting in South Wales. Soc. Sci. Med. 65(3):572-585.

Rhodewalt, F., & Morf, C. C. (1998). On self-aggrandizement and anger: A temporal analysis of narcissism and affective reactions to success and failure. J. Pers. Soc. Psychol. 74:672-685.

Ripoll, C., Salazar, J. & Bobes, J. (2010). Validez de la versión española de la Hypersensitive Narcissism Scale (HSNS) en una Unidad de Conductas Adictivas [Validity of the Spanish version of the Hypersensitive Narcissism Scale (HSNS) in subjects attended at an Addiction Treatment Unit]. Adicciones, 22(1):29-36.

Robson, C. (2002). Real world research: a resource for social scientists and practitioner-researchers. Jon Wiley and Sons.

Ronningstam, E. F. (2005). Identifying and understanding the narcissistic personality. Oxford University Press.

Roy, A. & Jones, G. (1979). Hostility on and off opiates. Compr. Psychiatry 20(5):433-434.

Salazar, F. J, Ripoll, A. C. & Bobes, J. (2010). Narcisismo manifiesto, narcisismo encubierto y trastornos de personalidad en una Unidad de Conductas Adictivas: validez predictiva de respuesta a tratamiento [Open narcissism, covered narcissism and personality disorders as predictive factors of treatment response in an out-patient Drug Addiction Unit]. Adicciones 22(2):107-112.

Schäfer, I., Reininghaus, U., Langeland, W., Voss, A., Zieger, N., Haasen, C. & Karow, A. (2007). Dissociative symptoms in alcohol-dependent patients: associations with childhood trauma and substance abuse characteristics. Compr. Psychiatry 48(6):539-545.

Small, M. & Lewis, S. (2004). Changes in hostility in residents undergoing treatment for drug and/or alcohol misuse in a residential rehabilitation centre. Therap. Comm. Int. J. Therap. Supp. Organ. 25(3):219-235.

Somer, E., Altus, L. & Ginzburg, K. (2010). Dissociative psychopathology among opioid use disorder patients: exploring the “chemical dissociation” hypothesis. Compr. Psychiatry 51(4):419-425.

Stein, J. A., Leslie, M. B. & Nyamathi, A. (2002). Relative contributions of parent substance use and childhood maltreatment to chronic homelessness, depression, and substance abuse problems among homeless women: mediating roles of self-esteem and abuse in adulthood. Child Abuse Negl. 26(10):1011-1027.

Ucman, S. & Prosan, S. (2007). Drug-addicted adults: Their self-concept, self-esteem and their role in treatment. Eur. Psychiatry, 22(S1):S214.

Ulman, R. B. & Paul, H. (2006). The self psychology of addiction and its treatment: Narcissus in Wonderland. New York: Routledge, Taylor & Francis Group.

Wiechelt, S. A. (2007). The spectre of shame in substance misuse. Subst. Use Misuse, 42:399-409.

Winnicott, D.W. (1958). The Maturational Processes and Facilitating Environments. Madison, CT: International Universities Press, 1965.

Witte T. H., Callahan K. L. & Perez-Lopez M. (2002). Narcissism and anger: an exploration of underlying correlates. Psychol. Rep. 90(3):871-875.

Wurmser, L. (1974). Psychoanalytic considerations of the etiology of compulsive drug use. J. Am. Psychoanal. Assoc. 22:820-843.

Zeigler - Hill, V. & Jordan, C. H. (2011). Behind the mask: Narcissism and implicit self-esteem. In: The handbook of narcissism and narcissistic personality disorder: Theoretical approaches, empirical findings and treatments, eds W. K. Campbell & J.D. Miller. New Jersey: John Wiley & Sons, Inc, (pp. 101-113).




Copyright © 2019 ADG, SA. All Rights Reserved.  
A Private Non-Profit Agency for the good of all, 
published in the UK & Honduras