Working with addiction
Healthcare Counselling and Psychotherapy Journal, April 2020

Working with clients who struggle with addictions raises many questions. Why do people carry on with a behaviour that eventually causes so much pain and damage? Why is relapse so common? Do we each have our own sticky, self-damaging behaviours?

I write this article mainly from a psychoanalytical perspective, and focus on four, interrelated aspects of addiction: changing how we feel, some neurological models, object constancy and pathological organisations. A client might struggle with one or all of these aspects of addiction. Or, the focus might shift as the work progresses. But I have found all four aspects useful in my thinking as a psychoanalytic psychotherapist.

What is addiction?

There are many different definitions and theories of addiction. Some emphasise the physical experience of dependence, as indicated by withdrawal symptoms; others are more concerned with psychological dependence. Some theories explain an addiction with a medical model, while others explore social and cultural issues. A number of theorists also see an addiction as a sub-category of compulsive disorders.¹

I take a broad view of addiction, as I have found this approach to be clinically useful in working with a wide range of issues, from addictive drug use to repeated destructive relationships. I use the term ‘addiction’ to apply to any behaviour, whether involving a substance or not, that:

• is persistent, repetitive and has begun to dominate
• has serious negative consequences, but the individual carries on regardless 
• has a quality of compulsion – it does not feel as if there is a choice
• may involve physical or psychological dependence, and stopping the behaviour brings significant physical or psychological distress
• often involves an element of denial, to the self or to others, of the negative consequences and of the dependence.

Changing how we feel

Addictive substances or behaviours change the way we feel. The change is sometimes the result of the direct effect of a drug on the nervous system. On other occasions, it is the result of a behaviour, such as gambling, that stimulates the brain’s own reward mechanisms and alters the way we feel.

Initially, the use of these substances or behaviours is a form of self-medication, an attempt to reduce an unbearable psychological or physical pain (although sometimes that ‘pain’ is an intolerable surfeit of happiness or of an instinctual tension). Psychological pain can take the form of anxiety or depression, while physical pain might be due to injury or illness. For some people, their pain could be associated with the trauma of social factors, such as poverty or racism. An addiction can also start as an attempt to manage the distress caused by an underlying psychiatric condition.

We can perhaps begin to understand that an addiction is not a search for pleasure, but an attempt to cope with the unbearable. The individual is faced with something unmanageable and seeks a solution in a substance or behaviour. Such a response need not be problematic, even if it carries on for some time. The person might even eventually ‘get over’ their addiction by finding other ways of coping, or if their situation changes. More commonly, however, the individual will begin to rely more and more on the shortcut to coping that the addiction provides. As the dependence increases, so too do the physical or psychological consequences of stopping the use of addictive substances or behaviours. Avoiding the effects of withdrawal therefore becomes a significant reason to continue with the addiction.

Along with an increased dependency, there is often also an increase in tolerance. The individual adapts to the presence of the substance or behaviour and so needs higher doses in order to achieve the desired effect. As the addiction gains prominence, other aspects of the person’s life become less important. Relationships, finances and work can all become secondary in importance, causing problems that, in turn, lead to an increase in the addiction as a way of coping. A self-perpetuating cycle of addiction-destructiveness-further addiction is established.

Treatment issues

It’s difficult to break the cycle of addiction and destructiveness, because it involves facing the painful reality of the present situation, as well as any underlying issues. People will often seek treatment only when the pain of carrying on with the addiction becomes greater than the pain of stopping. Occasionally, there is a honeymoon period soon after stopping, as immediate problems associated with the addiction are resolved. However, without addressing the underlying issues, the chances of relapse remain high.

Treatment is more likely to be successful if the client develops an awareness and acceptance of difficult feelings and thoughts. Sometimes, additional support might be needed to manage the consequences of stopping, including physical assistance to deal with withdrawal symptoms.

Neurological models

Early neurological models of addiction were built around descriptions of the brain’s reward system. In the middle of the last century, Olds and Milner² described how electrical stimulation of certain areas of the brain reinforced learning in rats and produced pleasurable feelings in humans. Centred on the mesolimbic dopamine pathway, this reward system helps us to react to internal stimulus and the external environment by prioritising decisions to ensure the survival of the individual and of the species. For example, the pleasure associated with eating can reinforce our search for life-sustaining nourishment. However, the reward system can be a harsh master, as shown by those experimental rats. When taught to press a lever to electronically stimulate their reward system, the rats would prefer to press the lever until exhausted, rather than consume the food.

In 1998, Berridge and Robinson^3,4 developed these ideas further with the incentive salience model, which divided the reward system into two parts: an incentive or ‘wanting’ system associated with the dopamine pathways, and a pleasure system associated with opiate-benzodiazepine pathways. In this model, the two systems start off working together, with the pleasurable effects of the substance or behaviour reinforcing our desire to seek out this experience. However, through repeated use, operant conditioning over-sensitises the seeking system to cues for the addictive substance or behaviour. As a result, these cues can stimulate seeking behaviour without any reference to possible pleasure.

By separating wanting from pleasure, the incentive salience model provides a useful clarification. The craving that addicts report can be seen not as an overwhelming desire for pleasure, but as a motive force in itself. Many addicts describe how their addiction has long since ceased to have anything to do with pleasure, but is now about satisfying a compelling sense of craving.

Even after a period of non-use, this craving can be stimulated by environmental triggers, such as meeting a friend with whom one used to get high.

The above ideas have been further elaborated by writers such as the psychoanalyst and neuropsychologist Mark Solms,⁵ who drew upon Jaak Panksepp’s model of seven basic affective systems. Panksepp was a neuroscientist whose ground-breaking publication, Affective Neuroscience,6 described seven primary emotions – SEEKING, RAGE, FEAR, PLEASURE-LUST, CARE, PANIC-GRIEF and PLAY – each with its own distinct brain anatomy and neuropharmacology. Panksepp capitalised the terms used to denote these systems to distinguish them from their everyday usage.

The evolution of these subcortical systems gave mammals a major advantage in adapting to their environment in order to meet their needs. The dopamine-mediated SEEKING system is seen as fundamental, because it activates the mammal to search the environment for ways to satisfy its needs. The other systems then mediate the individual’s various relationships with the environment. The PLEASURE-LUST system rewards behaviours that promote individual or species survival, or acts to reduce pain. The PANIC-GRIEF system is the basis for attachment, binding together mothers and infants, and strengthening social bonds.

The SEEKING system is similar to the incentive system described by Berridge and Robinson; both drive us to seek out significant objects in our environment, such as food or a mate. However, Solms’ model of addiction differs from that of Berridge and Robinson in that he doesn’t refer to operant conditioning. Instead, Solms sees the opioid-mediated PLEASURE-LUST and PANIC-GRIEF systems as working alongside the SEEKING system. In Solms’ view, the basis of an addiction is not a learnt desire based upon conditioning, but rather an ongoing attempt to soothe the pain of an unmet need for a secure attachment. In linking addictions to faulty attachments, Solms and Panksepp point the way to a more psychodynamic understanding of addictions and of their aetiology, and open up an object relations view of addiction.

Treatment issues

Neurological models show that craving plays a central role in addiction. The role of pleasure is more complicated. Certainly, many addicts report that their addiction no longer brings pleasure. However, the analgesic effects of the PLEASURE-LUST system may be used to soothe the pain of faulty early attachments. In tackling their addiction, the individual will need strategies to cope with their craving and ways of building secure attachments; for example, with a counsellor or a support group.

Object constancy

The search for object constancy is related to the need for a secure attachment. Addicts often speak of a feeling of emptiness and describe their addiction as a search for something to fill that gap. Brian Johnson⁷ writes of the way in which the addictive substance or behaviour can function as an object to which the individual can relate. Like Winnicott’s transitional object,⁸ for the addict, the substance or behaviour exists not just in the external world, but as an internal object that gives a sense of identity. Part of the stickiness of the addiction is that the individual is faced with letting go of a part of her or himself, a part of who they are.

Several theorists postulate how problematic early relationships can lead to this sense of emptiness and to an internal world that is insecure and self-destructive. Heinz Kohut,⁹ for example, describes the way in which an individual’s sense of wholeness and self-worth is based upon the love, the mirroring, they receive as an infant. When that love is insufficient, the individual might embark on a lifelong search for a dependable substitute, sometimes with pathological outcomes. Addicts sometimes describe their gear or bottle as their best friend, the only thing they can rely on, the only constant object in their life.

Treatment issues

The loss of the addictive substance or behaviour can leave a serious gap in the individual’s life, especially if any personal relationships were based upon shared addictions. Thought needs to be given to how to fill this gap in less self-destructive ways, avoiding the transfer of a dependence from one addiction to another. Some individuals seek object constancy by signing up to a treatment philosophy or group. The constancy of their therapist is obviously very important.

Pathological organisations

In some cases, the pain of an unmet, early need for love is so great that we seek security and potency, even a sense of self, by denying that need and by identifying with our capacity for destructiveness. In this way, we identify with bad internal objects to form a pathological organisation that gives us a sense of power and security.

To understand these organisations, we can turn to the two positions outlined by Melanie Klein: the paranoidschizoid and the depressive. These positions describe challenges faced by an infant in its first few months of life. In the paranoid-schizoid position, the infant’s primary challenge is to make safe its inherent destructiveness. It does this by splitting its self and its environment into good (loving) and bad (destructive) elements or objects. However, these bad internal and external objects continue to pose a threat to the infant. As the infant matures, it comes to recognise these disparate elements as belonging to whole people, primarily to those on whom it depends for its survival. With this realisation can come the pain of guilt, as the infant comes to terms with its own destructiveness.

Pathological organisations provide a structure that protects us from the fears of the paranoid-schizoid position, but avoids a progression to the depressive position, with its associated pain. Many theorists have detailed such internal organisations. Herbert Rosenfeld, for example, describes the attempt to eliminate any trace of dependent feelings and, as a result, to attack those who might offer us the love that we desire.¹⁰

A pathological organisation often plays a central role in addiction and helps to explain the tenacity with which the individual holds on to the addiction, despite its painful and self-destructive aspects. For example, I observed a counselling group for addicts in which one member after another described the dangerous or harmful situations to which their addiction had led, in each case outdoing the previous speaker. One spoke of waking up in a police cell, the next about waking in a ditch, the next of being covered in blood or with a broken leg. There was a strong sense of triumph in the recounting of each story. Of course, there was competition to impress the inexperienced group facilitator. However, I believe they were ultimately describing a triumph over death. In recounting their survival, despite the pain and danger they experienced, each group member was claiming the omnipotence of a pathological organisation, an omnipotence that took away any feeling of vulnerability or of dependence upon another person.

Treatment issues

Anyone who seeks to relinquish a pathological organisation faces a terrible contradiction, because the structure is a defence against the fear of depending upon another person. Herbert Rosenfeld¹⁰ outlines the sense of triumph felt by an individual following the rejection of help or after an act of self-harm. The pathological organisation is like an omnipotent and destructive internal gang that demands absolute loyalty. Consequently, negative therapeutic reactions are common, where reliance upon a therapist or an expression of gratitude is closely followed by an undoing of progress and the rejection of help.

Change is possible and requires a dependable therapist, who can survive these attacks over a long period of time. Eventually and gradually, the addicted client might allow their more vulnerable self to emerge. Through this experience, the individual becomes wise to their internal bully and so can loosen its hold. As a patient of Elizabeth Bott Spillius explained, they may come to see this part of themselves ‘as a “poor devil”, rather than the Devil’.¹¹

There is a common thread to each of the four aspects of addiction described above: they all involve an attempt to solve a problem. The problem might be an unacceptable thought or feeling, a sense of emptiness, or the fear of being dependent upon another person. The solution might be misguided or self-destructive, but it is an attempted solution nonetheless – and to a difficulty with which we are perhaps all familiar. By seeing an addiction as an attempt to find a solution to a challenge that we all potentially face, the practitioner can approach their client with understanding and acceptance. Ultimately, it is those very qualities in the therapist that I believe help to bring about change.