jap a

Brian Johnson 47/3

THREE PERSPECTIVES
ON ADDICTION

Three perspectives on addiction promulgated during the 1990s are

reviewed, along with many earlier contributions to the understanding of
addictive illness. It is suggested that these distinct yet overlapping
formulations of the dynamics of addiction form a hierarchy for each patient
suffering from an addiction. Assessment of a patient’s ego strength, and
of the relative importance of addictive behaviors in overall character
structure, allows referral to various types of treatment, including
psychoanalytic therapy. Case examples are presented, including material
from the psychoanalysis of a woman addicted to heroin, methadone,
cocaine, amphetamines, nicotine, alcohol, and shopping.

I n the field of addiction treatment there has been a tendency to

eschew dynamic understanding for simple descriptive diagnosis
based on verifiable criteria. This tendency has been accompanied by a
focus on behavioral treatments that can be reliably evaluated using
objective outcome measures and by an immense research effort to
understand the biology of addiction. All this leaves the thoughtful
clinician with the unanswered question, How does one understand
these behaviors empathically? It leaves the insight-oriented clinician
with the question, Does a patient’s capacity for self-observation
contribute anything to the treatment of addiction? It can leave the
clinician asking, Is addiction treatment a constant process of identi-
fying an addiction and referring the patient away to physicians
who prescribe medications such as disulfiram and naltrexone, to
Twelve Step programs where mysterious events somehow keep
the patient sober, and to relapse prevention specialists who
lecture on how to “identify your triggers”? The psychodynamically

Medical Director, Chemical Dependency Service, Bournewood Hospital;

Assistant Clinical Professor of Psychiatry, Harvard Medical School.
An earlier version of this paper was presented to the Discussion Group “The
Substance-Abusing Patient in Psychoanalysis and Psychotherapy” at the fall 1997 meeting
of the American Psychoanalytic Association. Submitted for publication March 13,1998.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

oriented clinician can feel that addictive disorders somehow fall out-
side his or her purview.
Nonetheless, addiction has been an important issue in psycho-
analysis since its inception. In 1908, for example, Abraham published
“The Psychological Relations between Sexuality and Alcoholism,” in
which he suggested a number of possible dynamics. In the mid-1960s
the early psychoanalytic literature was nicely summarized by Rosenfeld
(1965), and since then psychoanalysis has benefited from the work of
a number of practitioners specializing in addictive disorders. Their con-
tributions have dealt specifically with addictive dynamics, providing a
range of views perhaps regarded as “perspectives” (rather than mutu-
ally exclusive schools of theory), useful guides to understanding and
interpretation (see Spezzano 1998).
Three perspectives on addiction recur in the psychoanalytic and
addiction literature: addiction as a biologically mediated disease,
addiction as a response to inability to tolerate affect, and addiction as
an object or transitional object equivalent. These themes will be pre-
sented with reference to the literature and their usefulness explored.
792
In a field that has been accumulating knowledge for over a century,
none of the authors chosen here as exemplars has a completely
original idea, and all of them have carefully reviewed the many
pathways leading to their specific formulation. In what follows I
have resorted to simplification in the service of making these perspec-
tives more salient.

THE NEUROBIOLOGICAL CONCEPT OF ADDICTION

Addictive drugs seem to become entrained into the same drive system
that motivates animals to seek food, water, and sex (Miller and Gold
1993; Volkow quoted in Swan 1998). One perspective, articulated by
Robinson and Berridge (1993; Berridge and Robinson 1998), describes
the progression of interest in drugs from incidental to driven. This
theory might be described as an attempt to localize drive within
mesotelencephalic dopamine pathways of the brain. However, the
authors combine introspective exercises and a discussion of social
factors involved in addiction to produce a complex and comprehensive
way of thinking about addiction. Robinson and Berridge begin with
three key questions concerning the nature of addiction: (1) Why do
addicted persons crave drugs? (2) Why does drug craving persist even

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

after long abstinence? (3) Is “wanting” drugs the same as “liking”

drugs? Their answer has four main points.
1. Addictive drugs share the ability to enhance mesotelencephalic
dopamine neurotransmission.
2. One psychological function of this neural system is to attribute
“incentive salience” to the perception and mental representation of
events associated with activation of the system. Incentive salience is
a psychological process that transforms the perception of stimuli,
imbuing them with salience, making them attractive, “wanted” incen-
tive stimuli.
3. In some individuals repeated use of addictive drugs produces
incremental adaptations in this neural system, rendering it increasingly
and perhaps permanently hypersensitive to drugs and drug-associated
stimuli. The sensitization of dopamine systems is gated by associative
learning, which causes excessive incentive salience to be attributed
to the act of drug taking and to stimuli associated with drug taking.
Sensitization of incentive salience transforms ordinary wanting into
“craving.”
793
4. Sensitization of neural systems responsible for incentive salience
(wanting) can occur independently of changes in neural systems that
mediate subjective pleasurable effects of drugs (liking) and neural sys-
tems involved in withdrawal. After sufficient exposure, the pleasure of
addictive behaviors becomes irrelevant because the wanting neural sys-
tem is built in to stimulate the organism to pursue a goal. Compulsive
drug taking ensues, despite lack of pleasure and despite strong disin-
centives—loss of job, homelessness, the agony of withdrawal.
The neurobiological concept of addiction (of which this is only one
particularly well articulated example) includes as a strong central tenet
that of all the plant-derived chemicals humans have ingested, a small
number have been found to mimic in some fashion a natural process
affecting parts of the brain. Natural incentives such as food, water, or
desirable sexual partners are endowed by evolution to condition plea-
sure and incentive salience under conditions such as those created by
hormones or thirst. If one is drawn to a desirable sexual partner, one
may modify the impulse if one notices a wedding band. In the same
way, one may be drawn to a drink but have the impulse modified by last
night’s meeting of Alcoholics Anonymous.
The process of endowment of a stimulus with salience has three
steps: (1) Pleasure is a consequence of a particular event or act. (2)

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

Pleasure is associated with a mental representation of the object, act,

event, or place in which the pleasure occurred via classical (associational)
conditioning. (3) Incentive salience is attributed to subsequent
perceptions and mental representations of the associated object, event,
act, or place, which causes them to be “wanted.” Stimuli that signal
the availability of the incentive become attractive. Acts that led to the
situation in the past are likely to be repeated.
Robinson and Berridge suggest the possibility that this whole
process, or part of this process, can occur unconsciously. There is no
need to know one is being influenced by craving in order to want some-
thing. For example, when subclinical doses of amphetamine are
administered to subjects who cannot distinguish the effects from
placebo, and who have no measurable electrophysiological response
to drug injection, these subjects choose the drug lever at higher
than chance incidence, all the while insisting that there is no dif-
ference in the effect caused by either lever, and that their choices
are random.
The incentive sensitization theory nicely explains the common
794
clinical phenomenon that patients say they do not “like” smoking ciga-
rettes, or using cocaine, and yet have intense cravings that seemingly
can be responded to only by using the drug.
Recent work (e.g., Sora et al. 1998) suggests that regarding
dopamine as the sole neurotransmitter system mediating these phe-
nomena is simplistic. However, while our understanding of the under-
lying biology of the incentive sensitization model may be modified, its
basic conceptualization remains an important perspective from which
to understand the driven “it,” ego-dystonic quality of addiction.

ADDICTION AS A MANIFESTATION OF
INABILITY TO TOLERATE AFFECT

The self-medication hypothesis, first articulated by Khantzian (1985,

1997) states simply that drugs relieve psychological suffering and that
preference for a particular drug involves some degree of psycho-
pharmacological specificity. Khantzian believes that opiates attenuate
feelings of rage or violence, that CNS depressants such as alcohol
relieve feelings of isolation, emptiness, and anxiety, and that stimulants
can augment hypomania, relieve depression, or counteract hyperac-
tivity and attention deficit.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

Khantzian sees his work as expanding on the work of self psy-

chologists, especially Kohut (1971, 1977). Khantzian (1995) traces the
origins of the inability to regulate affects to early life, and to a failure
to internalize self-care from parents: “Self-care is a psychological
capacity related to certain ego functions and reactions. This capacity
protects against harm and assures survival, and involves reality test-
ing, judgment, control, signal anxiety, and the ability to draw cause-
consequence conclusions. The self-care capacity develops out of the
nurturance, ministrations, and protective roles provided by the parents
from early infancy, and subsequently, out of child-parent interac-
tions” (p. 30). Because they lack these internalizations, addicted per-
sons cannot regulate self-esteem or relationships, or provide them-
selves with caring.
This emphasis on affect intolerance related to early developmental
failures is similar to that of Zinberg (1975) and Krystal (1988, 1995;
Krystal and Raskin 1981) . However, there is an important difference
between Khantzian and Krystal. Khantzian views lack of self-care or
self-governance as an ego defect, as a function that never developed,
795
whereas Krystal views self-care as having been prohibited by an over-
controlling parent. In Krystal’s view, addicted individuals are entirely
capable of self-care but “believed that if they took over the control of
their vital or affective functions, which they believed to belong to
mother, that would be a ‘Promethean’ transgression, punishable by a
‘fate worse than death’” (1995, p. 85).
The self-medication hypothesis is constantly confirmed by listen-
ing to patients’ reports of responding to intolerable affective states by
using drugs. A man in a rage sniffs a bag of heroin rather than kill his
girlfriend. The heroin allows a pleasant interaction with her. A teenager
finds that after a few beers she can enjoy a party rather than be trapped
by anxiety. A man’s depression can be overcome with cocaine suf-
ficiently to allow a social interaction. A woman who has been abused
and molested can engage in sexual relationships after premedication
with alcohol or heroin.
While the most important evidence for the self-medication hypoth-
esis is found in the reports of patients, Khantzian carefully examines
more quantitative studies in the addiction literature. He finds that psy-
choanalytically informed experience becomes a check on some of the
conclusions offered by researchers who employ more operationalized
methods in the attempt to understand and describe addictive behaviors.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

For example, he considers the possibility that some longitudinal inves-

tigators—e.g., Schukit 1986; Vaillant (1983, 1996)—find affective dis-
orders a consequence rather than a precursor of addiction, because of
their failure to detect earlier subclinical conditions that subjects are
already medicating by the time they are diagnostically apparent.
Khantzian suggests that relatively infrequent interviews and the
requirement that subjects meet diagnostic criteria for relatively severe
affective disorders runs against the reality that some people go into
action with drugs early in the course of these disorders to alter affec-
tive states that are experienced as unbearable. Khantzian’s view
is confirmed by a prospective longitudinal study (Kushner, Sher, and
Erickson 1999) that demonstrates a reciprocal causal relation over time,
with anxiety disorders leading to alcohol dependence and vice versa.
The subjective stance provides support for other objective findings.
Khantzian suggests that nicotine use is self-medication. He cites a
study by Breslau, Kilbey, and Andreski (1993) showing that 1,007 sub-
jects with nicotine dependence were higher on rating scales for nega-
tive affect, hopelessness, neuroticism, and general emotional distress
796
than were nondependent smokers. He also cites a study (Anda et al.
1990) in which the quit rate for depressed smokers was found to be 10
percent, as against 18 percent for nondepressed.
Dodes (1990, 1996) suggests that addicted persons have a narcis-
sistic vulnerability to feeling overwhelmed by experiences of helpless-
ness. The centrality of helplessness in the creation of psychic trauma is
cited by Freud (1926, pp.166–167), and helplessness as a central addic-
tive dynamic created by overwhelming shame by Wurmser (1978).
Dodes believes that the enactment of addictive behavior functions to
restore a sense of potency against helplessness. He states that the
intense aggressive drive to restore this potency, which arises from the
narcissistic injury of helplessness, is identical with narcissistic rage.
Finally, he notes that the major symptoms of addiction, as well as
its intensity and unrelenting, boundless quality, can themselves be
explained by the presence in addiction of this narcissistic rage.
Dodes also suggests that addictions can be shown to be compro-
mise formations identical with compulsions. He gives case examples
that demonstrate restoration of a sense of power via addictive behavior
as a displacement from actual reassertion of power in the real world.
For example, a patient who is enraged with his son for embezzling from
the patient’s company goes on a drinking binge. The man feels that it

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

would be wrong to fire his son, so he is rendered helpless to act.

Drinking makes him feel better because it is an action he can take; he
doesn’t feel helpless anymore.
The empathic understanding that patients have been traumatized by
helplessness, and are responding in an aggressive but displaced manner,
allows the clinician to make interventions that appreciate the drive
without encouraging the behavior: (1) the aggressive drive for control
of one’s existence with integrity is nothing to be ashamed of; (2) the
patient needs to struggle to be conscious of what he or she really wants,
rather than settle for addictive responses; (3) conflicts and vulnerabili-
ties regarding self-assertion, and difficulty tolerating helplessness when
necessary, have their origin in childhood experiences that need to be
remembered and worked through in treatment.

THE OBJECT / TRANSITIONAL OBJECT

NATURE OF AN ADDICTION

The object-quality of addictive behavior is central to many theories of

797
addiction. Winnicott’s original formulation of the transitional object
(1951) described it as an addiction. Kernberg (1975) describes several
object-related dynamics of addiction: it may replace a parental imago in
depression or an all-good mother in borderline personality, or may
refuel a grandiose self in narcissism. Wurmser (1995) describes the
terror of being separated and sees the intense shame and rage mani-
fested in addictive behaviors as in part an attempt to maintain a con-
nection with objects. Wurmser’s important contributions (e.g., 1974,
1978, 1981) include, as one dynamic, the difficulty of internalizing
interactions with parents into effective superego functioning, and the
resulting alternation of slavish submission to unreasonable internal pro-
hibitions with completely unregulated rebellious addictive behaviors.
Meyers (1994, 1995) shows, in the psychoanalytic therapy of patients
addicted to compulsive sexual behaviors, that these behaviors can
resolve as patients begin to rely on self or others as a nurturant object.
In a recent contribution (Johnson 1993) I presented an object model
that employed a unique definition of addiction: “An addiction is an
ostensibly pleasurable activity which causes repeated harm because a
person involuntarily and unintentionally acquires an inability to regu-
late the activity, and has a persistent urge to engage in the activity. A
psychological system, referred to as ‘denial,’ is created around the

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

harmful behavior. Denial allows the addicted individual to continue this

activity despite its detrimental effects” (p. 25).
The function of the denial system of an addiction is to protect the
relationship with the addiction. It is made clear with case examples
that if there is no denial, then there is no addiction. Denial is part
of the pathophysiology of the disease (Johnson and Clark 1989). The
definition is psychological in a way that is true to the phenomenon
of addiction. While genetic, biological, or social aspects may con-
tribute to the course of the illness, they do not define its essence. This
definition both allows addiction to fall into the mainstream of psycho-
analytic consideration, and adds the characterological response of the
individual to drug-effects as an important consideration in assessing
the impact of drugs (see, e.g., Kernberg 1975). It allows the psy-
chology of the relationship of each individual with his or her addiction
to be articulated and elaborated by the dynamically oriented clinician
(see also Kaufman 1994).
This definition is used to link a number of pleasurable activities
that are addictive only if they become compulsive behaviors: drinking,
798
gambling, stimulant use, exercise/endorphin release or opiate (heroin)
use, eating, making love, shopping, working, or being slim. These
activities are required to be compulsive for characterological reasons
because they provide a constant sense of being accompanied. Addicted
individuals are unable to have their dependency needs effectively met
in human relationships and are unable to tolerate being alone; their
need for object constancy is provided by whatever compulsive activity
is chosen. A particular addiction is chosen then as a function of envi-
ronment and gender, and can be shifted with changing environmental
conditions. For example, a bingeing/purging food-addicted woman
may shift to cocaine dependence because it keeps her weight down, and
may subsequently become preoccupied for a time simply with obtain-
ing, using, and recovering from cocaine. A man who is in trouble
because of his drinking may shift to compulsive gambling because, at
least for a while, he can better get away with this compulsive behavior.
When pursuing heroin becomes too much trouble as people grow older,
they may shift to alcohol dependence.
I have suggested (Johnson 1993) that a defect that occurs during
preoedipal development becomes manifest as an addiction during ado-
lescence because the teenager needs to leave the parents yet lacks the
internal development to survive without them. The adolescent does not

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

have a confident sense of object constancy. This property of recall

memory is internalized by most toddlers during the period between one
and three years of age via a process of separating and returning to the
facilitating parents, the “emotional refueling” of Mahler, Pine, and
Bergman (1975). The developing child gradually begins to carry an
internal sense of being accompanied by the parents ideationally, with-
out needing the concrete parent as a constant reassurance of protective
presence. Especially during the rapprochement period, from sixteen to
twenty-five months, the child is beset with rageful fantasies of parental
destruction because of omnipotent wishes to have the world conform to
one’s desires. The facilitating adults must help the child hold aggres-
sive urges in safety. The rules and prohibitions of the parental adults are
internalized as a superego—an internalized sense of which behaviors
are permissible and which behaviors must be held in check. It may well
be that inability to negotiate this step has much to do with the environ-
ment created for the child by caregivers (Lyons-Ruth 1991); premorbid
parent-child interactions that predispose to addiction are described by
Shedler and Block (1990). I hypothesized that children who will go on
799
to suffer from addictions do not internalize object constancy during the
preoedipal period, and have a specific fear that their aggressive urges
may destroy their relied-upon objects. Inability to effectively use super-
ego prohibitions makes their aggressive urges frightening. Years later
children are faced with the need to separate from their family of origin
and respond by adopting an addiction. The adolescent who has newly
adopted an addiction is extremely content. The annihilation anxi-
ety previously experienced has given way to an idealized relationship
with the addictive behavior.
The use of an addiction, then, is akin to Kernberg’s borderline and
narcissistic personality disorders (1975). In narcissism the inability to
tolerate being alone is solved by reliance on an organized inner set of
idealized fantasies that allows the individual to be indifferent to the
comings and goings of real relationships (Volkan 1973). In an individual
with borderline personality, affective instability is responded to via
a constant, desperate need for reassurance by an idealized person. In
addiction, the relationship is neither with idealized internal fantasies nor
with idealized persons, but rather with an idealized addictive behavior.
According to the developmental model, some addictions represent
a regression under stress, rather than a true adaptation to absence of
object constancy. Individuals who have a regressive addiction find

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

that they can give it up relatively easily. In these cases, the addiction
is a neurotic behavior that lacks the destructive forcefulness of addic-
tive behaviors clung to as a means of preventing the inner experience
of abandonment.
Using this model, I suggested that some patients who have their
underlying conflicts analyzed may return to recreational use of alcohol;
I cited the liver enzyme results of a patient whose hepatitis resolved
during three-times-a-week treatment despite her continued use of alco-
hol (Johnson 1993). The Twelve Steps of Alcoholics Anonymous, I
suggested, involve relinquishing the object constancy delivered by the
addictive behavior; adopting, through a “leap of faith,” the belief that
reliable human objects exist; reworking the superego; and extending
this remedial work to the ego ideal, or internalized social values (see
also Dodes 1988; Khantzian 1994). AA encourages members to “rely
on people, not alcohol (drugs)” and to be carried by an inner “higher
power” that provides a sense of purpose and of being accompanied at
all times. In an earlier paper (Johnson 1992), I presented the psycho-
analysis of a man with active alcoholism and showed the resolution
800
of his addictive drinking as the highly conflictual dependence entered
the transference neurosis.

COMMONALITIES OF THE THREE PERSPECTIVES

Authors writing from all three perspectives regard as completely erro-

neous any suggestion that addiction is driven by a desire for pleasure.
The incentive sensitization model suggests that the mesotelencephalic
pathway carries wanting/craving and that pleasure soon becomes
an irrelevant factor in addictive drug use. The affect intolerance
perspective posits that chronic inability to master feeling states results
in recurrent flight into drug-altered states. According to the addiction-
as-substitute-object model, lack of capacity to use relationships,
internal or external, results in the constant need for addictive behaviors
as a transitional object.
Typical features of addictive disorders are explained in each of the
three perspectives in ways that are complementary. For example, the
mesotelencephalic pathway is responsible for activation of the animal
to seek gratification. When this pathway is cut in rats, the animal does
not bother to eat, even though eating (as shown by rat facial expression)
is still a pleasurable activity. If a light signals that food is about to

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

appear, the light causes discharge in the mesotelencephalic pathway.

Dopamine transmission is triggered not solely during the gratifying
activity, but by the simple assurance that gratification is impending.
Patients with cocaine dependence often remark on this phenomenon.
Their bodies react to the certainty of gratification; symptoms of gut
motility are initiated by the mere intention to purchase cocaine after a
period of abstinence. For instance, they will pass wind on the way to
the dealer. Dodes notes the same phenomenon, dubbing it “signal satis-
faction, akin to signal anxiety,” and suggests that the ability to create a
satisfying situation gives the individual a sense of power. For a sober
person with alcoholism, Dodes says, the very act of ordering a drink at
a bar relieves a sense of helplessness.
Helplessness is considered a key affective state in the psycho-
analytic models. Dodes (1990) has suggested that his view helps
us understand the role of drugs in avoiding certain affects, as
described in Khantzian’s self-medication model. He suggested that
intolerable helplessness is the result of the psychic trauma of being
overwhelmed by whichever affective state each individual person
801
finds the most troublesome. I myself have traced the history of help-
lessness to early experiences in which the child is unable to master
aggression without parental assistance. The addicted person is left with
a choice of helpless submission to inner and outer authority, or defiant
rebellion against it. (This position is identical to that of Wurmser.)
Dodes (1988, 1990), Khantzian (1994), and I (Johnson 1993) all
suggest that this experience is reflected in Step One of Alcoholics
Anonymous, which begins, “We admitted we were powerless. . . .” By
contrast, Robinson and Berridge might take the position that the
organism is powerless against a biologically driven demand for drug
seeking. The mesotelencephalic pathway demands that the animal take
action to secure water, food, sex, or drugs.
In summary, these three perspectives on addictive behaviors
offer overlapping and complementary explanations. At one or
another time, one of these dynamics may appear most prominent
as a motivating force. Taken together, they represent a substantial
framework from which to listen to patients, to empathically under-
stand their associations and behaviors, and to guide interventions
that help them move toward safety and toward more effective ways
of living.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

CLINICAL EXAMPLES

This section will begin with examples drawn from patient encounters
in which only one of our three perspectives is appropriate. Combined
use of the models will be shown later.

Use of the Neurobiological Perspective

Case 1. A forty-year-old man with schizophrenia is referred from a
psychiatric hospital to a substance abuse outpatient clinic because of
persistent use of cocaine. Auditory hallucinations and paranoid delu-
sions are in remission as a result of fluphenazine decanoate injections
administered every two weeks. The patient is eager to become sober,
but finds that on the first of each month, despite having a payee for his
Social Security checks, he can’t help but use any money he can find to
buy crack. This results in loss of his housing when he can’t pay his rent,
and rehospitalization.
The incentive sensitization theory is used by caregivers to under-
stand that money in his pocket is the element that turns on craving. This
802
patient lacks the relatedness required to use either Twelve Step groups
or psychotherapy. Lack of adequate supervision during vulnerable
periods will result in continued cocaine dependence. Placement in
a staffed residence and tighter control over his money result in a
remission of use.
Case 2. A substance abuse counselor, sober six years and active in
AA, travels to an old haunt in order to help his mother sell her house.
He notices unexpected powerful urges to pick up a prostitute, drink, and
buy crack—all associated activities during his years of drug depen-
dence. He realizes that helping his mother sell her house is a kind of
help he is not capable of providing in safety. Simple avoidance of the
old neighborhood resulted in complete resolution of the urges to return
to addictive behaviors.
Case 3. An international businessman presents for treatment for
active heroin use, complaining that he has injected more than a million
dollars worth of heroin into his veins over the last fifteen years. He
has also supplied his wife with a second million dollars worth. The
expenditure is undermining the capitalization of his business. The ini-
tiation of heroin use is understood as a consequence of intense stress
during immigration from Lebanon to the United States, and the begin-
ning of a business from the back of his car. This stress is now in the

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

past, no longer a factor contributing to ongoing use. The cause of con-

tinued use is the unstoppable craving.
For the first two months of weekly meetings, the businessman
injects eight bags of heroin before each morning psychotherapy hour.
The history of intense craving after detoxifications results in a plan to
switch over to methadone detoxification and accomplish a six-month
taper. Supportive psychotherapy focuses on tolerating craving. When
the patient is down to 5 mg of methadone, he believes that his intense
craving will undermine his attempt to decrease the dose to nothing, and
he flies to England to obtain his own supply of methadone. He tapers
from 5 mg to abstinence over the next three months. He realizes that
his wife has a more complicated addiction and separates from her.
Supportive psychotherapy is terminated when he is abstinent from
opiates for three months. Alcohol and marijuana use do not cause any
symptoms. On two-year follow-up he is abstinent from opiates, except
for a single use of heroin, which he thinks of as having been “stupid.”
At that point he does not meet the DSM-IV criteria for any disorder
except for “opiate dependence, in long-term remission.”
803
Case 4. A physician was raised in a culture where cigarette
smoking was the norm. When in his early thirties he was diagnosed
with gingivitis by his dentist, he immediately recognized this as a
medical complication of smoking. He has a clear memory of throwing
his pack of cigarettes out the car window as he left his dentist’s parking
lot. He had minimal craving when first abstinent, and has not smoked
a cigarette in twenty-five years.
One might speculate that for some individuals, such as this physi-
cian, the neurobiological aspect of addiction is insufficient to sustain
the behavior. Because of relatively healthy ego functioning, denial is
easily disrupted, resulting in “spontaneous” long-term remission (see
DSM-IV, “Substance Related Disorders” section, p. 189; Shaffer and
Jones 1989).

Use of the Affect Intolerance Perspective

Case 1. A thirty-three-year-old woman has a ten-year history of
alcohol and cocaine dependence. She has been through twenty detoxifi-
cations, has never been sober two weeks, and complains that counselors
tell her to go to AA when she has emotional issues to deal with. She tells
a horrific set of stories of abuse and neglect, starting when she was seven.
Her father was drunk and slapped her mother. Her eighteen-year-old

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

sister went to the kitchen and stabbed her father in the chest. Her father
refused to move, stood there for twenty minutes, then collapsed. Her
mother reached down, felt for the father’s pulse, said he was alive, and
ran off to hide the sister, leaving the patient with the dying father in a
spreading pool of blood. Although the family myth is that the father fell
on the knife, the sister did prison time for manslaughter. No one has
spoken to her regarding this event since. She says that as she sits in the
detox interview room, she can see it all as if it just happened.
Two other traumata, including a rape, have left her with a full syn-
drome of posttraumatic stress disorder. Cognitive function is entirely
intact, suggesting that psychotherapy would be of help. A Hamilton
Rating Scale for Depression score is 28, suggesting a major non-
psychotic depression. The patient, who is one day sober in detox, begs
for medication to help her sleep because she becomes terrified as she
falls asleep, with hypnogogic illusions of being touched sexually.
The self-medication hypothesis is invoked as the most relevant
paradigm for this particular patient. Fully appreciating that a depression
cannot reliably be diagnosed only one day away from alcohol and
804
cocaine, the posttraumatic stress disorder is rated as the most pressing
diagnosis, despite presentation at a detoxification center. Trazodone,
because of its sedative side effect, is selected as the antidepressant of
choice and is given in gradually increasing doses to 300 mg. The
patient is referred to a women’s halfway house that specializes in
victims of sexual violence, and is seen in psychotherapy focusing on
memory reexposure and grief work.
Case 2. A thirty-five-year-old woman is unable to stop smoking,
despite several attempts. She complains of intense dysphoria when off
cigarettes, and of an experience of white-knuckle emotional pain until
she resumes smoking. Her addiction to cigarettes is understood as self-
medication of an underlying depression. She receives a course of
twelve weeks of weekly psychotherapy abetted by sustained release
buproprion, 150 mg twice a day. She chooses a quit date five weeks into
the psychotherapy, and is amazed at how much easier it is this time.

Use of the Object Perspective

A forty-five-year-old professional woman has been addicted since
her teenage years to heroin, methadone, alcohol, cocaine, and nicotine.
She has been unable to remain reliably sober, despite a considerable
investment in Alcoholics Anonymous. Psychotherapy is begun imme-

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

diately following discharge from heroin detoxification, and eight

months later, when she is sober from all the drugs listed above, she
begins four-days-a-week psychoanalysis. The transference is difficult
to manage because her alcohol and opiate dependent mother was hate-
ful and manipulative, and has never expressed any interest in sobriety.
Her father was himself addicted to work and did nothing to protect her
from her mother, from her abusive stepmother, or from her addiction.
The patient attends AA meetings and an AA women’s group, and
has a sponsor. However, splitting is evident from the beginning of the
treatment. Her sponsor is alternately idealized and devalued. Comments
describing her sponsor as unavailable, uncaring, or even worthless are
interpreted as an expression of the paternal transference toward the
sponsor—the patient fears the sponsor is not available and attending
to her needs. The maternal transference is active directly in the rela-
tionship with the analyst. As one dynamic, the patient expects the
analyst to “catch” her with feelings that will be used to humiliate her.
Seven months into the analysis, the intense negative transference
seems to have settled down. There are associations, with references
805
over several weeks, to substantial purchases. When the analyst hears
that the patient’s teenage son has been bought a new car, and that the
patient is contemplating a new dining room set, he has an awful reali-
zation about why the transference has lessened. He asks directly about
credit card use, and learns that during the course of treatment the
patient has been involved in an escalating debt that is now $66,000. The
debt involves twenty credit cards, including some that have been fraud-
ulently obtained in the name of an incapacitated relative. The analyst
interprets spending addiction as a resistance to the further deepening of
the transference relationship, and gives direct advice about the neces-
sity of immediate cessation of credit card use and of consulting a
lawyer regarding bankruptcy. The patient confesses a fantasy that two
or three months hence the analysis would have to end because she could
no longer afford treatment and credit card interest payments, and that
this would be just like the period of transition from feeling in control of
a gradually escalating heroin habit to becoming desperate and realizing
that she needs to go to detox. She notes that never before has she had
any trouble with credit cards or spending.
This sequence of feeling and action enacted in the psychoanalytic
relationship is understood as a repeat of the patient’s experience, as a
teenager, that she could no longer endure the intensity of her feelings,

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

especially of anger and humiliation with regard to her mother, in the

context that she was not protected by the father, and that she adopted an
addiction to enable her to tolerate the continued relationship with both
parents. However, the relationship with the addiction supplanted the
parental relationships. Despite the relationship with the psychoanalyst,
this patient is using addiction as her only reliable object. The analyst
recognizes and interprets that active addiction is incompatible with
psychoanalysis. The patient continues in psychoanalysis three years
after this intervention and is tolerating the transference in part because
of the alliance generated by this transaction.

Combined Use of the Three Perspectives

During an earlier hour from this woman’s psychoanalysis, the
patient began by noting that she had arrived an hour early, realized her
mistake, and gone for a frantic hour of shopping. Her next set of associ-
ations included dread at meeting a new internist, an addiction specialist
to whom her analyst had referred her as a replacement for a physician
who ordered any medications she requested. Her fear of seeing a
806
physician who “knows about” her—“It’s hard to trust them when I don’t
know their thoughts”—had been interpreted as a fear that the internist
would humiliate her as her mother had. She thought of the abuse her son
was suffering from his stepmother, and remembered being nine: “We
went out to eat. I was whining that I didn’t like anything on the menu.
My mother said with a smile, ‘Sweetie, would you want to come in the
bathroom with Mommie?’ I said okay. When we walked in she slapped
me so hard it almost knocked my head off. She told me that I was to
order something on the menu, eat it without talking, and never mention
what had happened in the bathroom to my father. It wasn’t the pain that
was the worst, it was the surprise.”
Rather than accept that this was only a past memory, the analyst
interpreted current concerns about how her son was being treated. The
patient responded, “I’ve been on this mission for a week. I’m cleaning
and cleaning. I was thinking, When did I use to behave like this?
I worry I have to get prepared. Even when I went to detox the last
time I brought my taxes. I used to do this when I was twenty-seven.
Ralph, the bum who lived with me, said, ‘For god sakes, did you wash
the f loor again?’ ”
The analyst asked what feeling she had at that time. The patient
replied, “I dunno. I just used to clean. Are you supposed to have a

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

feeling? I remember when our dog Spotty died, the one we had for
years, my mother said in a sad voice, ‘Spotty died.’ ” The patient laughed.
“I didn’t care a goddamn thing about Spotty. I thought, ‘I’m supposed
to be sad.’ Like when my father told me he was divorcing my mother
I thought, ‘Am I supposed to act sad?’ ” The patient laughed. “I didn’t
care. But I think I feel good now. I think I enjoy that running
around shopping. You shop, you clean, you fix, you shop, you clean,
you fix.”
The analyst asked, “Fix?”
The patient answered, “Fix things, make them right.”
The analyst said, “Of course, ‘fix’ has another meaning.”
The patient answered, “I don’t know why I said that. I meant, you
straighten things.”
Noting the theme of helpless anger, the analyst said, “I wonder if
you don’t feel furious.” The patient responded:

On and off since I’ve been coming here, I’d be walking down the
street, or in my car, and I’d feel I was dying. I didn’t feel bad about it.
I just felt I was dying. Then I thought, “That’s what my mother is doing, 807
slowly dying.” Then I thought, “I hope that’s not an identification.”
I looked at my hands the other day. I didn’t like what they looked
like. I’m a hand person. I can remember everybody’s hands. I may not
remember what guys were like in bed, but I remember their hands. I
remember what your hand felt like when I shook it the first time
I met you.
I bite my nails, even when I put acrylic nails on top. I get frantic.
I just have to bite. I want short nails. I want man’s hands. My nails are
red now. I don’t like the color red. My hands look old. Do my mother’s
hands look old? No. I put on the acrylic nails because once I start biting
them, I’m on a mission, I bite them until they bleed. . . .
My mother has long nails. My stepmother had long red nails. My
fifth-grade teacher moved my desk near her. When she didn’t like what
I did she’d dig her nails into my arm to shut me up. My mother used
to grab me with her nails too. . . .
My mother used to bite her nails. She’d wear bandages. I’d bite
my nails. She’d scream, “Stop it!” I’d stop for five seconds, and do it
again. I couldn’t stop.

The analyst asked, “Do you see how the anger and the compulsion
go together?”
The patient asked, “What compulsion?”
The analyst said, “Biting, cleaning, shopping, fixing.”

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

The patient answered, “Other people clean their houses.”

The analyst asked, “What do you think about coming early today?”
The patient answered, “I was pissed at myself. Now I try to
ignore it, laugh it off. I’d be beating myself up all the time if I contin-
ually thought about what I do.”
She next associated to a constant need to drive past her ex-
husband’s house when she had to drop her son off there, with her
son complaining each time that “the house is back there.” The ana-
lyst suggested she was angry about having to leave him.
Her next associations were about whether she would cancel her
next hour to go skiing. When the analyst took this as a violation of the
contract to meet four times a week, the patient seemed reassured. She
then realized that she was also scheduled to speak at a commitment of
Alcoholics Anonymous that evening. She associated to the need of a
friend to keep seeing his psychiatrist, and how his physician-father was
known in the addict community as a “croaker” who would sell benzo-
diazepine prescriptions unethically.
The analyst interpreted the story as a displacement to the transfer-
808
ence experience of the patient. She had undone her anger at the analyst
by coming early instead of making him wait; she was angry about the
loss of time with her son because of the divorce; her associations about
compulsive behaviors and compulsive drug use represented associa-
tions about how angry she was; and she tended to contain her aggres-
sion either by undoing it as a compulsion or by displacing it into addic-
tive behavior. The story of the doctor/father who had injured his son
indicated that she was feeling unsafe with the analyst. When she
whined to her parents about ordering at the restaurant when she was
nine, she had been humiliated for expressing her feelings. The urge to
cancel an hour was another means of expressing her anger.
The patient called the interpretation “far-fetched,” associated to
forgetting to set her two alarm clocks so that she could pick up her son
at his father’s and drive him to school, and then suddenly looked at her
watch and told the analyst that the hour was over. She was exactly right.
The patient is using her treatment to explore her experiences of
addiction and compulsion, including her compulsive shopping.
Because of her experience growing up with her parents, the analyst’s
expectation that she associate triggers intense anger and a feeling of
helplessness and shame. Dodes’s assertion that addiction and compul-
sion overlap, and might be considered identical, is nicely illustrated.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

Is she shopping compulsively, or does she have a shopping addiction?

Both are true.
All three perspectives could be invoked to understand this material.
The patient was active with her shopping addiction at the time of this
hour. The analyst was completely unaware of this, and the patient may
well have not been conscious of the addictive nature of her behavior
at that time. Robinson and Berridge might say that the anger she was
feeling might have been an associational trigger of her compulsive
shopping. Use of their model suggests that there is no possibility of
empathic understanding of the behavior, because it is driven by a sub-
cortical pathway. The patient might have the experience that she was
“just shopping,” and might then construct a denial system to explain or
excuse the behavior.
The developmental model I have advanced might be used, as in the
earlier example, to explain that the patient was already experiencing
abandonment by the analyst, and had taken up shopping as an alterna-
tive dependence-gratifying relationship. “Is the time up yet?” might be
heard as the experience of a person who knows that shopping never lets
809
her down, while her psychoanalyst-as-mother has repeatedly crossed
the line from caring to intrusive, hateful probing, and therefore has
already been dismissed as a person who can be there for her.
Khantzian would undoubtedly point to opiates as the drug of choice
and would suggest that this patient is unable to tolerate anger/rage as an
underlying cause. The patient has no idea how to take care of herself
when she is overwhelmed by the experience of anger and humiliation
at the inquiring stance of the psychoanalyst, which she finds so remi-
niscent of her mother’s sarcastic “Are you having a feeling, sweetie?”
However, in this particular hour, it seems that the most helpful
interpretations for the patient are of aggression directed toward the
analyst as a defense against the transference experience of being help-
less against a figure who would humiliate her for her feelings. Her
compulsive behaviors might be described by Dodes (1996) as a dis-
placement. She is shopping, cleaning, and fixing rather than articulat-
ing her angry feelings toward her analyst.
The treating clinician who uses the three models is thereby in a
position to evaluate each patient who presents for treatment in the
context of the level of ego functioning he or she displays. A healthy
patient who has regressed to the use of an addiction as a defense during
a stressful period may easily be able to tolerate the craving that comes

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

with cessation of drug use. For example, a relatively healthy patient

might be sent to a smoking cessation program. The heroin-dependent
patient described in the first clinical section needed only some attention
to his experience, some factual explanations, and methadone detoxi-
fication. Beyond these relatively simple interventions lies the need to
correct the underlying dynamics of the addictive process. Sometimes
this can be accomplished by brief behavioral interventions, or by atten-
dance at Twelve Step recovery programs.
Clinicians need to be aware of the tendency to shift from one addic-
tion to another. Researchers investigating the outcome of treatment of
addictive diseases need to employ more sophisticated models of recov-
ery. For example, if a patient stops smoking cigarettes and gains a
hundred pounds, should this individual be counted as a success, or as
someone whose addiction has shifted to a less scrutinized substitute?
For many patients, substitution of one addiction for another must be
counted a relative therapeutic triumph. For example, Bill Wilson, the
founder of Alcoholics Anonymous, died of his nicotine addiction, but
many productive years after he became sober from alcohol. In other
810
cases, substitution needs to be taken into account as a sign of inability
to attain a stable recovery. Studies of methadone maintenance, for
instance, tend to use abstinence from opiates as an outcome measure,
when many patients continue to use alcohol, cocaine, or benzodi-
azepines in an addictive, self-destructive manner (Miller and Gold 1993;
Condelli et al. 1991).
For the dynamically oriented clinician, the three perspectives
presented here orient the treatment according to whether simple crav-
ing is driving the constant impulse toward drugs, or whether more
complex dynamics must be taken into account. In this context, diagno-
sis, relapse prevention coaching, Twelve Step meetings, and supportive
or expressive psychotherapy, either alone or in combination, all become
understandable, applicable modalities for helping the patient.
The question of whether to treat the patient with psychoanalytic
therapy rests not on the diagnosis but on the patient’s behavior. As
described by Dodes (1984), patients who frequently miss treatment
hours, whether because of hostility or drug use, or who are physically
present but impaired by chemical use, cannot be treated in an outpatient
psychotherapy practice. However, patients who come and work, regard-
less of their involvement with addictive substances or compulsive
behaviors, can be helped. Addictive behaviors might have to be

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

addressed directly in order to preserve the treatment relationship. For

example, in the psychoanalysis described above, the analyst had to
suggest directly that the patient cut up her credit cards, stop her illegal
use of a relative’s card, and see a bankruptcy lawyer as a condition
of her continuing analysis. Flexible use of the three perspectives
abrogates any artificial distinction between patients appropriately
treated with behavioral, Twelve Step, or psychoanalytic therapies. Any
or all are applicable to specific patients, depending on the particular
nature of their addictive dynamics.
There can be a tendency to either ignore the addictive process or
to elevate it to the only concern. For example, patients who compul-
sively eat, and who present to psychotherapy, might not address
their food addiction directly in their associations. They might have
a denial system the clinician complies with, so that a central symptom
is left out of the treatment. Many members of Alcoholics Anony-
mous have complained that they were in psychotherapy or psycho-
analysis, yet their drinking was either ignored or relegated to a
subordinate position. However, by a strange twist, psychological
811
treatment is often withheld until a patient becomes sober. Some
addiction clinicians will tell patients to stay sober for a year using
nonexploratory treatments and only then return for uncovering
psychotherapy. The case presented above of the man who used eight
bags of heroin before his psychotherapy hours, and who continued
to use alcohol and marijuana after the treatment, might be regarded
as an anathema by some clinicians, despite the excellent outcome
in terms of functioning. Using the three perspectives allows a flexi-
bility in treatment that is true to the individual being helped. It
allows for the centrality of abstinence in some treatments, yet
eschews an insistence on abstinence as a prerequisite for treatment
in all cases. At the same time, there is a focus on the use of any
compulsive behavior as a sign of distress, whether or not a chemical
substance is used in the behavior.
Finally, use of the three perspectives eliminates the strange-
ness of addiction, which tends to frighten some clinicians away
from engaging with patients who are actively addicted. Addiction
is not viewed as a bizarre, awful, or degrading behavior that suggests
that the patient be sent elsewhere for treatment. Rather, it is seen as
one of the most common character adaptations seen in everyday
clinical practice.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

CONCLUSION

No claim is made that any of the three models of addiction presented

above are the “truth.” They are models in the engineering sense—they
exist to help get a real job done. Based on some science, some obser-
vation, they are directed toward trying to be effective in the real world.
It is likely that the models described will be revised and superseded
over time.
There are two advantages to the use of three perspectives on
addiction. The first is that it removes the need to find any one magical
solution to addiction. Instead, we are content to use the particular way
of thinking of an addiction that fits a particular patient at a particular
time. The second is that there is a correspondence between more
general psychoanalytic psychology and the ways of understanding
addiction presented above. This allows for further investigation and
elaboration of addictive dynamics. However, no attempt is made here to
rival other psychologies or treatment methods. On the contrary, inclu-
sivity is recommended, as is the attempt to understand the relationship
812 of psychoanalytic theory and other psychologies (for example, the way
mesotelencephalic activation and associated learning contribute to the
drive to obtain chemicals).
Within the context of the three perspectives on addiction, it is
hoped that clinicians find empathy for the compulsive behaviors of
addiction, because empathy is the essential first step in any attempt
to be of service.
REFERENCES

ABRAHAM, K. (1908). The psychological relations between sexuality and alco-

holism. In Selected Papers of Karl Abraham. New York: Basic Books,
1927, pp. 80–89.
ANDA, R.F., WILLIAMSON, D.F., ESCOBEDO, L.G., MAST, E.E., GIOVINO, G.A., &
REMINGTON, P.L. (1990). Depression and the dynamics of smoking: A
national perspective. Journal of the American Medical Association
264:1541–1545.
BERRIDGE, K.C., & ROBINSON, T.E. (1998). What is the role of dopamine in
reward: Hedonic impact, reward learning, or incentive salience? Brain
Research Reviews 28:309–369.
BRESLAU, N., KILBEY, M.M., & ANDRESKI, P. (1993). Vulnerability to psy-
chopathology in nicotine dependent smokers: An epidemiologic study of
young adults. American Journal of Psychiatry 150:941–946.
CONDELLI, W.S., FAIRBANK, J.A., DENNIS, M.L., & RACHAL, J.V. (1991). Cocaine

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

use by clients in methadone programs: Significance, scope, and behav-

ioral interventions. Journal of Substance Abuse Treatment 8:203–212.
DODES, L.M. (1984). Abstinence from alcohol in long-term individual
psychotherapy with alcoholics. American Journal of Psychotherapy
38:284–256.
——— (1988). The psychology of combining dynamic psychotherapy and
Alcoholics Anonymous. Bulletin of the Menninger Clinic 52:283–293.
——— (1990). Addiction, helplessness, and narcissistic rage. Psycho-
analytic Quarterly 59:398–419.
——— (1996). Compulsion and addiction. Journal of the American
Psychoanalytic Association 44:815–835.
F REUD , S. (1926). Inhibitions, symptoms and anxiety. Standard Edition
20:75–175.
JOHNSON, B. (1992). Psychoanalysis of a man with active alcoholism. Journal
of Substance Abuse Treatment 9:111–123.
——— (1993). A developmental model of addictions and its relationship to
the twelve step program of Alcoholics Anonymous. Journal of Substance
Abuse Treatment 10:23–34.
——— & CLARK, W. (1989). Alcoholism: A challenging physician-patient
encounter. Journal of General Internal Medicine 4:445–452. 813
KAUFMAN, E. (1994). Psychotherapy of Addicted Persons. New York: Guilford
Press.
KERNBERG, O. (1975). Borderline Conditions and Pathological Narcissism.
New York: Aronson.
KHANTZIAN, E.J. (1985). The self-medication hypothesis of addictive disorders.
American Journal of Psychiatry 142:1259–1264.
——— (1994). How AA works and why it’s important for clinicians to
understand. Journal of Substance Abuse Treatment 11:77–92.
——— (1995). Self-regulation vulnerabilities in substance abusers:
Treatment implications. In The Psychology and Treatment of Addictive
Behavior, ed. S. Dowling. Madison, CT: International Universities Press,
pp. 17–42.
——— (1997). The self-medication hypothesis of substance use disorders:
A reconsideration and recent applications. Harvard Review of Psychiatry
4:231–244.
KOHUT, H. (1971). The Analysis of the Self. New York: International
Universities Press.
——— (1977). The Restoration of the Self. New York: International
Universities Press.
K RYSTAL H. (1988). Integration and Self-Healing: Affect, Trauma,
Alexithymia. Hillsdale, NJ: Analytic Press.
——— (1995). Disorders of emotional development in addictive behavior.
In The Psychology and Treatment of Addictive Behavior, ed. S. Dowling.

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 Brian Johnson

Madison, CT: International Universities Press, pp. 65–100.

——— & RASKIN, H.A. (1981). Drug dependence: Aspects of ego function.
In Classic Contributions in the Addictions, ed. H. Schaffer & M.E.
Burglass. New York: Brunnel-Mazel, 1981, pp.161–172.
KUSHNER, M.G., SHER, K.J., & ERICKSON, D.J. (1999). Prospective analysis of
the relation between DSM-III anxiety disorders and alcohol use
disorders. American Journal of Psychiatry 156:723–732.
LYONS-RUTH, K. (1991). Rapprochement or approchement: Mahler’s theory
reconsidered from the vantage point of recent research on early attach-
ment relationships. Psychoanalytic Psychology 8:1–23.
MAHLER, M.S., PINE, F., & BERGMAN, A. (1975). The Psychological Birth of the
Human Infant: Symbiosis and Individuation. New York: Basic Books.
MEYERS, W.A. (1994). Addictive sexual behavior. Journal of the American
Psychoanalytic Association 42:1159–1182.
——— (1995). Sexual addiction. In The Psychology and Treatment of
Addictive Behavior, ed. S. Dowling. Madison, CT: International
Universities Press, pp. 115–132.
MILLER, N.S., & GOLD, M.S. (1993). A neurochemical basis for alcohol and
other drug addiction. Journal of Psychoactive Drugs 25:121–128.
814 ROBINSON, T.E., & BERRIDGE, K.C. (1993). The neural basis of drug craving:
An incentive-sensitization theory of addiction. Brain Research Reviews
18:247–291.
R OSENFELD , H.A. (1965). On drug addiction. In Psychotic States: A
Psychoanalytic Approach, ed. H.A. Rosenfeld. New York: International
Universities Press, pp.128–143.
SCHUKIT, M.A. (1988). Genetic and clinical implications of alcoholism and
affective disorders. American Journal of Psychiatry 143:140–147.
——— IRWIN, M., & BROWN, S.A. (1990). The history of anxiety symptoms
among 171 primary alcoholics. Journal of Studies on Alcohol 51:34–41.
SHAFFER, H.J., & JONES, S.B. (1989). Quitting Cocaine: The Struggle against
Impulse. Lexington, MA: Lexington Books.
SHEDLER, J., & BLOCK, J. (1990). Adolescent drug use and psychological health.
American Pscyhologist 45:612–630.
S ORA , I., W ICHEMS , C., TAKAHASHI , N., L I , X.-F., Z ENG , A., R EVAY, R.,
LESCH, K.-P., MURPHY, D.L., & UHL, G.R. (1998). Cocaine-reward mod-
els: Conditioned place preference can be established in dopamine and in
serotonin-transporter knockout mice. Proceedings of the National
Academy of Science 95:7699–7704.
SPEZZANO, C. (1998). The triangle of clinical judgment. Journal of the
American Psychoanalytic Association 46:365–388.
SWAN, N. (1998). Brain scans open window to view cocaine’s effects on the
brain. NIDA Notes 13(2):12.
VAILLANT, G.E. (1983). The Natrual History of Alcoholism. Cambridge:

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015

 THREE PERSPECTIVES ON ADDICTION

Harvard University Press.

——— (1996). A long-term follow-up of male alcohol abuse. Archives
of General Psychiatry 53:243–249.
V OLKAN , V.D. (1973). Transitional fantasies in the analysis of a narcis-
sistic personality. Journal of the American Psychoanalytic Association
21:351–376.
WINNICOTT, D.W. (1951). Transitional objects and transitional phenomena.
In Collected Papers. New York: Basic Books, 1958, pp. 229–242.
WURMSER, L. (1974). Psychoanalytic considerations of the etiology of com-
pulsive drug use. Journal of the American Psychoanalytic Association
22:820–843.
——— (1978). The Hidden Dimension: Psychodynamics of Compulsive
Drug Use. New York: Aronson.
——— (1981). The Mask of Shame. Baltimore: Johns Hopkins Press.
——— (1995). Compulsiveness and conflict: The distinction between
description and explanation in the treatment of addictive behavior. In The
Psychology and Treatment of Addictive Behavior, ed. S. Dowling.
Madison, CT: International Universities Press, pp. 43–64.
ZINBERG, N.E. (1975). Addiction and ego function. Psychoanalytic Study of
the Child 30:567–588. 815

5 Park Place
Newtonville, MA 02160
Fax: 617–469–5013
E-mail: [email protected]

Downloaded from apa.sagepub.com at Freie Universitaet Berlin on May 9, 2015