Traditionally treated with wariness, drug addictions have provoked a serious interest in psychodynamically oriented clinicians in recent decades. This paper discusses the development of contemporary psychodynamic conceptualizations of addictions, focusing specifically on mentalization-based theories. The concept of mentalization refers to a complex form of self-regulation which includes attribution of psychological meaning to one’s own behavior and affective states, as well as those of the others. We hypothesize that drug-addicted patients have severe impairments in mentalizing, associated with developmental deficits, characteristic for the borderline personality disorder and psychosomatic conditions. Psychodynamic models of mentalization and their corresponding research operationalizations are reviewed, and implications for a contemporary understanding of drug addictions and psychotherapy are drawn. The authors propose that mentalization-oriented theories provide an adequate conceptualization, which is open to empirical testing and has clear and pragmatic guidelines for treatment. 1. Introduction We know that the onset of drug addictions is determined by a complex combination of constitutional (biological), social, and psychological factors. Physiological components play a crucial role in the maintenance of psychological anxiety, associated with physical abstinence, but they are not the one and only etiological factor behind this disorder and they can not entirely explain the motivation for subsequent relapses [1]. It is clear that every psychoactive drug induces a specific state of intoxication, but individual psychopathology largely defines the subject’s reaction towards the pharmacological effects [2]. Bearing in mind these assumptions, we review a series of developments in the understanding of substance abuse starting with classical psychodynamic approaches based on drive/conflict models. Then, we present comprehensive theories of affect regulation which we see as a starting point for the transition to modern mentalization-based conceptualizations. We describe the shift from the initial emphasis on instinctual gratification to the investigation of ego development and pathology. We show how contemporary psychodynamic clinicians and researchers can increasingly rely on mentalization based theories to explain personality pathology. We outline some of the implications of this shift for evidence-based practice. There is clear evidence supporting neurobiological and neurocognitive adaptations to specific drug exposure, the natural history of addiction
References
[1]
L. M. Dodes, “Addiction and psychoanalysis,” Canadian Journal of Psychoanalysis, vol. 11, pp. 123–134, 2003.
[2]
H. Wieder and E. H. Kaplan, “Drug use in adolescents. Psychodynamic meaning and pharmacogenic effect,” Psychoanalytic Study of the Child, vol. 24, pp. 399–431, 1969.
[3]
K. Abraham, “The psychological relations between sexuality and alcoholism,” International Journal of Psycho-Analysis, vol. 7, pp. 2–10, 1926.
[4]
S. Radó, “The psychical effects of intoxication: attempt at a psycho-analytical theory of drug addiction,” Journal of Psycho-Analysis, vol. 9, pp. 301–317, 1928.
[5]
O. Fenichel, “The marihuana addict in the army,” Psychoanalytic Quarterly, vol. 14, p. 578, 1945.
[6]
E. Glover, “On the aetiology of drug-addiction,” International Journal of Psycho-Analysis, vol. 13, pp. 298–328, 1932.
[7]
E. J. Khantzian, “Understanding addictive vulnerability: an evolving psychodynamic perspective,” Neuropsychoanalysis, vol. 5, no. 1, pp. 5–21, 2003.
[8]
G. E. Woody, “Psychiatric aspects of opiate dependence: diagnostic and therapeutic research issues,” in Psychodynamics of Drug Dependence Rockville, J. Blaine and D. Julius, Eds., National Institute on Drug Abuse, Maryland, Md, USA, 1977.
[9]
L. Wurmser, “Mr. Pecksniff’s horse? (Psychodynamics in compulsive drug use),” in Psychodynamics of Drug Dependence, J. Blaine and D. Julius, Eds., National Institute on Drug Abuse, Rockville, Mad, USA, 1977.
[10]
E. L. Jurist, “Mentalized affectivity,” Psychoanalytic Psychology, vol. 22, no. 3, pp. 426–444, 2005.
[11]
H. Krystal, “The genetic development of affects and affect regression,” Annual of Psychoanalysis, vol. 2, pp. 98–126, 1974.
[12]
P. E. Sifneos, “The prevalence of ‘Alexithymic’ characteristics in psychosomatic patients,” Psychotherapy and Psychosomatics, vol. 22, no. 2, pp. 270–285, 1973.
[13]
G. Taylor, R. Bagby, and J. Parker, “The development and regulation of affects,” in Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness, G. Taylor, R. Bagby, and J. Parker, Eds., Cambridge University Press, Cambridge, UK, 1997.
[14]
A. De Mijolla, International Dictionary of Psychoanalysis, Macmillan Reference, New York, NY, USA, 2005.
[15]
P. Fonagy, “The mentalization-focused approach to social development,” in Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications, F. Busch, Ed., Taylor & Francis Group, New York, NY, USA, 2008.
[16]
J. Bowlby, Attachment and Loss, vol. 1, Hogarth Press, London, UK, 1969.
[17]
E. Weinberg, “Mentalization, affect regulation, and development of the self,” Journal of the American Psychoanalytic Association, vol. 54, no. 1, pp. 251–269, 2006.
[18]
A. Bateman and P. Fonagy, “8-Year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual,” American Journal of Psychiatry, vol. 165, no. 5, pp. 631–638, 2008.
[19]
T. J. Trull, K. J. Sher, C. Minks-Brown, J. Durbin, and R. Burr, “Borderline personality disorder and substance use disorders: a review and integration,” Clinical Psychology Review, vol. 20, no. 2, pp. 235–253, 2000.
[20]
J. G. Allen, P. Fonagy, and A. W. Bateman, Mentalizing in Clinical Practice, American Psychiatric Publishing, Washington, DC, USA, 2008.
[21]
M.-A. Bouchard and S. Lecours, “Contemporary approaches to mentalization in the light of Freud’s project,” in Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications, F. Busch, Ed., Taylor & Francis Group, New York, NY, USA, 2008.
[22]
P. Marty, Mentalisation et Psychosomatique, Synthélabo, Paris, France, 1991.
[23]
“Affect tolerance,” Annual of Psychoanalysis, vol. 3, pp. 179–219, 1975.
[24]
J. Piaget, La Formation du Symbole Chez L’enfant, Delachaux et Niestlé, Neuchatel, Switzerland, 1959.
[25]
A. W. Bateman and P. Fonagy, Psychotherapy for borderline personality disorder. Mentalization Based Treatment, Oxford University Press, New York, NY, USA, 2004.
[26]
M. G. Haviland, M. S. Hendryx, D. G. Shaw, and J. P. Henry, “Alexithymia in women and men hospitalized for psychoactive substance dependence,” Comprehensive Psychiatry, vol. 35, no. 2, pp. 124–128, 1994.
[27]
A. MacBeth, A. Gumley, M. Schwannauer, and R. Fisher, “Attachment states of mind, mentalization, and their correlates in a first-episode psychosis sample,” Psychology and Psychotherapy, vol. 84, no. 1, pp. 42–57, 2011.
[28]
S. Taubner, H. Kessler, A. Buchheim, H. K？chele, and L. Staun, “The role of mentalization in the psychoanalytic treatment of chronic depression,” Psychiatry, vol. 74, no. 1, pp. 49–57, 2011.
[29]
S. Lecours and M. A. Bouchard, “Verbal elaboration of distinct affect categories and BPD symptoms,” Psychology and Psychotherapy, vol. 84, no. 1, pp. 26–41, 2011.
[30]
P. Fonagy, T. Leigh, M. Steele et al., “The relation of attachment status, psychiatric classification, and response to psychotherapy,” Journal of Consulting and Clinical Psychology, vol. 64, no. 1, pp. 22–31, 1996.
[31]
D. W. Levy and S. Truman, Reflective Functioning as Mediator between Drug Use, Parenting Stress and Child Behavior, College of Problems of Drug Dependence, Quebec City, Canada, 2002.
[32]
T. Ostler, O. S. Bahar, and A. Jessee, “Mentalization in children exposed to parental methamphetamine abuse: relations to children's mental health and behavioral outcomes,” Attachment and Human Development, vol. 12, no. 3, pp. 193–207, 2010.
[33]
H. Steele and M. Steele, “On the origins of reflective functioning,” in Handbook of Mentalization-Based Treatment, J. Allen and P. Fonagy, Eds., West Sussex, John Wiley & Sons, 2006.
[34]
S. Lecours, Manuel de Cotation de la Grille de l'élaboration Verbale de lAffect GéVA (version 4), 2002.
[35]
D. Diamond and O. F. Kernberg, “Discussion,” in Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications, F. Busch, Ed., Taylor & Francis Group, New York, NY, USA, 2008.
[36]
L. W. Choi-Kain and J. G. Gunderson, “Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder,” American Journal of Psychiatry, vol. 165, no. 9, pp. 1127–1135, 2008.
[37]
K. S？derstr？m and F. Sk？rderud, “Mentalization-based treatment in families with parental substance use disorder: theoretical framework,” Nordic Psychology, vol. 61, no. 3, pp. 47–65, 2009.
[38]
M.-A. Bouchard, M. Target, S. Lecours et al., “Mentalization in adult attachment narratives: reflective functioning, mental states, and affect elaboration compared,” Psychoanalytic Psychology, vol. 25, no. 1, pp. 47–66, 2008.
