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An Ego/Self Theory of
Substance Dependence

A Contemporary Psychoanalytic
Perspective

Edward J. Khantzian, M.D.

INTRODUCTION

Drug dependence is tied intimately to an individual's attempt to cope with his or her internal emotional and external social and physical environment. Viewed from a contemporary psychoanalytic perspective, drug dependency can best be understood by examining how such a person's ego organization and sense of self serve or fail the individual's attempts to cope, and how the specific effects of various substances facilitate or impede such attempts.

Although early psychoanalytic investigators appreciated the presence of underlying depression, tension, and distress in addicts, most of the early psychoanalytic formulations of substance dependence emphasized the instinctive, pleasurable aspects of drug use to explain the compelling nature of addiction (Yorke 1970; Khantzian 1974; Khantzian and Treece 1977). More recent psychoanalytic formulations have placed greater emphasis on problems in adaptation, ego and self disturbances, and related psychopathology as etiological factors in drug dependence (Krystal and Raskin 1970; Wurmser 1974; and Khantzian 1978).

A variety of drug-use patterns and degrees of dependence in which everyday problems of living are involved may be identified (Khantzian et al. 1974). Nevertheless, l have become convinced, as has Wurmser (1974), that becoming and remaining addicted to drugs is in most instances associated with severe and significant psychopathology. Necessarily, some of the observed pathology evident in addicts is the result of drug use and its attendant interpersonal involvements (Zinberg 1975; Mirin et al. 1976; Khantzian and Treece 1979). However, it is my opinion that drug-dependent individuals are predisposed to use and to become dependent upon their substances mainly as a result of severe ego impairments and disturbances in the sense of self, involving difficulties with drive and affect defense, self-care, dependency, and

need satisfaction. Hence, my theoretical work has focused on these impairments and disturbances in the ego and the sense of self.

ADAPTATION AND DRUG USE

ln one of our first papers on substance dependence (Khantzian et al. 1974), we explored the relationship of heroin use to a range of human problems, including pain, stress, and dysphoria. ln attempting to adapt to one's emotions and environment, the powerful action of heroin and immersion in the attendant rituals and subculture could be used to mute, extinguish, and avoid a range of feelings and emotions. That is, rather than settling for more ordinary defensive, neurotic, characterological, or other adaptive mechanisms as a way of dealing with distress, heroin addicts had adopted a more extraordinary solution by using a powerful drug and immersing themselves in the associated rituals, practices, and pseudoculture. ln this early report, we stressed the costly consequences of the heroin involvement and why the addict was so desperately dependent on the drug, that is, "the central problem for most people who have become addicted to opiates is that they have failed to develop effective symptomatic, characterologic, or other adaptive solutions in response to developmental crises, stress, deprivation, and other forms of emotional pain which may not in themselves be extraordinary. Their response has been to revert repeatedly to the use of opiates as an all powerful device, thereby precluding other solutions that would normally develop and that might better sustain them" (p. 164).

AGGRESSION AND HEROIN DEPENDENCE

ln contrast to a general sense that heroin could be used to deal with a range of human emotions and troubles, l also quickly became impressed with a rather specific reason why opiates could be so appealing to many heroin addicts. From the outset of my clinical-investigative work with drug dependency, l was immediately impressed with the enormous, lifelong difficulties heroin addicts had with feelings and impulses associated with aggression. ln repeated life histories obtained from addicts, l was impressed with how dysphoric feelings associated with anger, rage, and restlessness were relieved in the short term by heroin and other opiates. This was even more apparent when observing addicts in treatment as they became stabilized on methadone and their aggression and restlessness subsided. l began to suspect that heroin addicts might be using opiates specifically as an antiaggression drug.

As a result of these initial impressions, l published a preliminary report (1972) and subsequently expanded and formulated a hypothesis (Khantzian 1974) which proposed that problems with aggression predisposed certain individuals to opiate dependence and was central in the development and maintenance of an addiction. l emphasized how addicts took advantage of the antiaggression action of opiates in the service of drive defense. l stressed the disorganizing influence of aggression on ego functions in individuals whose ego stability was already subject to dysfunction and impairment as a result of developmental arrest or regression. l also proposed that the same but sustained, longer antiaggression action of methadone was the basis for "success" of methadone maintenance.

SELF (NARCISSISTIC) PATHOLOGY

Over the past decade, considerable attention has been focused on self pathology. ln contrast to ego pathology, in which the emphasis is on disturbance in structure and function in coping with drives and emotions, self pathology relates more to troubled attitudes and experiences about the self and others. Kohut (1971) and Kernberg (1975) have explored how disruptions and disturbances in a person's early development, particularly around nurturance and dependency needs, lead to self pathology in adult life. Both investigators consider substance dependencies as manifestations of such disorders, although neither Kohut nor Kernberg has systematically explored this relationship. A number of investigators have attempted to relate this recent better understanding of narcissistic processes and disturbances to substance dependence. Reports by Wieder and Kaplan (1969), Wurmser (1974), and Krystal and Raskin (1970) have stressed narcissistic vulnerabilities and decompensation as predisposing factors. Wurmser, in particular, has emphasized how drugs are used to counteract the distress and dysphoria associated with decompensated narcissistic states.

ln my own psychotherapeutic work with addicts, l became interested in some of the unique and characteristic traits of compensated addicts (i.e., addicts who were either drug free or on drug maintenance) that are related to underlying narcissistic processes and disturbances, and how such traits might predispose an individual to drug dependence. l repeatedly observed the addict's special problems in accepting dependency and actively acknowledging and pursuing goals and satisfactions related to needs and wants. Extreme and alternating patterns in pursuing need satisfaction were evident: Cooperation and compliance might suddenly alternate with outbursts of rage, refusal, or resistance; passivity and indifference could shift rapidly or coexist with active, intense, and restless involvements that often led to danger, violence, and death; disavowal of needs and solicitousness of others might suddenly convert to angry demands and an entitlement that was totally oblivious of other people.

To explain such patterns, l proposed that the rigid character traits and alternating defenses employed by addicts were adopted against underlying needs and dependency in order to maintain a costly psychological equilibrium. Prominent defenses and traits included extreme repression, disavowal, self-sufficiency, activity, and assumption of aggressive attitudes. l concluded that "defenses (and the associated character traits) are employed in the service of containing a whole range of longings and aspirations, but particularly those related to dependency and nurturance needs. lt is because of massive repression of these needs that such individuals feel cut off, hollow and empty . . [and that the] . . . addicts' inability to acknowledge and pursue actively their needs to be admired, and to love and be loved, leave them vulnerable to reversion to narcotics" (Khantzian 1978, p. 196).

SELF-SELECTION AND THE SPECIFIC
APPEAL OF HEROIN

Most substance-dependent individuals prefer and self-select a particular drug. This preference and selection is the result of the drug of

choice and its distinctive psychopharmacologic effects interacting with the unique personality organization and reactive patterns of an individual. lt is this interaction between drug effect and personality organization that predisposes a person to dependency on a particular drug. The specific appeal of opiates, stimulants, sedative-hypnotic drugs (including alcohol), and other drugs has been explored from a psychodynamic perspective (Wieder and Kaplan 1969; Wurmser 1974; Milkman and Frosch 1973; Khantzian 1975). Wieder and Kaplan, and others, continue to stress the regressive and pleasurable ego states produced by these drugs (including opiates) to explain their appeal, while Wurmser and l have placed greater emphasis on the progressive and adaptive use of drugs. ln this respect, l have been particularly interested in the narcotic addict's preference for opiates. As already indicated, my early work with heroin addicts led me to conclude that the compelling nature of opiates for many narcotic addicts resides in a specific antiaggression action of narcotics, namely, to relieve and counteract regressed, disorganized, and dysphoric ego states related to overwhelming feelings of rage, anger, and related depression. Whereas the use of drugs such as the amphetamines and hypnotics (including alcohol) results in the mobilization and expression of aggressive and sexual impulses, opiates have the opposite effect. This effect is particularly needed and welcomed in certain individuals whose ego mechanisms of defense, particularly against aggressive drives, are shaky or absent. On close examination, we have been impressed repeatedly that the so-called "high" or euphoria produced by opiates is more correctly a relief of dysphoria associated with unmitigated aggression. The short-term effect of the drug is to reverse regressed dysphoric ego states by muting and containing otherwise uncontrollable rage and aggression (Khantzian 1972, 1974, 1978).

SELF-CARE DISTURBANCES

The previous sections have focused on how drug addicts attempt to use drugs adaptively to overcome and cope with ego and self problems. ln this final section l would like to focus on a more obvious maladaptive aspect of drug use.

The influences of early psychoanalysis are evident in "id" formulations of addictions that invoke and presuppose the existence of unconscious death wishes and self-destructive trends (death instincts) to account for the destructiveness and dangers associated with drug dependence. Clearly, certain individuals are driven or are compelled to be selfdestructive, with suicide the most extreme manifestation of such a compulsion. lndeed, it has been suggested rather cynically by some that drug dependence and abuse is a form of suicide on the installment plan. Menninger (1938) is representative in presenting such a point of view, referring to such behavior as "chronic suicide." The psychology of conscious and unconscious human destructiveness is complex and may well be a component in the destructive aspects of substance dependence. However, in my experience, many of the self-destructive aspects of drug dependence represent failures in ego functions involving self-care and self-protection.

Self-care functions originate and are established in early phases of human development. They become internalized as a result of and through the ministrations of the caring and protective role of the parents, particularly the mother. lf optimal, children gradually

incorporate a capacity to care for themselves and to protect against and anticipate harm and danger. Extremes of indulgence and deprivation may do injury to the individual's developing ego and sense of self around vital functions of self-preservation and care, and may leave individuals vulnerable to a whole range of hazards and dangers, not the least of which is the use of dangerous drugs.

Self-care as an ego function is complex. lt is probably the result of a
number of component functions and defenses such as signal anxiety,
reality testing, judgment, control, and synthesis, and when impaired,
such defenses as denial, justification, projection, etc. We are all
subject to our instincts, drives, and impulses, and if they are expressed
indiscriminately, we are subject to hazard and danger. Most of us
check ourselves more or less and automatically exercise caution, or we
are appropriately worried and fearful of the prospects of danger or
hazardous involvements. Such checking or cautionary responses are
an integral part of our ego mechanisms of defense. However, it is
exactly in this regard that addicts are deficient in their ego.

These are problems that l consider to be related to self-care
(ego) functions that are impaired, deficient or absent in so
many of the addicts we see. The problems with self-care
and regulation are apparent in their past histories (predating
their addiction) by a high incidence of preventable medical
and dental problems, accidents, fights, violent behavior and
delinquent behavioral problems. Their impaired self-care
functions are also evident in relation to their drug/alcohol
problems, where despite obvious deterioration and imminent
danger as a result of their substance use, there is little
evidence of fear, anxiety or realistic assessment about their
substance involvement. One might correctly argue that in
this latter instance, the lack of self-care is secondary to
regression as a result of prolonged substance use. Although
this is probably true, we have been impressed with the
presence and persistence of these described tendencies in
such individuals both prior to becoming addicted and subse-
quent to becoming detoxified and stabilized."

(Khantzian 1978, p. 193)

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