Nosological, neuroscience, and psychoanalytic approaches to addiction have diverged over the last third of a century. In terms of nosology, the 1980 DSM-III featured a distinction between alcohol abuse and alcohol dependence. Alcohol dependence required symptoms of tolerance and withdrawal in addition to the symptoms of alcohol abuse. This distinction between abuse and dependence was applied in DSM-III to all addictions, although this paper will be restricted, by its nature as a case report, to alcohol addiction.
Under DSM-III abuse and dependence were researched as separate illnesses. For example Vaillant (2003), in his 60 year followup of alcoholic men, described one of the most surprising findings being that DSM-III alcohol abuse could continue for decades without progression to alcohol dependence. The abuse/dependence distinction was continued in the 1994 DSM-IV (American Psychiatric Association, 1994) but will be written out of the DSM-V (dsm5.org). This paper will question the epistemology and conclusions of the DSM-V recategorization of alcoholism.
From the neuroscience side, addiction is about the brain. For example, a review by Koob and Volkow (2010) described three stages of addiction: compulsion to seek and take the drug, loss of control of intake, and emergence of a negative emotional state during abstinence. The compulsion phase features key elements in the ventral tegmental area and ventral striatum. The extended amygdala becomes a central locus of activity in the withdrawal/negative affect phase. The final phase involves a number of centers including the orbitofrontal cortex–dorsal striatum, prefrontal cortex, basolateral amygdala, hippocampus, insula, cingulate gyrus, dorsolateral prefrontal, and inferior frontal cortices.
The owner of the brain is not particularly central in the neuroscience approach. For example, Berridge (2004, p. 196) stated, “The incentive-sensitization theory is an explanation of a human clinical problem that sprang entirely from basic behavioral neuroscience research and concepts. The theory applies to human addicts, but originally was developed as a deductive concept wholly from results of animal laboratory experiments on neural sensitization and on incentive salience functions of brain dopamine systems.” When psychological concepts were needed to tie brain function to human addiction, Koob and Volkow invoked a simple human/animal behavioral paradigm. Behaviors are learned. Conditioned stimuli are bound to unconditioned stimuli. Oddly, their psychological concepts originated in behavioral psychology, where the brain was specifically left out of consideration in constructing these concepts (Panksepp, 1998, p. 12, quoting B. F. Skinner).
Psychoanalysts have viewed addictions as a purely psychological condition (for example Dodes, 1990, 1996, 2002, 2003, 2009; Khantzian, 1999, 2003; Petrucelli and Stuart, 2001; Director, 2002, 2005; Mann, 2002; Burton, 2005; Waska, 2006, twentieth century psychoanalytic literature reviewed in Johnson, 1999). The advantage of the psychoanalytic approach is that it features hundreds of systematic observations of a single patient, made over time. Psychoanalysts treat addiction by examining their relationship with the patient and use psychodynamic principles. An interpersonal vantage point produces different data about the disease of addiction. This vantage point is the subject of the case report below.
The DSM-V change in addiction nosology is the result of a shift in the type of information considered to make diagnostic categories. Assessments of the 1970s and before were designed to be administered by clinicians. In the 1980s a new approach emerged that has remained popular in the addiction field – assessing of behaviors by non-clinical interviewers using questions prepared by researchers. These interviewers are sent out to collect information that is analyzed by statistical experts (Cottler and Grant, 2006). People are reduced to numbers, the numbers are categorized, and these numerical categories are meant to be applied in further research, “To provide information on prognosis, response to interventions, course of illness over time, neurobiological findings, and comorbidity” (Cottler and Grant, 2006). This assumption of leadership by statistical experts over clinicians will be challenged with the case presented below.
The DSM-V definition of addiction will be, “Loss of control over the intense urges to take the drug even at the expense of adverse consequences.” (O’Brien et al., 2006). DSM-V will abolish the distinction between “abuse” and “dependence.” In the place of two independent disorders will be a dimensional category of addiction where severity is rated on a continuum (Cottler and Grant, 2006; Grant et al., 2007; Teeson et al., 2010). Patients will have mild alcohol addiction or severe alcohol addiction.
The author has suggested a nosology of addiction based on neuropsychodynamics (Johnson, 2003). In this conceptualization, psychological addiction is a character style involving a repetitive, stereotyped response to addiction via compulsive behaviors (Johnson, 2003), a type of behavior is most accurately described as a variant of compulsion (Dodes, 1996). In Dodes’ description of the compulsive nature of addiction, when the person makes the decision to perform his addictive act, he no longer feels helpless. In making the decision, he has reasserted a sense that he is in control, that he can act to alter his affective state. Traumatic helplessness is normally accompanied by rage, and Dodes noted that it is this rage at helplessness that both drives addiction and gives to it a powerfully insistent quality. Finally, he showed that all addictions are displacements, in which a reversal of helplessness is achieved by the indirect, substitute action that is the addiction. In Dodes’ classification scheme, when the displacement of rage at helplessness is expressed through drinking, the addiction is alcoholism. When the displacement of rage at helplessness is expressed through gambling, the addiction is gambling addiction (Dodes, 2011).
In Johnson’s neuropsychodynamic system, physical addiction involves a completely different pathophysiology than psychological addiction; capture of the ventral tegmental dopaminergic SEEKING system by addictive chemicals (Johnson, 1999, 2001). Once captured by the addictive substance, the process cannot be reversed. These persons will have addiction forever. Re-exposure to the drug turns on intense craving. In this model, tolerance and withdrawal are epiphenomena of drug exposure involving re-equilibration of dynamically interacting brain mechanisms; a position also espoused by the architects of DSM-V (O’Brien et al., 2006). The key to physical addiction is not withdrawal, but midbrain-mediated craving which is usually accompanied by drug dreams (Johnson, 2001, 2003). Of course, developing physical addiction with brain changes does not alter the psychological reasons that persons use addictive drugs. It only adds to the malignancy of the illness.
As summarized by Eagle and Wolitzky (2011), the case study method has the following advantage as a source of data:
• It enables us to study rare phenomena
• It generates insights and hypotheses about personality dynamics that are not readily elicited in other situations
• It suggests different kinds of interventions
• It can disconfirm certain hypotheses by finding instances that run counter to a theory
The following case report is submitted in the interest of using all four of these properties to defend the distinction between alcohol abuse and dependence. It describes a shift from alcoholic to recreational drinking as a consequence of treatment; a phenomenon that is rarely described. It shows some of the underlying psychodynamics that provoked the alcoholic drinking, and it shows how recovery of the capacity to modulate drinking, and in this case compulsive/addictive working, was achieved. It suggests that psychoanalytic treatment of alcohol abuse is a reasonable approach. Most importantly for the issue addressed above, it is a case that runs counter to the DSM-V conceptualization of a spectrum of addiction severity, and supports the dichotomy of alcohol abuse versus alcohol dependence. Specifically, if a patient has had alcohol tolerance and withdrawal, the author has suggested (Johnson, 2003) that this is because the ventral tegmental dopaminergic SEEKING system has been captured by alcohol, drinking dreams are produced, and having one drink turns on intense craving for more alcohol.
The distinction between Alcohol Abuse and Alcohol Dependence was shown to create different life courses in Vaillant’s (2003) 60 year longitudinal study. Men with alcohol dependence either get sober or suffer serious consequences of alcoholism – often death. Men with alcohol abuse have a different course of illness. They continue to drink with consequences, do not progress to alcohol dependence or death, do not have withdrawal, and can remain persistently ill due to their drinking (Vaillant, 2003). Of note, Vaillant is a psychoanalyst, not a statistician.
Vaillant (2003) suggested that stable remission of over 5 years might indicate recovery. If psychological addiction is different from physical addiction, if alcohol abuse is different from alcohol dependence, then it should be possible to psychoanalyze this compulsive symptom in a patient who meets the DSM-IV criteria for Alcohol Abuse, with subsequent remission of alcoholic drinking. This case report is offered as a proof of this concept.
When someone is drinking alcoholically because they cannot stand their feelings, the reason for the drinking is not to know what they are upset about. When a patient arrives with a compulsion, the treating therapist has to decide whether to focus on stopping the symptom, or on analyzing what the symptom hides in the unconscious. Ideally, one would try to make an individual decision for each person. The approach of just stopping compulsive drinking may do nothing for the underlying problem; the person may remain in intense distress, without knowing why. That is what happened for this particular patient.
When Dick came to see me in my psychoanalytic practice, he was a 42-year old married business executive. The chairman of the board at his corporation took him aside and said, “Four of the officers think you have a drinking problem.”
I asked Dick to tell me the story of his drinking.
When he first went to college Dick was arrested for drunk driving. He spent his freshman year playing poker for money. He flunked out. He married and 2 years later enrolled in night school.
With this added responsibility in his life, drinking and gambling were no longer problems. He had a child. He worked his way through college. At the end of his second year he lost his job just before finals. Rather than glide through his exams while on unemployment insurance payments from the government, Dick felt it was the ethical choice to take any job he could get, which turned out to be a 2-h commute each way.
With this decision, he began a period of stupendous working. He completed undergraduate and graduate degrees while supporting his family. He became enormously successful in corporations where working many hours was the norm. On occasion he had to leave as early as 7 p.m. He described feeling guilty, and sneaking out.
Dick climbed from one position to another until he was an officer with an innovative high-tech firm. He would go on work jags where he spent a night or two in his office so as not to lose the time it took to drive home. His wife complained that she could only get a word with him if she went to a restaurant with him and pinned him behind the table. He worked all the time.
From college until age 40 he had no problem with his drinking. Then he noticed that, “Once I started, I wanted to keep going.” He had missed 10 days of work in the previous 6 months because of hangovers. He felt sluggish and began to doubt his intellectual abilities. It seemed he had hurt his brain with his drinking, that he was not as intellectually sharp as he had been. This was in the context that he made his living with his wits. He did not have blackouts or drink in the morning.
The Chairman of the Board of the corporation for which Dick worked took him aside and told him that he had been the subject of a discussion among the other corporate officers. They all felt that Dick had alcoholism. He was coming to work looking awful and reeking of booze. The Chairman told him that he should go for alcoholism treatment, and referred him to me because of my reputation as an addiction psychiatrist.
Dick met the DSM-IV criteria for Alcohol Abuse, “A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance abuse…)”
After the Chairman of the Board of his corporation told Dick that he had alcoholism and needed treatment, Dick did not have another drink in the 2-weeks until his appointment with me. He had lost 9 lb and felt much better.
Dick had never had any psychiatric treatment.
He was about 40 lb overweight. He had suffered from hypertension for 8 years, treated with two medications. He had sciatic back pain. This former high school athlete was aging rapidly.
Dick’s maternal grandfather and brother were alcoholic. His father, an architect, was alternately successful and unemployed because of recurrent bouts of severe depression. Family finances were usually poor. His mother worked most of the time. As a boy, Dick had resented his father because his father was not like his friends’ fathers. His father was angry and tyrannical. His father could frequently be found lying on the couch at home. Dick had a sister 4 years younger and a brother 8 years younger. He was an Eagle Scout, an excellent student, and a popular athlete in high school. But Dick rebelled against his father’s constant haranguing about the value of education by gradually studying less and less.
Dick’s Extended Evaluation
There was something very wrong, but we could not understand it from his history. I began seeing Dick once a week for an extended evaluation. By the fourth hour, I told him I thought his most important and damaging addiction was to work, and that the alcoholism was his second addiction. In fact, during the first year in college, he seemed to be searching for an addiction (as described by Wurmser, 1974). He tried drinking, he tried gambling, but workaholism seemed to fit into his life in the smoothest way. He would not be the lazy lout he saw his father to be. He would be the exact opposite. In the fifth hour I suggested that in all his relationships, he was in charge, he was the nurturant one, and no one seemed to take care of him.
In the seventh hour a story came up about a day when he was in third grade and his sister was in kindergarten. He was required to come home each day to look after his sister despite his father being home, spending his days lying on the couch. This particular day his teacher was angry at how the class was behaving, and his whole class was kept after school for punishment. When Dick came home an hour late, his father was in a rage.
At the time that I first heard this story, it sounded as though this was a story of Dick’s resentment about being required to perform his father’s duties. But the story turned out to be a screen memory, a memory which hides something important. Sometimes events are so painful and overwhelming that we cannot bear to remember them. Dick glossed over the important part. This memory still had the emotional intensity of the awful event. As Dick first presented this memory, it was simply a consciously acceptable; Dad was a jerk. There was something about this story, the way Dick told it, that made it unforgettable for me.
After several months and 15 h of evaluation we agreed that we did not understand the reason he had been abusing alcohol, and agreed that we would investigate this question further in 4 days per week psychoanalysis.
Why would Dick want to come in and lie on my couch 4 days a week? I could have sent him to Alcoholics Anonymous, but that would not have addressed Dick’s primary addiction, and he was no longer drinking. Almost every addiction has a 12 step group, but there is no group for compulsive workers.
Dick was conveying a sense of severe distress, but there was no information available regarding the nature of his underlying suffering. His compulsive working, and alcoholic drinking, seemed to be symptoms of something. But we had not a clue what it was. His wife and teenage children seemed to love him. His work seemed successful. So the extended evaluation ended, and the psychoanalysis began.
The First Day of Psychoanalysis
Dick’s first thought on lying on the couch was that something had been troubling him. He asked, “Is there any possibility I could be dangerous; committing suicide or hurting anyone else?” I asked him to say more about this idea. He said it was triggered by seeing a movie on TV about a killer. “All of a sudden it flashed through my mind. I do not feel I would be dangerous to myself or anybody else.”
The first issue that came up in his analysis was safety. Since he did not seem the dangerous one, I thought that he might see me as the dangerous one. I suggested that we had reversed his usual “I’m in charge” and that he might be thinking in this context that I could seem as unpredictable as his father.
Dick agreed that he could be worried about me, and that not having to depend on someone had protected him from the possibility that the one he depended on was dangerous. He thought being in analysis felt like getting detention in school (there’s the screen memory again, but we did not know it at the time). He thought again about the movie with the murderer. He added that the murderer was aggressive toward his own family. (Traumatic memories were being triggered by the onset of analysis, but at this point they were deeply unconscious, completely defended against by “isolation” – the idea came up without feeling or connection.)
Late in the hour I asked Dick about his experience lying on the couch. He said, “It feels different. I’m not sure if it’s good or bad different. There’s something strange about laying here, looking up above and not at the person you are talking to. Physically it feels like there’s more relaxation of the muscles. There’s a little more of a floating feeling to it. Sitting up and looking toward you, or around the room, there are different things that can distract your attention. Lying here is like lying up in the clouds. I think sitting up can cause responses and discussions to take on more of a structure – a bit like being in a work situation. This feels like it breaks down some barriers. Still, there’s something awkward about it.”
The Growing Crisis of Non-Communication
It is hard to describe how powerful was the experience of non-communication of feeling in Dick’s early analytic hours. This is an example from hour 45. It won’t be easy reading.
“Today was a day I was anticipating being more difficult than it really was…We are shifting our fiscal year from December 31 to September 30…there’s always disruption at this time of year…
I’m feeling uneasiness about my availability in work. It feels like having just come off vacation, next week is a full week, the week after we have an officer’s trip…I wish the timing had been spread a little more. I think today, although the work day wasn’t as hectic as I expected, I didn’t have time to just stop and think about anything except the project I was working on at the time. (This is how compulsive working functions – there is never any time to think about anything except projects, projects, projects.) One of the things that struck me as strange, it seems a common trait I have – as we talked of the potential ramifications of the current fiscal year…”
There was no communication of feeling. The constant attention to minute detail which led to a lack of communication was a defense against feelings which Dick could not tolerate. I could not ask him to go any faster. A lot of the time I was working on staying with Dick’s associations, and waiting for something to break.
His style of associating 4 h per week bred a feeling in both of us, “Why go on? What does it mean to have a man obsess over details of his schedule for a year and a half?” He was entirely incapable of feeling anger. He did not feel much of anything. He had both a sense of stalemate, and a sense of urgency.
Dick was asked to leave his company 4 months after his analysis had begun. No particular reason was given. Over time he realized that his company was going public. He had been moved out to increase the profit of his fellow officers. But he had little reaction.
He then pursued the life of a consultant; a shadowy position some highly paid individuals enter between jobs. He could not get to sleep at night, but did not seem clearly depressed. He came day after day to say something that was not coming out.
I was almost as uncomfortable as Dick. I was sticking with the quiet psychoanalytic stance which I felt would be most helpful. But we had not had much in terms of results so far.
Psychoanalysts do not trust themselves to know everything that is going on in a treatment. There is a constant question running through our minds, “What might be going on that I’m not aware of?” And we get consultations. At the time I was meeting with my mentor Ralph Engle M.D., a senior analyst, every other week as I did for 8 years. Dick was a central focus of our work.
The answer in psychoanalysis is to make an interpretation, but which one? I had tried masochism; he needed to suffer in order to be in relationships. I had tried the idea that he had to help everyone else, and could not allow himself to be taken care of. I had tried workaholism; his need to be in a constant intense hurry, always behind, hid his emotional life. I tried interpreting the idea that he was turning his anger at others against himself. None of these interpretations had an impact. All of these are “defense” interpretations, about how Dick would stay away from his feelings. We needed an effective “transference” interpretation about how Dick and I were stuck in a recreation of something he had found intolerable with one of his parents. A parental ghost was haunting our relationship.
We Find Dick’s Mother’s Introject Lodged in Me, Strangling the Analysis
Almost 2 years into analysis came an unusual hour with nothing but a dream and associations. He was trotting into woods with someone else. As they passed a car that was stuck, two men got out and began firing rifles. He ran from tree to tree and was shot in the hand. Later in the night he heard the radio and looked at the clock, “4:30” – it had been a dream. (We will see later, he was again trying to bring up repressed memories.) Dick associated to being in the woods with a friend, his sister, and a friend’s sister when he was 9 or 10. The friend wanted the younger girls to pull down their pants. “I said something to stop that.” Being shot in the hand made him think the men were bad shots. He had heard something about incest between his father and sister, and mentioned it to his wife, but knew no details. He said that his wife had told him that she was careful not to discuss the incest because it would upset him.
There was a characteristic lack of feeling as the new idea of incest was introduced. The “isolation” defense was shockingly powerful, as I experienced it. Dick had the idea that incest had occurred in his family, but he did not give it the emotional weight to correspond with the injury to his sister. His associations to the dream indicated a wish to protect his sister from a sexual affront. The woods, two men, his sister, his father; all these elements were isolated from each other by the lack of connecting feeling.
Soon after, we hit the key interpretation. He was going on, as usual, with a business discussion. He mentioned a lack of confidence in presenting himself, and lay awake at night with self-criticism. I said, “I’m going to say something that’s a little theoretical, but I think it will help as we talk. If you are a little kid who is being hurt by parents, it is too much for anyone to bear. So you project out your view of yourself as a caring and loving person into the parent to make them caring and loving and you take on abusing yourself. It feels safer.”
He responded with a correction. “To the best of my recollection, back to 10, I cannot remember feeling that way about my father. I hated the guy.”
I asked, “How about your mother?”
He answered, “I’m not sure there was any time I can remember I blamed her for anything.”
I asked, “Why not?”
He replied, “I think it may have had something to do with my feelings that my father was a violent person. She was afraid for her safety.”
I stated, “I’m sure she was. Why did she have kids around a guy like that?”
The answer was that mother’s mother had always disliked his father and had constantly berated his mother for her marriage. In response, his mother dug in her heels and insisted on staying in the marriage, but divorced his father within a year of her mother’s death as a way to protect Dick’s younger brother. Dick was already out of the house. His brother was 10. Dick described an angry jealousy that mother would protect his much younger brother, but not him.
This was the first time there was some overt anger. In subsequent hours I interpreted his emotional flatness as a response to his mother’s introject lodged in me. He seemed to feel that like his mother, I was not really interested in what he had to say, or what he was really experiencing. The hours became much more alive.
Over the next year of analysis a triad of themes was interpreted; his workaholism as a defense against all feelings and relatedness, his anger and distance from me as a reflection of his anger and distance at his father, and his lack of expressiveness toward me because I did not really care, as if I were his mother.
Dick began to wonder if his father had been violent enough to murder someone (remember his first association when he first lay on the couch – a TV movie about a killer). He remembered as a young man feeling he would not live past 25. Because of his father’s explosiveness he had expected his father to kill him. He now remembered the mornings after his cat had given birth that he came into his kitchen to find that his father murdered one of his kittens and left the body lying in the bowl of milk the father had drowned it in. One day at a time, every kitten was murdered. He remembered his response had been that he decided that he did not like cats. This seemed to be the beginning of his not feeling anger.
A pattern of suffering in relationships with father figures was interpreted. Repeatedly engaging in work relationships where he was abused by a senior man became apparent to him when he was not paid appropriately for very time-consuming consultation and had to separate from the company.
This insight did not help. He got worse. He met the criteria for DSM-IV Major Depressive Disorder and was begun on an antidepressant. His fee had to be reduced to allow him to stay in analysis. His distant stance was interpreted many times. He was able to experience his conviction that either he would engage emotionally with me and be hurt, or maintain an emotionally empty distance. One day, as he was associating to a work situation where he was talking to a female executive about the need to keep financial information confidential, it popped into his head that when he was growing up, he was not able to tell anybody what was going on in his house. His sense of non-communication reminded him of how his mother must have known about the rages where his father hurt him. However, at this point in the analysis, we were living out this transference. He was being injured again and again as – despite my best efforts – he felt all alone.
Dick Comes Close to Dying
Nearly 3 years into analysis Dick was talking about his despair about getting a job. He was feeling depressed. When I asked him what came to mind about the feeling he abruptly remembered a dream featuring Ken, a man who had not paid him for a consulting job, as his “uncle.” It included, “My grandmother was acting strange. It seemed clear she’d had drugs…Someone said Ken did something to her. I saw her all messed up. I asked Ken to come into the other room. I was punching and punching him; my hands were cut and bruised…” He associated to work issues for a while. I eventually interpreted that the dream helped show him replaying feelings about his parents in his work. He recognized that he was furious at not being paid, and that he had not known this before. I interpreted that his angry feelings were inhibited, and came out as depression or endless focus on the details of work. He said, “I’m sensing a tremendous amount of anger locked up inside me. I think there is a feeling that somehow it has to get out. If it does, it would help me a lot. I sense it rising closer to the surface, yet I still feel a sense of frustration about not being able to open it up.”
Two hours later, he was thinking about his lack of anger when a gang of boys beat his daughter severely. Then he spoke about everyone crying at his grandmother’s funeral, how he had disliked her, and how he had not expressed any feelings at all. Two weeks later he described the intense discomfort he had felt in a conversation with his sister Betty which included a sense that she wanted him to do something for her.
Betty had told him that he was lucky that he could not remember what had happened during their growing up years. He thought back to the dream where “Someone said Ken did something to her” and his feeling “helpless anger.” He remembered some mild abuse by his father, such as being forced to mow the lawn despite a severe grass allergy and painful sunburn, while his father lay on the couch.
The next hour he was associating to a dream with no content, only a feeling of terror. He thought of his intense, guilty sense of responsibility as a 12-year-old Boy Scout leader taking two troubled boys into his patrol. He knew something was wrong, and he should have sensed it. (This is another screen memory.) I remembered his associations earlier in the hour about his brother and sister, and asked if some of the guilt might have to do with them.
He responded, “Having heard what happened to Betty, I have a lingering question if there is something I could have done or sensed.”
I asked, “What happened?”
He said only, “Incest.”
I asked, “What was the incest?”
He answered, “I guess I’m not really sure…”
I suggested that he might feel guilty about living in his house while his sister was a victim of incest.
He then remembered his mother was in the dream with no content except for a feeling of terror.
Ken, the man who had refused to pay his consultant’s fee, came up more clearly as his father, several hours later. He noticed his fantasy shifted from anger, to a fear Ken might be hurt, to feeling depressed, and to enumerating his own shortcomings. The recurring cycle of anger to depression to self-abuse was demonstrated repeatedly. In this cycle of abuse, I was his mother, standing by passively and watching him be hurt over and over. I advised him that if he did not start addressing his anger directly, it would kill him. He was 45, overweight, hypertensive, depressed, and constantly criticizing himself.
Dick’s wife was alarmed. She seemed to experience a level of suicidal intent that he was unaware of. The next day he reported to me his wife’s concern with a fantasy that he would kill himself in his car, rationalizing that his family would be better off financially collecting his life insurance than having him around depressed and unemployed (as his father had been).
On the way home from the hour he was rear-ended by a truck. He thought it had nothing to do with him; it was 100% the truck driver’s fault. The next day, when he told me this, I found myself tremendously upset. Like his wife, I could feel something working to the surface. It was evil, dangerous. It was so intolerable to Dick that he might rather be dead than know it. And this evil presence was unconscious. This ghost was in a position to dictate his behavior because we had not named it, brought it to light. Dick had no conscious intention to hurt himself. In fact, he felt that his wife and I were overconcerned. As he left, I had a foreboding that I might not see him again.
On the way to my office the next morning he braked in the fast lane on the expressway, and went into a skid. Helplessly out of control, he crossed all four lanes of a rush-hour superhighway without being touched. He stopped in the breakdown lane facing the wrong way. It was a miracle that he escaped. That did it! He could see that his anger was potentially fatal to him. Now we both had a sense that he was acting in a dangerous, potentially suicidal manner without any conscious control over his behavior. He had to do something.
We Meet Dick’s Family
Dick called his mother and asked her if she used to witness his father hitting him with a strap. He grew up in a tiny house, and he was starting to remember that his father hit him with a strap while his mother sewed quietly in another room; as if nothing was happening. He remembered feeling pride that he could be beaten without crying. His mother denied any abuse, suggesting that he was probably remembering the couple down the street that his parents were friendly with. His mother said calmly that they used to beat their children. Dick called Betty, and asked if she remembered the beatings as he had. He explained that their mother denied that any beatings occurred.
Betty went into a rage. She said that she used to watch the beatings, and added that their father had intercourse with her in the house for 9 years until she married at 18 to escape the situation. Dick’s mother changed her story, saying not only that the beatings did occur, but that she had actually been afraid that 1 day Dick’s father would murder her in one of his rages. Despite this, she said she had always been sure that the father “would never hurt you kids.”
Dick began to be capable of tolerating some of his angry feelings. One day he rushed in 27 min late and immediately began with a dream where his father was mortally ill, but he was trying to hasten his father’s death by drowning him. Then Dick set off to kill two boys (the two boys again – the screen memory). He associated to feeling like assaulting another driver who had made an impolite turn.
Dick had been trapped. His anger at his father for his constant degradation, and at his mother for not caring, was interpreted as they appeared as the introjects of his parents hiding in me, over and over and over. Now the interpretations made sense to Dick and had an effect. At Christmas he exploded with feeling about his workaholism, that he had lived his life like Scrooge in Dickens’s story, and that his life was passing him by. Dick’s deep identification with Scrooge, and empathy for his plight, took me by surprise. This perspective on the story with Scrooge as the heroic protagonist fighting to overcome his addiction to work had never occurred to me. Dick saw his commitment to work as a way to never have to ask for help. He realized how he had made me an uncaring person like his mother, and that this was not the reality of our relationship. He was able to ask me directly to help him. This appeal for help from me was repeatedly voiced.
Dick’s capacity to work effectively was enhanced. He found himself sitting down and getting things done directly. The hallmark of workaholism, like his driving 4 h to another state to save $85, or consulting for someone who did not pay, is that while you are engrossed in the activity, it does not have any benefit to you. Dick’s obsessional details about work dropped away as an obstacle to free expression. He experienced the tie between low self-esteem and intolerance of anger. As he became able to tolerate anger, he more easily saw his experience of non-communication with me as a repetition of his relationship with his mother. He would come to analytic hours with something on his mind, and ask for help with it. His sleep normalized. The antidepressant was discontinued without any recurrence of depressive symptoms. He became able to ask for the help of his wife and his sister, and saw his experience in psychoanalysis as “a religious experience.” He lost weight, began exercising regularly, and had no medical problems. After 4.5 years of analysis, and more than 1,000 h of treatment, he seemed nearly done. It seemed to me that he was in the “termination phase” where issues still arose, but were easily interpreted, with a return of free associations.
A new theme began gradually to arise. One day he was wondering if he had remembered to put something in a document he had written, and suddenly his stomach dropped out, like it did when he was on a plane trip with his father when he was 10. He thought there must be something he remembered. He thought of a “malevolent presence.” His first response was to confront his mother more directly, bringing up his feelings about his childhood experiences with her.
After a few months I held a family meeting with Dick, his wife, his sister, his brother, his mother, and his adult daughter. Dick’s sister, who was in an incest survivor’s group, and Dick, found it a positive experience. Dick’s brother was critical of the meeting, and of Dick’s relationship with me, as disruptive to family closeness. Dick’s mother and brother defended their relationship with the deceased father, claiming (bizarrely) that here were “two fathers,” the brother and the mother experiencing one that they loved.
This is typical of incestuous family dynamics. While the shorthand description of this situation is “crazy,” the longer description follows. The “two fathers” is a way people hold onto a relationship where they both hate and need a person. The family member can keep their feeling that they are a good person, and that the abusive, hated person is good, by splitting their thinking about themselves and the hated one into two completely dissociated categories.
It sounds strange, but while Dick and I were sitting there thinking, “Two fathers?” the mother and brother were being absolutely sincere. We all find some things intolerable, and the information at the family meeting that the mother had tolerated her husband’s physical abuse of Dick, and constant incest between her husband and Betty, was simply refused. Dick’s brother was probably also thinking that if there were “two fathers” that there were also “two mothers,” the one he loved, and the one who had sat in her sewing room believing, “Dad would never hurt you kids” while the abuses were occurring.
In incestuous families the reasonable approach of acknowledging what has happened, apologizing, and trying to help the victims, is seldom taken. Usually the conscious victims are shunned by the part of the family which puts staying related ahead of truth. Dick’s mother did divorce his father to protect the 8-years younger brother once her disapproving mother had died. Inexplicably, the father had returned to living with mother and younger brother a few years later. The father died of a kidney ailment during Dick’s first year of treatment.
The Final Memory
As we worked through the guilt about confronting his mother, and his anger at her response, Dick kept bringing up a feeling that there was something important that he was not remembering. The memory was accompanied by images of the woods near his house when he was a 10 year old, and a feeling of anxiety. He asked if I could hypnotize him.
At first I asked him to associate and see what came up. He was not satisfied. Something was very wrong. He was cold, could not think, felt out of sorts. We entertained the possibility that he had thyroid disease, but his blood tests came back normal. He pressed me to help him recover something awful that he could not remember. He felt urgent, tortured. After several weeks, I referred him to Fred Frankel M.D., who specialized in hypnosis. Dr. Frankel was emphatic that he did not want to prompt Dick to create false memories, memories which are suggested by the hypnotist, and that he would only help him remember things that were there (Frankel, 1995). Referring Dick under these circumstances probably also fostered additional alliance. Patients from incestuous families are always happy to see their analyst show that the intensely private work of analysis can be examined by someone outside the transference “family.”
Dr. Frankel had 10 weekly visits with Dick. Dr. Frankel reported that Dick was easily hypnotized. One day Dr. Frankel asked Dick to begin at the house he lived in when he was 10, and see what came up. Dick remembered his father being angry that he had not worked fast enough putting together a radio set. Then he remembered being in the basement, seeing rocks in the back yard, and hearing that someone was dead. He remembered a search party in the woods and a feeling of horror. He began to wonder if he had witnessed his father murdering a boy by smashing his head with a rock. In subsequent analytic hours, he felt terror, and remembered an empty seat in his class at school. But he could not make a connection between himself, the dead boy, and his father. He was on edge week after week as he would go to Dr. Frankel, then return for four analytic hours where he tried to force this memory to come out. He had one memory after another about the woods near his house, such as being chased by a man in the woods, falling on a tree stump and having a stick pierce his side, yet just get up and keep running. (Remember the dream where he was shot in the hand while running through the woods to escape.) Both he and Dr. Frankel began to feel that they had found all that they could. He described feeling in one hypnosis hour that here was nothing new or different. “The last thing I was thinking about when he told me to come out of hypnosis – I felt this feeling in my chest, up through my throat. I was again feeling terrified.” He expressed frustration, “It’s like someone erased the blackboard.”
Dick went on his summer vacation. When he returned, he and his wife went to the library and looked up newspapers from his hometown during the time when he was 10 which kept coming up in his mind, to see if any murders had been reported. In fact, an escapee from a nearby prison for the criminally insane had sexually molested and murdered two of his classmates in the woods near his home on the day that his father was in a rage that he had been kept after school, and not been able to take care of his sister. The woods where the murders occurred were the woods to which he always took his sister to play after school. He realized that if he had not been kept after school, and then been punished by his father by being kept in his house, it might have been himself and his sister who would have been killed. He read that the pallbearers at the funeral had been Boy Scouts. The boys who had been killed had been Boy Scouts. He remembered looking at their empty desks after the murders; one boy had sat right in front of him. Apparently, his sense of responsibility for helping the two troubled Scouts later had something to do with this repressed memory.
His father had not murdered anyone. Yet these murders by the psychotic killer, on top of his father’s rages, beatings, and incestuous victimization of his sister, accompanied by his mother’s quiet detachment despite her fear that she would be murdered by his father, had created a climate of terror in his household.
The issue of termination began to come up. There continued to be much work around anger, feeling neglected, and neglecting his own needs.
Five months after the solution to the murder memory, after 1,200+ hours over 5.5 years, Dick finished his analysis. In the last hour I asked him about his drinking. He said, “I have a cocktail every once in a while…My wife and I went on a cruise, we had a bottle of wine a couple times…When we go out to dinner sometimes I drink, more often than not, one or two drinks…It hasn’t been a problem for me…There haven’t been any examples of how it was in the past, when I felt I had to go home and have beers to relax. I’ve learned that drinking like that leads to more stress the next day.”
Dick met the DSM-IV criteria for Alcohol Abuse, “A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period. (1) Recurrent substance abuse resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use…).” Dick had one drunk driving conviction at 18. In the 2-years before starting his treatment he missed about 10 days of work because he was hung over, arrived impaired and smelling of alcohol, was the subject of a meeting by the other officers of his company who felt that he had alcoholism, and was asked by the Chairman of the Board to get alcoholism treatment. He met the DSM-IV criteria for Alcohol Abuse, and not for Alcohol Dependence.
I want to be sure that I have conveyed how Dick’s alcoholic drinking, from ages 40–42, was understood in psychoanalysis. Dick had apparently been depressed after he left home for college. He searched for an addiction to help him get away from his feelings of anger about his own abuse and neglect, and survivor guilt about the incest of his sister and the murders of the two boys he knew. After trying out alcohol abuse and gambling, and being punished by flunking out of college, he found his work addiction a compromise between his high ideals and his profound guilt.
The company he was with at the start of his analysis was about to go public, potentially yielding him an enormous financial windfall. Because his work had become more gratifying, alcohol abuse returned at 40 as a way to further punish himself for surviving. Without knowing the underlying psychodynamics, a lay person might have labeled this as, “executive burnout.” The way that his alcohol abuse quickly resolved reflected that his work addiction was his primary means of encapsulating his distress. As Dodes (2011) explains it, the rage about helplessness can be displaced into any compulsive behavior. When the unconscious expression of rage was disadvantageously exposed by his high-tech coworkers and board chairman identifying his behavior as alcoholic, he shifted back to workaholism. He went from very successful in his work to quite unsuccessful, for the first few years of his analysis, reinstating the punishment.
The main defense interpretation of the analysis was to constantly draw his attention to his drab recitation of work details, and his preoccupation with deadlines, as a way to stay away from emotions. It turned out that the drab flatness of his associations was a manifestation of his inability to consciously tolerate aggression. The most important transference interpretation was his experience of me being like his mother. The drab recitation of work details enacted in our relationship that I (mother) would not really care what terror he had been through.
As we know from Freud’s (1909) original explanation of how compulsions work, the symptom both hides and expresses rage. Dick had the childhood experience of having a mother who ignored his father’s abuse of himself and his sister. He was terrified of his father. His difficulty experiencing anger originated with his inability to both depend on his mother, and to be angry at her – both at the same time. As a result, he was emotionally flat and had compulsions; first working, and later drinking.
Once we could understand the overwhelming fear of his father, reenacted in business, and the recreation of his relationship with his mother, reenacted with me, we were in a position to understand that he had been utterly helpless growing up. His relationship with his mother was revealed to be with a woman who was both self-centered and capable of primitive thinking. The bizarre concept of the “two fathers” left him terrified and alone. In the mother’s mind, he and his sister were with the “good” father. The brother was strongly bonded to the mother in a way that required him to defend the incest and abuse. The sister, like Dick, was preoccupied with guilt.
Guilt is a common way to bind oneself to a hateful parent. “It is better to be a sinner in a world ruled by God than a good person in Hell,” is an aphorism that shows this survival mechanism of poor children who are too young to tolerate being alone. Apparently, one needs to grow old enough before one can consciously identify that one lives without any loving parents. Before that age, the goodness of the child is projected into the parents, and the abuse of the parents is introjected into the child. The guilt is also about the underlying rage at the parents, the wish to destroy them, and the resulting fear of one’s aggression.
The murder of the two boys was the last straw. He had been terrified of his father, and so was everyone else in his house. His father beat him during rages, had intercourse with his sister starting when she was 9, and drowned his kittens in their milk one at a time. When two boys he knew well, who were Boy Scouts with him, one of whom sat right in front of him at school, were killed in the woods behind his house, he resorted to intense repression of these events of his childhood. The repressed memory of the boys’ deaths was replaced in consciousness with the screen memory of his father keeping him in the house to punish him for not caring for his sister after school. His father’s restriction from playing in the woods that day may have saved his life – provoking more survivor guilt.
Dick became so busy with work, and eventually drinking, and so comfortingly punished by their consequences, that he continued with these addictions until his boss told him that his character/defensive style would not be tolerated. Unlike his mother, his boss noticed his distress, and wanted him to be taken care of. This ability to have a new kind of relationship continued in his positive sense about treatment with me.
The death of the boys began to come up as an unconscious theme in his treatment years before it was understood. The story of the father’s rage when he was kept after school and did not come home on time to look after his sister came up in the seventh hour of evaluation as a screen memory. At the time of the first association in his first analytic hour about a murderer, and my interpretation of that I might remind him of his father, we could have no idea about the murders. At the time of the dream where two men wanted to kill him, and was shot in the hand, our experience was that this dream had no available explanation. Why two men? (The number two was displaced from the victims to the aggressor.) Despite 10 h with a gifted hypnotist along with 4 days a week in psychoanalysis, the repression persisted. Yet in retrospect, it was this intense support, and my willingness to refer him out of the analytic “family” which we had recreated, which confirmed that we were not repeating an incestuous, “we keep our secrets here” dynamic. Dick was able to follow the next logical step of reading the newspapers along with his wife. The end of analysis came with his no longer holding any guilty secrets. They were all out in the open.
What would his course have been if I had responded to the presenting issue of alcoholic drinking with a referral to Alcoholics Anonymous (A.A.)? We will never know, but the worry would be that it would have repeated his experience with this mother, that if he was upset about things that were going on with him, I really did not want to know about it. He may well have been “too busy” to go to A.A., and had a recurrence of alcoholic drinking for the reasons which we only came to know about through his psychoanalysis. At some point then, with further losses, and concrete proof that he was the cause of all the trouble, he would have gotten sober (hopefully) and spent his time focused on the symptom of his distress, not the cause of it. In this particular case, A.A. would have helped him take responsibility for his causing of pain to others. This would have been an expression of his urge to take responsibility for being a frightening and destructive person. This urge came up in his first analytic hour where he wondered if he could be a murderer. In that way that we make intuitive leaps, and learn why later, I interpreted that he might see me (father transference) as the dangerous one.
The reader should not feel that I have any reservations about Alcoholics Anonymous. I believe that it is the outstanding public service organization of the world. Millions of people volunteer their time to help themselves, but also to help the millions of people with addictions to alcohol and other drugs. However, it is more helpful to some persons with addictions than others. I believe that for alcoholism, it is the most helpful for persons who have had a brain change due to alcohol which causes constant craving for a drink, a sign of physical addiction, which is then added to the psychological reasons to drink. Physical addiction to alcohol also features dreams of drinking (Johnson, 2003), which had not developed at Dick’s level of alcohol intake. There was not a single “drinking dream” during Dick’s psychoanalysis.
What about interventions that some analysts would dismiss as “non-analytic,” such as prescribing an antidepressant, holding a family meeting, or referring Dick to a hypnosis expert during this 4 days a week, on the couch, treatment? Bush and Meehan’s (2011) study of psychoanalysts’ own treatment concluded that, “…the most beneficial analyses were associated with having a caring and emotionally engaged analyst who possessed positive relational and personality qualities, used supportive techniques in addition to classical techniques, and pursued therapeutic as well as analytic goals.” I have explained my deviations from classical technique as facilitating a therapeutic alliance that allowed effective transference interpretation of the repetition within the treatment of the incestuous/abusive family structure. Holding to a more orthodox stance might have been experienced as a repetition of the selfishness of the parents/lack of response to the perceived needs of the patient.
Alcohol Abuse means that the person’s drinking recurrently interferes with their life. Dependence means that the person’s life recurrently interferes with their drinking. Alcohol dependence is almost always accompanied by physical withdrawal from alcohol. You will remember that Dick stopped drinking on his own. He never had withdrawal symptoms. This crucial distinction between abuse and dependence rests on a hugely important difference in the underlying mechanism of the commonly shared symptom of alcoholic drinking (drinking with negative consequences). In this case report, the addiction is (psychologically speaking) a compulsion. This relationship between addiction and compulsion was first identified by Dodes (1996).
The reader may suspect that Dick was returning to alcoholic drinking at the end of analysis and that if I had further contact with him, I would have learned that psychoanalysis does not cure alcoholism. The combination of ignorance regarding addiction, and grandiosity regarding the therapeutic power of psychoanalysis, is well known. Therefore, some followup information is needed.
Nine Year Followup
Nine years after I terminated the psychoanalysis with Dick, I contacted him again to request permission to include information regarding his treatment in this report. I sent him a draft copy, then spent time speaking to him regarding his responses.
Dick’s first reaction was anger. He put the report in a drawer for a week. He felt horribly misunderstood regarding the basic facts of his life. I had gotten many of those facts wrong, as if I had not listened at all. A week later, he reread the draft and realized that my cover letter indicated that I had changed the facts of his life in order to protect his privacy. In addition, he recognized that he had repeated what happened in the psychoanalysis; I was just like his mother, I did not listen, and I did not care to understand him.
Dick described his current life with pleasure. He had been successful in his work life, but was not working too hard. He was enormously pleased that he had new grandchildren, and had moved so that he and his wife could be closely involved in their care. Dick felt that his analysis had been one of his most significant life experiences. He was a light to moderate drinker and had had no problems whatsoever regarding his use of alcohol.
Could Dick be lying? Isn’t it common for substance abusers to lie? Isn’t the rule that you take whatever they say they are drinking and double it?
This is a single case report. I have no reason to doubt what I was told by Dick, his comments all rang true in the context of our relationship, but there was no way to test his statement. I will conclude this section by saying that I think Dick is telling the truth. His alcohol abuse was a compulsive symptom. Because his psychoanalysis helped him to bear the anxiety of feeling his aggression consciously, he had no need to return to his former compulsive symptom.
Epidemiological studies are of great value in understanding addiction. So are neuroscience studies. So are psychoanalytic studies. Ideally, understanding of psychiatric disorders would involve combining of information that can only be understood by looking at information gained by interviewing populations such as that reported by Grant et al. (2007) – 43,093 persons, neuroscience studies such as those summarized by Koob and Volkow (2010), longitudinal studies over 60 years such as reported by Vaillant (2003), and psychoanalytic studies such as this one that involves one patient studied for 1,200 h. This case report is an exact replication of an earlier formulation by Dodes (1996). In other words, two clinicians making separate observations see the same thing.
Combining epidemiological, neurobiological, longitudinal, and psychoanalytic observations would allow multiple sources of information to be used in creating diagnostic categories. Losing details of human behavior by relying only on epidemiological studies is likely to cause errors in categorization of disorders. In turn, having faulty categories as the basis of further research is likely to impair identification of specific effective treatments.
Conflict of Interest Statement
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Cottler, L. B., and Grant, B. F. (2006). Characteristics of nosologically informative date sets that address key diagnostic issues facing the DSM-fifth edition and International Classification of Diseases, eleventh edition substance use disorders workgroups. Addiction 101(Suppl. 1), 161–169.
Grant, B. F. Harford, T. C., Muthén, B. O., Yi, H. Y., Hasin, D. S., and Stinson, F. S. (2007). DSM-IV alcohol dependence and abuse: further evidence of validity I the general population. Drug Alcohol Depend. 86, 154–166.
Teeson, M., Hall, W., Slade, T., Mills, K., Grove, R., Mewton, L., Baillie, A., and Haber, P. (2010). Prevalence and correlates of DSM-IV alcohol abuse and dependence in Australia: finding s of the 2007 National Survey of Mental Health and Wellbeing. Addiction 105, 2085–2094.