Are Drugs and Alcohol the Problem or the Solution?

Upon first glance, models of addiction that view drugs and alcohol as the problem can be quite compelling.  For instance, it is hard to argue that if there are no methamphetamines, there are no meth addicts.  But what about the second and third glances?  That is what the Hungarian psychoanalyst, Radó,* contemplated in a 1933 article that revolutionized how we think about severe substance use disorders.  And its impetus was simple…he noticed the field of psychiatry focused on the poisonous nature of the substances.  Therefore, the degenerative clinical pictures that emerged were the result of injuries to the brain and body.

*While I don’t agree with everything he said, I don’t believe it takes away from the contributions discussed or his role in the history of addiction theory.

From this perspective, if someone does not use drugs or alcohol there is no problem.  But the toxin theory had no real interest in, or capacity to explain, why someone uses.  This was a problem for Radó, as he believed it was the impulse (and not the drugs or alcohol) that made one addicted.  And that the focus of study should be on the psychological factors that make a person susceptible to using.  His launching point for this was the conviction substances produce two types of effects in people, pleasure, and elation. While producing similar emotional events, they were, in fact, two distinct phenomena.

The pleasure-effect of alcohol or a drug is quite variable in people (and also depends on their psychological preparedness for the effect).  In general, when it occurs, the result is either a reduction in pain or an increase in pleasure.  The reason to drink or use drugs is obvious in this case.  The second type of effect, elation, results in the same thing and something else…a rapid improvement in the sense of self.  And for addiction to emerge, this latter experience has to occur.  It need not even happen right away.  But if this is true, the question of why some people encounter elation and others do not become extremely important.

So Radó explored the histories of those with severe substance use disorders and found a response to the frustration he termed “tense depression.”  It may first appear as symptoms of neurosis (e.g., anxiety, obsessiveness) and later change into other expressions of psychic distress.  But this is where the potential for addiction starts: there is an uncomfortable tension and difficulty tolerating pain…and the mind becomes focused on relief.  In this condition, if a person happens to drink alcohol or uses a drug, even a prescribed one, they are at risk of experiencing elation.  The psychic condition, in effect, has sensitized them to the pleasure effects.

Not only that, if the drug is well-suited to the person and given in the right amount, and depending on the degree of relief that has been sought, this first event may alter the entire course of a life.  This type of experience is “as a rule the most impressive event of its kind in the whole course of the illness.”  It is as if a miracle has occurred, only it is something a person can do on their own and whenever they want.  The effect only lasts a short period, though, and the ego is again plunged back to its former state.  Thus the cycle of addiction emerges, as the person uses to regulate how they feel about themselves and connection to reality is eventually lost.

From this angle, addiction looks much different.  Drugs and alcohol are not the problem (or are only a small part of it).  And it is sobriety that leads to a state of dis-ease, while using is an effort, without better tools, to treat it.**  As well, the long-standing and generalized vulnerabilities in people, in other words, the characterological patterns, that made them susceptible to elation will persist once clean and sober.  This partially explains the tendency to relapse, switch to other substances or develop other compulsive behaviors, e.g., eating, work, sex, etc.  Indeed, it may be said these are the right ideas, wrong solutions.

**A few years later, Silkworth, the physician who treated Bill W., the co-founder of AA, offered a similar idea, “Men and women [alcoholics] drink essentially because they like the effect produced by alcohol.  The sensation is so elusive that, while they admit it is injurious, they cannot differentiate the true from what is false…They are restless, irritable and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks.”

Beyond being interesting, then, Radó’s theory is immensely useful in my clinical work.  Of course, it is an overly simplified, psychologized view of addiction and many other factors are involved.***  But it makes comprehensible addicts loneliness in childhood and the confusing, constant seeking for something more in life.****  In addition, it alerts the patient to the need for lifelong self-care and vigilance to self-esteem injuries and the pursuit of artificial enhancements.  Most pragmatically, though, I have witnessed patients profoundly resonate and identify with it…and thereby receive the most important intervention possible…a sense of being understood and connected.

*** It should be mentioned that not everyone with a severe substance use disorder has the premorbid conditions Radó described and many are powerfully impacted, both physically and mentally, from the protracted use of drugs and alcohol.  To further complicate things, I also believe both situations can be, and often are, true.

**** In addition to his elation theory, Radó discusses the origins of the “tense depression.”  Specifically, he references a disturbance in the process by which an infant goes from a state of healthy narcissism to having to “cope more and more laboriously with the environment.”  While preceding attachment theory, and not naming the caretaker/child dynamic, this appears to be the direction he was heading.