The Basic Nature of
Substance Dependency
 by N.J. Gersabeck, MD
Substance dependency is what is commonly thought of when "addiction" is mentioned. Unfortunately, it has lost
much of its association with the more general concept of addiction. It also includes non-substance addictive
practices- or dry addictions." For example, there is a frequent association between alcoholism and compulsive
gambling. Not only are they found frequently in the same person, but the alcoholic person may occasionally
switch completely from alcohol to compulsive gambling- or visa versa. Both substance dependency and compulsive
gambling are addictive practices. The former just happens to also involve the ingestion of addictive
substances. Of course, the psychopharmacological properties of the addictive substance are important- but
substance dependency is much more than the sum of these effects. At one time, cocaine addiction was not
thought to really exist, because there were not any pronounced withdrawal effects upon cessation of its
regular use. Substance dependency represents a group of very complex behavioral disorders. The addictive
process in all addictions is a learning one. It follows that the value of animal experimentation to better
understand human substance dependency is very limited.
There was a psychological experiment carried out on volunteer alcoholic persons who were recent dropouts from
treatment programs. They were truthfully told that (a randomly chosen) half of their group would receive a
placebo beverage, and the other half would receive a alcoholic one. The placebo drink was pure tonic water,
and the experimental one contained tonic water and vodka at a ratio of five parts to one. Essentially, the
two beverages looked, smelled and tasted the same. Each group were given subtle, but misleading clues as to
which beverage they were actually receiving. Each person was given an amount of beverage, which if it were
the alcoholic one, would yield a blood alcohol level of 0.10%. After drinking the beverages, the volunteers
were then subjected to some relatively minor provocative behavior of a negative type. The individual responses
could be objectively evaluated and the results were very interesting. They showed that "typical alcoholic
behavior" was elicited much more by what the person thought he or she was receiving- as opposed to what
actually was received.
Placebo effect is a very real thing, especially in "voodoo death." It is a phenomenon which is found
occasionally in some primitive cultures. After breaking a major taboo, a person simply lies down to die
(by the "hands of the gods"), and is usually dead within 24 hours. It is an interesting and consistent
finding among substance dependent persons that they are all strong placebo responders. This is partly
because the stimulating of a habitual placebo response to the substance is an integral part of the
addictive process. The great importance of the placebo-affecting "set and setting" in addictive drug
use is well exemplified by the case of the alcoholic man who responds so differently at times to the
same amount of alcohol, but in different situations. He may be: somnolent in a library; tearful at a
sentimental movie; belligerent at a bar; the life of a party; sexually passionate in the back seat of
a car.
Many years ago in his book "The Natural Mind," Dr. Andrew Weil insightfully referred to addictive
substances as "active placebos." This was because their inherent pleasure producing qualities insured
that they were particularly likely to elicit placebo response, and that the majority of these would be
of the positive variety. Nicotinic acid (with its skin flushing effects) is often added to the otherwise
inert placebo used in double blind investigations of new drugs. This makes it a different type of "active
placebo," and improves the validity of the findings. He also noted that the use of any set of consistent
rules which applied to the times, occasions and amounts of addictive substance use had some protective
effect against a dependency occurring, or in limiting its negative behavioral effects when a dependency
already existed.
Though Dr. Weil did not mention how or why this effect occurred, I am convinced that the reason is the
narcissistic-limiting effects of any rules. Obviously, using the addictive substance whenever, and to
whatever extent that the person feels like at the moment is a more narcissistic position to take. An
understanding of narcissism is crucial to a good understanding of any type of addiction. Everybody has
a narcissistic side to their personality. Hopefully, the more mature, adult, and altruistic side of a
person s personality and character will be able to play the role of "good parent" to the vulnerable
"inner child" to safely control its immature and narcissistic tendencies. Narcissistic satisfaction
and power is the all-important common denominator in substance and non-substance addictions. One way
to understand a strong and progressed substance dependency is to see that it both represents and fuels
an unconscious, compulsive, and destructive quest for unconditional love. In a marriage, the illusion
of such may be partially satisfied merely by the mistreated partner not leaving the mistreating
addicted partner.
It is fairly well-known fact that the use of heavy doses of opiate-type drugs for the relief of chronic
and severe pain seldom results in an opiate addiction. I think the explanation for this phenomenon is
inextricably linked to the issue of narcissism. The conditions of this strongly utilitarian use of
opiates precludes enough narcissistic leeway for an addiction to develop. The psychologist Gary Forrest,
in his book "Alcoholism, Narcissism, and Psychopathology," reported an interesting finding involving a
relatively small number of alcoholics. They are true sociopaths, who fail to show any compulsion to drink.
Should the results of their alcohol use become too painful, they simply stop drinking quite easily- at
least for awhile. I think the reason for this is that, in these alcoholics (who are definitely not AA types),
there is no inner conflict between the altruistic and narcissistic aspects of the self to fuel the compulsion
to drink This is because the former is essentially absent. Therefore, unlike the case for most alcoholic
persons, the person s narcissistic values are not put at any risk by not drinking.
A "biological" understanding ignores narcissism as having any role in the development of substance dependency.
I always use quotation marks when using the term "biological" in the context of the current predominant
"Biological Psychiatry," with its subtle ideological positions. This is because it is a misuse of the real
meaning of the term. "Biological Psychiatry" has a general anti-psychological bias, and has had the very
unfortunate influence of eliminating any training in psychotherapy at many psychiatric training programs.
The practice of any addiction is an exercise in narcissism. Dr. Aaron Stern, in his book about narcissism, made
the wise comment that "all addictions were a narcissistic force." Actual regression, or the potential for
same, is an integral part of any addiction. Sexual enjoyment has been characterized as a "regression in the
service of the ego," and ideally, this will continue to be the case. But like the enjoyment of alcohol, the
issue/practice of sex involves some finite risk of addiction. Substance dependency entails a greater risk of
regression than for non-substance addictions. This is largely because there is the added pharmacological
effect of the substance to stimulate narcissism. In turn, this invites unconscious and irrational fantasy
related to its ingestion and, therefore, its becoming "part of the self." By definition, enough regression
can result in a psychosis. This actually happens somewhat frequently in what I have termed "substance
dependency-induced psychoses." It is a new diagnosis that I am working to establish. A university psychiatrist
reported an association of the diagnosis of substance dependency in 80% of state hospital cases of
schizophrenia. Unfortunately, he erroneously assumed that the mental illness comes first in these cases.
The person who later becomes an addict does not necessarily initially have a greater amount of narcissism than
the average person. But the process of becoming an addict and, especially, the practice of an addiction always
increases the person s narcissism, or potential for same. This does not mean the person necessarily becomes
a "narcissistic person." Such implies that a person s narcissistic tendencies exceeds their altruistic ones.
A recovering alcoholic person, for example, may have become quite a mature and altruistic person. Most
"biologically oriented" psychiatrists support the use of 12 step programs like AA. But they can only see it as
offering a general type of support. Their orientation prevents them from realizing that these groups can also
offer a specific type of therapy. Their altruistic structure and functioning can often help their members to
effectively and directly combat the excessive narcissism of their addictions.
The psychologist husband and wife team of the McAuliffes operated a training center for substance dependency
councilors in Minneapolis for many years. Their book, "The Essentials of Chemical Dependency" stated at the
very beginning that chemical (substance) dependency was "essentially a pathological or sick relationship of
a person with a mood-altering chemical substance, a psychoactive substance, in expectation of a rewarding
experience." They developed this understanding on an intuitive basis in their work with substance dependent
persons- and were "innocent" of any psychoanalytic understanding or background. They helped to found the
American Chemical Dependency Society whose motto is "Love Heals."
The alcoholic's essential error is poetically, but accurately stated in a revealing statement by psychologist
Charles Hampden-Turner in his book "Maps of The Mind:"
"Much as wine symbolizes communion, the alcoholic has taken the symbol for the reality and uses drinking
as a substitute for the relaxation, fusion, surrender and security of deep personal relationships."
In Smokey Robinson's lyrics to a song, it is unclear whether he was referring to a woman or an addictive drug.
Most likely, he was consciously referring to both:
"I don t like you but I love you, Seems I m always thinking of you, Though you treat me badly, I love you madly,
You really have a hold on me."
The book "Love And Addiction" by Peele and Brodsky was a best seller. Robert DuPont (a former White House Chief
on Drugs) wrote in his book "Getting Tough On Gateway Drugs" that "getting addicted to drugs is a lot like
falling in love." In the book "Craving For Ecstasy" (subtitled "The Consciousness and Chemistry of Escape"), its
biochemically-oriented psychologist authors stated that: "Love is the piece de resistance of addictions." This
is because it manifests quite strongly the three ingredients of any type of addiction- which are arousal,
satiation, and illusion.
Some alcoholic persons claim that they initially liked the effects of alcohol so much that this must mean they
were alcoholic from the first drink- obviously implying a genetic etiology. There is a little bit of truth in
this idea. The addictive process always requires some period of time. It is measured in terms of at least weeks,
and much more frequently- months or years. But barring unlikely events or circumstances, such persons are so
strongly predisposed to become alcoholic that they will become so within a fairly short time. The predisposing
factors include a number of circumstances- of which heredity is a relatively minimal one. Their basic
self-esteem levels are usually low- and in turn this often relates to such strong predisposing factors as the
existence of borderline personality and narcissistic personality disorders. Of course, a dysfunctional family
background is an important factor. Peer pressures in the teenage years and the example of (especially heavy)
parental drinking are also important predisposing factors.
Alcoholism and substance dependency in general are properly regarded as diseases. It is falsely assumed by not
only the general public, but also by the psychiatric profession, that alcoholism has a strong genetic or
"biological" element. This understanding supports a reductionistic and overly simplistic biochemical
theorizing about it- because genes control the basic biochemical make-up of the organism. It also fosters hope
that eventually a medication will be found to neutralize or eliminate the harmful effects of an alcohol
dependency by getting at the inner-most source or workings of the disorder. But the reality is that no such
possibility exists (like discovering insulin for diabetes). Of course, this is not to say that psychoactive
drugs are not often useful in helping to treat dependencies and their complications- such as depression, panic
disorders, manic-like behavior, etc.
David Lester, a prominent biological researcher recently concluded after a lengthy review of the pertinent
literature that the evidence for genetic involvement in alcoholism was "weak at best." He explained that the
popularity and persistence of the idea of a strong genetic factor had much to do with its "conformity to
ideological norms." The famous Danish genetic study so often cited to prove a strong genetic element applied
only to men (a sex-linked disease??). This is despite the fact that women were also included in the study.
Most importantly, the use of identical and fraternal twin comparison studies has never supported a genetic
etiology for alcoholism. And such a study is the most reliable genetic investigating tool available. Dr.
George Vailant (the author of the acclaimed "History of Alcoholism") commented succinctly on the matter:
"A person had as much chance of inheriting alcoholism as of inheriting the skill of being a good
basketball player."
In better understanding the nature of substance dependency, there is an important factor which is actually
very obvious. Yet its conceptual importance has been ignored. It is that of the great degree of overvaluation
of the addictive substance by the addict. It is the development of this irrational and narcissistically-driven
overvaluation which is really the "heart and soul" of the addictive process. I once made my "hypothetical offer
to the alcoholic" (or any other substance addicted) person to a man who had to attend an outpatient substance
abuse treatment program because of a couple of DWI offenses. He was in denial for his apparent alcoholism,
and wanted to convince me that he was not alcoholic. I asked him to imagine I was an eccentric millionaire
who was offering him in good faith the sum of $50,000 for his right or opportunity to ever drink any more
alcohol- no matter what. His very interesting response was an immediate refusal of the offer, and the comment
that accepting it would be like "selling my soul." He was smart enough to know that the best "denial answer"
would be to accept the money- whether or not he really felt that way. In effect, this option was overruled by
his strong unconscious need "not to deny alcohol." I then knew beyond any doubt that he was alcoholic.
Substance dependency is a disease of pathological transference to an addictive substance. Another way to
characterize it would be to say that it is a "a powerful and deeply ingrained disease that is characterized
by an unconscious, distorted, irrational, regressive, and archaic symbolizing of an addictive substance."
Transference is a ubiquitous and always irrational type of unconscious activity that can have both positive
and negative consequences in everyday human interaction. But when it is directed at things instead of persons,
it is all the more irrational and potentially quite harmful. As children, everyone has indulged to some extent
in the unconscious "splitting" of each parent into the "good parent" and the "bad parent."
The persistence and increased activity of this phenomenon is particularly evident in some alcoholics as they
get into increasing trouble with their addiction. The very important initial "good parent" symbolizing or
labeling of alcohol is now being sorely threatened. Some creative alcoholic persons will "act out" this
internalized splitting by creating a denial/defensive "good alcohol/bad alcohol split." The person will
maintain that he or she can handle beer or wine ("good alcohol") as well as ever. Its the "hard stuff," or
liquor ("bad alcohol") that causes them all the trouble. This choice of beverages is made less because of the
matter of its greater alcohol concentration, than stereotypes about it. But the person will always occasionally
use the "bad alcohol" anyway. Seldom, if ever, is the person wrong in his or her negative expectations of its
use. Inevitably, some negative (placebo) responses to the "good alcohol" still occur as the addiction
progresses.
The concept of substance dependency in general is important in understanding any single dependency. Yet there
is a "biological psychiatric" resistance to this. For example, it is difficult to "biologically" explain why
an alcoholic person would, or could, switch completely from alcohol to cocaine use- or visa versa. After all,
alcohol is pharmacologically a depressant type of drug, and cocaine, a stimulant type. This very subtle
resistance likely contributes somewhat to the unfortunate failure of the White House to utilize an obvious
argument in its battle against cigarette smoking. It is that cigarette smoking, as a substance dependency,
greatly facilitates the development of additional dependencies. The great majority of alcoholics are addicted
to cigarettes. In the large majority of cases, this addiction precedes the alcoholism. Cigarette smoking is a
very addictive behavior and the process of addiction to it is far quicker than that with alcohol.
There is a great deal of ignorance about substance dependency by even mental health professionals.
Additionally, "biological psychiatric" thinking operates as an effective obstacle to its better understanding.
There are some recovering alcoholic persons who are members of A.A. and understand many things about substance
dependency better than even some psychiatrists at medical schools- who are nominally experts in substance
dependency. There is a long-known and somewhat "tongue in cheek" "Four, Two, and Zero Rule" in the field of
substance dependency- and it still has much truth to it. It concerns the matter of substance dependency
education in medical schools and refers, respectively, to the number of years of medical school, the number
of hours of lecture on the subject, and finally- the amount learned. Sadly, psychiatric training programs are
little better in this area.
There is a new substance-related diagnosis psychiatric diagnosis of "substance-induced psychosis" which is
very "biologically/politically correct" in its formulation. It has the "biological" criterion that the
psychosis is the result of "direct physical effects of the substance." Unfortunately, it is a very inadequate
diagnosis. It should have been specifically limited to non-addictive substances- which actually comprise only
a very small percentage of the diagnoses made with this new diagnosis. Despite the obvious connotations of
the term "substance," its criteria completely ignore the issue of substance dependency. For addictive
substances, a far better diagnosis would be that of "substance dependency-induced psychosis."
Robert DuPont had some very interesting things to say about social drinking. He feels it is not definable
scientifically, and that many persons thought of as social drinkers are actually "only a short step or two
from active alcoholism." Some of them will inevitably eventually take those steps, and some of the others
will just be potential victims of fate. He cited the matter of consumption and problem curves of drinkers
not being bimodal. This means that they describe just one population of drinkers, not one healthy and the
other of sick alcoholics. In practice, the person considered to be "just a problem drinker is almost always
alcoholic." Along the same line of thinking, in their book "Alcoholism And Substance Abuse," Bratter and
Forrest always referred jointly to "substance abusers/dependents." It is an interesting finding that, not
infrequently, some persons, who are properly diagnosed as "alcohol abusers," are actually more strongly
addicted than some other persons who are diagnosed as "alcohol dependents."
About the author:
Dr. Gersabeck is a psychiatrist who served as the psychiatric
consultant at Brighton Hospital of Brighton, MI from 1974-1977. He has been interested in substance
dependency for more than 25 years. For the past three years, he has been particularly interested in the
official establishment of the new and proposed psychiatric diagnosis of "substance dependency-induced
psychosis" (SDIP). Dr. Gersabeck believes SDIP is a much better diagnosis for addictive substances than the
new official diagnosis of "substance-induced psychosis."
Copyright © 1999 N.J. Gersabeck, MD
Used with permission
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