Youth : gilded or loaded? (jeunesse dorée ou bourrée?)
By Luis de la Sierra.
1 Jul, 2007
The way in which some adolescents deal with their feelings is what concerns me today and for my presentation I have selected individuals who, among the many different ways of attempting to deal with painful feelings, often replace them with the sensations provoked by virtue of pharmacological intoxication.
In Confessions of an English Opium Eater, Thomas de Quincey (1890) writes:
I hanker too much after a state of happiness both myself and others; I cannot face misery, whether my own or not, with an eye of sufficient firmness; and am little capable of surmounting present pain for the sake of any recessionary benefit.
In Three Essays on the Theory of Sexuality (Freud 1905) Freud linked oral eroticism in men with their desire for smoking and drinking, and thus discovered the most important link in the chain of events underlying drug dependence. Nevertheless, the specific action of intoxicants must not be underestimated. Freud (1930) in Civilization and its Discontents says:
... In the last analysis, all suffering is nothing else that sensation ... The crudest but also the most effective among these methods of influence is the chemical one - intoxication. I do not think that anyone completely understands the mechanism; but it is a fact that there are foreign substances which, when present in blood or tissues, directly cause us pleasurable sensation; and they also alter the conditions concerning our sensibility, that we become incapable of receiving unpleasurable impulses. (p. 78)
Freud tells us that in their fight for happiness and to keep misery at bay, this group of people so highly values as a benefit the service rendered by the drug, that they have given them an established place in the economics of their libido. He does not specifically refer to adolescents, but it certainly applies to them too.
Anna Freud in "Normality and Pathology in Childhood" (1965) describes the overwhelming craving for sweets in children who use the satisfaction of the craving as an antidote against anxiety, deprivation, frustration, depression, etc. She sees a child's love for sweets as a comparatively simple, straightforward expression of a component drive with its roots in unsatisfied or over stimulated desires of the oral phase, desires which have grown excessive and by virtue of quantity dominate his libidinal expressions. According to her "a true addiction in the adult sense of the term is a more complex structure in which the action of passive-feminine and self -destructive tendencies is added to the oral wishes. For the adult addict, the craved-for substance represents not only an object or matter which is good, helpful, and is strengthening, as a sweet is for the child, but one which is simultaneously also felt to be injurious, overpowering, weakening, emasculating, castrating, as excessive alcohol or drugs actually are. It is the blending of the two opposing drives, of the desire for strength and weakness, activity and passivity, masculinity and femininity, which ties the adult addict to the object of his habit in a manner which has no parallel with what happens in the more benign and positively directed craving of the child"(P. 11).
In antiquity Homer already sang of Helen of Troy having "drugged the wine with a herb that overcomes all grief and anger and lets forget everything bad." Many of the youngsters who suffer from a compulsion to use drugs do so because of a powerful psychological dependency which pushes them towards drugs in order to avoid, regulate or run away from painful and distressing inner experiences. However, the powerful psychological component of drug dependency should not make us ignore the issue of ensuing physical dependency although I will not expand on this point as it is beyond the scope of this paper. The question of physical dependency though must be borne in mind when thinking about adolescents who are so seriously addicted to a drug that their craving becomes a major priority; in other words those youngsters who are physiologically as well as psychologically dependent on their drugs.
Problems of substance abuse can occur at any level of society and affect all socio-economic groups. It is the interaction of the cultural, environmental and constitutional elements with the conscious and unconscious forces operating within the addict (or, in other words, the interaction of his/her inner and external worlds) which mostly contribute to the creation of this condition.
Adolescence is our second chance to put right any unresolved crises from early childhood. This rather difficult phase is characterized by many and frequently conflicting issues, which include physical and endocrinological changes that influence the awakening of sexuality, academic demands, problems of identity, conflicts about dependency and independence, peer group pressures and concerns about status. Both childhood and adolescence are developmental stages in which we may observe either transient manifestations of internal stress or the signs of later pathology, but the problems which the ego has to deal with in adolescence are, qualitatively, different from those of childhood. They are now mostly related to the adolescent's reaction to the physical primacy of the genitals, the changing relationship to the original objects with the degree of psychic separateness from their internal primary objects, the difficult task of finding a new heterosexual love object and, finally, the complex task of integrating pre-Oedipal identifications, Oedipal identifications, as well as present internal and external expectations of conduct. If we take into account what goes on in terms of both the revival of infantile (pre-genital) drive activity and of newly emerging urges and experiences, we realise that both have to be integrated into the existing system at the same time as a new equilibrium has to be created.
The adolescent finds himself in the very difficult position of having to make all these readjustments at the same time as he has to deal with the subsequent conflicts and anxieties. There must be, simultaneously, a loosening of the attachments to the same people at the centre of his fantasies and the subject of intense feelings of love and hatred. The earlier attachment and dependency on parents must now be renounced until the adolescent reaches a point at which it is possible for him to confirm his own identity and find new love objects. These must neither be based too much on repetition of previous early attachments, nor be entirely and exaggeratedly opposed to them in hostility and rejection so as to make satisfactory adult life possible. It goes without saying that none of this can be achieved without much upheaval and experimenting. If, during childhood and latency, our main concern is with the child's ability to advance in both ego and drive development, in adolescence we are faced with results of either successful or faulty structuralisation which has to be understood in the context of the presence and primacy of genitality.
When things go wrong, children and adolescents may be unconsciously compelled to develop psychological and physical symptoms as they attempt to look after themselves. When the resources of his internal world fail him, the adolescent often seeks solace in external consolations such as drugs, alcohol, sexual acting out and juvenile delinquency. It is external dependency which becomes the only unresolved means of belonging, and we then see completed in adolescence a process that started in childhood. We frequently notice that dependence in the young person is accompanied by a crisis. For the youth childhood has passed, but adult life in the future cannot always be seen clearly. The greater freedom and opportunities that adolescents have to follow their instinctual drives is not always accompanied by more tolerance of dependence on their parents as it is the case until adulthood is reached.
Trying to understand the reasons why people abuse drugs is not an easy task. A full metapsychological assessment of such cases would certainly throw a greater light on the subject but, at the same time, it is important to bear in mind the relevance, to the addict, of any changes in self-cathexis, in self-perception under the effects of the drug. This leads to the question of what changes these people may be trying to achieve. Drugs have different effects on different individuals and, as I mentioned before, it is very difficult to differentiate between psychological and pharmacological effects. Often, young people use drugs for thrills, to obtain sexual gratification or as a substitute for it, and for them it is the ‘buzz' that really matters. They may or may not become addicted to the substance they abuse. This substance may be used only occasionally to produce pleasurable sensations when the lack or excess of feelings becomes intolerable to the individual. Others take drugs for the feeling of Nirvana they provide, to ease the despair and misery they experience, for example, some heroin users who, under the influence of the drug, no longer care.
If it is true that some drug users can be thought of as experimental users and controlled users, adolescence is not characterised as a period of moderation and self control and the younger the adolescent is, the less likely he is to control the use of drugs once he has become involved. The evidence of misuse is probably greatest among adolescents.
Many youngsters use drugs to increase their self-esteem. Those who have a defect in reality testing or whose egos are weak are indifferent to the dangers of the drugs which are outweighed by the effect on self-esteem.
Alan, a 19 year-old heroin addict, the only child of an apparently normal family, good-looking, intelligent and a good athlete, concealed a violent nature under a pleasant and polite façade. Like many of his kind, his self-esteem was rather low. Previous to his drug-taking, he had a history of outbursts of violence in school, manifested in the bullying of other children and, occasionally, gang fights and vandalism. His eccentricities, shyness and outbursts of violence had made him a rather isolated youth with no friends at school. He hated his violence and immediately conveyed to me that heroin made him much more peaceful, more at ease with himself, less aggressive and violent. He felt less paranoid and more willing to make friends with others. He felt better liked, particularly by the trendy youths who were experiencing with soft drugs and also cannabis and even heroin as something glamorous, attractive and daring.
For the addict, the drug represents an external object endowed with positive and negative characteristics, but however harmful it might be felt to be, it has a necessary function, since the addict feels there is something bad inside him/her (anxiety, violence, depression, guilt, perversion, psychosis, etc.), and uses the drug as if it were a medicine to anaesthetize or destroy the badness, to "cure" himself. Drug abusers are "self-medicators", who desperately and vainly try to deal with powerful, intense and disturbing inner experiences which threaten to overcome them. Unfortunately the addict himself is in one way or another in danger of being destroyed.
While many of these patients are thought of as suffering from borderline disorders, the reality is more complex. We can see a much greater variety that goes form the neurotic to the patient where either alcoholism or drug-addiction serves the purpose of keeping a psychosis at bay, to the overtly psychotic youth. There is an unfortunate tendency to see these patients as belonging to one and the same category and many erroneous generalisations come out of this misconception. One of them is classifying the psychopath and the addict as one and the same. If it is true that addicts may have their fare deal of trouble with the law and become involved in delinquent and criminal acts [in the way that children, as Anna Freud tells us, lie and steal in order to obtain their supplies of sweets], they are not to be confused with the psychopath with whom they, by definition, cannot be classed. The psychopath experiences no internal conflict and cannot create one. Instead he establishes a conflict with the outside world and in so doing uses alloplastic methods (adaptive responses which alter the environment). The addict does experience an internal conflict and tries to resolve it by a change of endopsychic functioning, which makes their condition an autoplastic one (adaptive responses which alter the self). This difference is an important one and has to be taken into account for the proper comprehension and management of the two conditions which I will to illustrate with the following vignettes:
John, a 15 year-old youth, the son of divorced parents, had felt abandoned and rejected by his father whom he had not seen since the age of 10. Undermined by his mother - who constantly criticized him and who found it difficult to tolerate his presence because it reminded her of her ex-husband - John had very poor self-esteem and had failed disastrously in his studies despite being of superior intelligence. At school he started mixing with the 'bad crown' and started experiencing with drugs, first with hashish and afterwards with amphetamines, to which he became addicted, after experiencing, for the first time in his life, positive feelings of self-esteem. He felt that 'speed' gave him a stronger, more powerful personality which, he thought, helped him to obtain his friend's admiration. In the course of treatment he was able to acknowledge his ‘feelings of inferiority' and how he took drugs in order to improve himself and feel ‘more normal'.
Linda, a 19 year-old girl who had been sent to a detention centre with a long history of antisocial activities, which included shoplifting, handling of stolen goods and vandalism, found herself a patient in an adolescent unit as a result of a probation order. She experienced no remorse over her delinquent activities and was convinced she had been caught only as a result of not being ‘clever enough'. The family history revealed an early life of emotional deprivation with a sadomasochistic relationship with a mother who had never helped her to master her environment, leaving her with the conviction that she should only conquer the environment by altering it if she had ‘special powers'. Magical thinking permeated her mental life and she only responded to treatment whenever she felt she was in the presence of a more powerful and clever therapist whose "magic" she could steal.
The implications of the treatment of this kind of patient have been dealt with by other authors (Aichhorn 1935; Hoffer 1949; Eissler 1950). The affect of the addict is usually a troubled and depressed one. There is none of the defiance, self-confidence and open aggressiveness of the psychopath in them, unless, obviously, under the effect of drugs or alcohol. When the delinquent uses drugs, he does it to increase his feelings of omnipotence.
The type of drug used by the person will influence our clinical judgment, since smoking cannabis cannot be equated with injecting heroin. The choice of a specific drug derives from the interaction between the psychodynamic meaning and the pharmocogenic effect of the drug with the particular conflicts in a person's psychic structure throughout his development. The choice of drug is certainly not as indiscriminate or capricious as it may appear from superficial observation. The anxious youth may use any drug while the young psychopath will generally take drugs which will accelerate mental processes. On the other hand, the continuous use of opiates may suggest a psychotic or borderline disturbance with an important depressive element. Something similar may be said about the persistent use of alcohol, although here it is important to remember environmental influences in certain cultures.
Changes in drug preference may also indicate internal psychodynamic changes. As mentioned earlier, it is extremely difficult, if not impossible to distinguish between symptoms resulting from pharmacotoxic affects and those caused by underlying psychopathology. The conscious and unconscious psychological changes of adolescence which are in the process of evolution are further obscured by exposure to pharmacotoxic influences. Fears and anxieties accompany the adolescent's curiosity about the functions of the body and mind; aggression and energy also become confused and the adolescent easily adopts the solution of mitigating his confusion with a "downer" rather than trying to deal with it. When initial experiments to dispose of sexual feelings through casual contacts fail, the adolescent is easily tempted to get rid of the resulting desolation, despair and emptiness by means of the instantaneous, though temporary, relief offered by drugs.
Psychotic anxiety brought out by hallucinogenic substances such as LSD and others can be very frightening to the young person who then turns to another drug to dispel the previously drug-induced disturbance. As a result, he may find solace in tranquillisers, cannabis or amphetamines. The escalation to hard drugs creates a vicious circle in which the adolescent is trapped as he struggles to keep at bay the menace of disintegration.
At the centre of the adolescent's turmoil is the revival of bisexual conflicts which the young person often tries to solve through promiscuity or complete withdrawal. When these attempts fail, they may look for others in similar circumstances in the hope that sharing their problem with others might improve their experience. In such cases, drug abuse is the common link which constitutes the only possible elective and shared experience.
However, it is important to bear in mind that the highly ambivalent attitude of the addict towards the drug, first seen as a remedy to his problems and later seen as an enemy, as a persecutor to get rid of, is recreated in the transference where the analyst becomes identified with the drug. This frequently takes place unconsciously in the mind of the patient who has to miss sessions in order to put a distance between himself and the analyst by whom he feels persecuted and threatened.
Thus Kevin, an intelligent and sensitive 16 year old heroin addict would report, after missed sessions, dreams of being persecuted by vampires who wanted to destroy him and suck his blood.
The understanding of this phenomenon and the way in which the analyst deals with it, will greatly influence the possible outcome of these analyses.
One often observes that the young addict craves to be united with an ideal object and one can say that when the addict develops an intense positive transference reaction when meeting an analyst, it is frequently linked with the unconscious fantasy that this ideal object has finally been found. Sadly, the conflict experienced by the addict is that at the same time he dreads that union with the object and feels persecuted by it. He then becomes addicted to acting out the drama of fantasy introjection and separation from the drug, which is at one and the same time the analyst.
It has been said that the mildest forms of addiction are largely reinforcements of unconscious homosexuality. This does not mean they are easy to treat, particularly in adolescence, for obvious reasons, and it has deeper implications in the case of the "needle" addict. The boy in conflict about his sexual identity may be unable to make a fundamental choice between the female within and the female without. The posture he adopts is overtly heterosexual, but his behaviour with drugs seems to negate this. The self-injection and the feeling of well-being that it engenders seem to symbolise and display the unconscious choice which, however, remains unacceptable. For the girl, the problem has a similar obverse meaning and the drug abuse has the same quality as the unrestrained promiscuity which often accompanies it. Her relation to drugs progressively replaces object relations until they virtually take over. Masturbation and sexual intercourse are often displaced by the intravenous injection of drugs.
The role of drugs in adolescence has, from a developmental point of view, many different and interesting implications. Sociological factors, trends, peer group influence etc. must be taken into account as well as psychodynamic factors when assessing psychopathology, for drug taking may be part of the normal adolescent's need to experiment, test or simply rebel against given adult values. This alone would be, of course, a very simplistic explanation. The use of drugs in adolescence is closely connected with failed attempts to deal with intense aggressive and sexual feelings which the adolescent then tries to relieve by turning to pills or injections which bring deceptive tranquility to his troubled mind. The analysis of many of these youngsters reveals a sadomasochistic relationship between the adolescent and his internalised objects with its accompanying persecutory anxieties. Glover describes the symbolic dramatisation of the love and hate relationship with the parents, namely the battle with continuous and unresolved problems which prolong a very disturbed relationship between infant and his mother, towards whom the adolescent remains highly ambivalent. If to all this we add the depression which we so very often find in adolescence, we can begin to understand the psychodynamic meaning of drug addiction in the young person.
Of even greater severity is the case of the confirmed addict characterized by a depressive organisation which, when combined with self-destructive and destructive factors, make for an uncertain and poor prognosis.
It is a fact that the number of confirmed addicts asking for psychoanalytic treatment is small. Their impatience and tension intolerance predispose them against the slowness of analysis. The number of analysts and psychotherapists who will accept them is even smaller and the number of addicts who complete their treatment, yet smaller. As in many other areas of psychopathology, there is no psychoanalytic consensus on the treatment and management of these patients. Opinions vary from those who consider these patients absolutely unsuitable for psychoanalysis to those who feel no need for any modifications whatsoever of the usual psychoanalytical approach.
I personally feel that I must respond to the addict who seeks help, but I also like to give careful thought to what sort of help I can offer. This may involve a tricky and long period of assessment, where I must be aware of the possible complications of an incipient transference which must be dealt with, even if a patient is to be referred to somebody else. I believe that some addicts can be treated psychoanalytically, but careful consideration of the patient's individual psychopathology must be accompanied by an even more meticulous evaluation of his personal external circumstances, and his environment in general (including contact with other agencies, relatives, etc). Special consideration must be given to facts such as the severity, frequency and quality of the addiction, and whether the patient has succeeded in abandoning it before or not. If I feel that the addiction is such that to start treatment in such a state would endanger the analysis, I suggest that the addict be admitted to an institution and that detoxification be carried out by a colleague with whom I could work closely in the future if appropriate. If I decide to start treatment outside the clinic or hospital, I make sure that the adolescent's living conditions are safe and I make a point of establishing a link or collaboration with someone living with the addict and prepared to take on the parental guiding role without which one finds it difficult to ensure the survival of the treatment or indeed of the patient. Close collaboration with other doctors involved, probation officer, social workers, hostels, etc. is, in my opinion, a sine qua non condition in these cases.
I also think that in addition to an accurate understanding of the addictive psychopathology and a great deal of empathy on the side of the analyst, one must be prepared to adopt the role of the indestructible object if one is to meet the great challenge that addicts presents us with. By the same token, however, we must also be prepared to let the young person go when the time has come.
Alan, the 19 year old heroin addict mentioned earlier, was in analysis with me for four years. After an initial period, during which I felt he was trying to frighten me with accounts of indiscriminate and dangerous drug taking, he seemed to feel reassured by my apparent lack of response. As the working alliance developed, he spoke of the deterioration of all his relationships, starting with his parents, who, unable to tolerate the stress to which he submitted them, had ended up by asking him to leave home. The analysis of some of the developmental contributions to his self-destructiveness was made possible by his making me into a stronger, saner and safer object than his parents.
However, this improvement did not last long and Allen went out of his way to make analysis extremely difficult. He would either attack me, saying that my interpretations were stupid and banal or he would miss sessions constantly. One day he came to see me after a whole week when he had not turned up and not even telephoned me to cancel. He had not expected to find me in my consulting room and expressed surprise at my persistence when I told him that I would always be there for his sessions, irrespective of whether he attended his sessions or not. After that session, he started to show some improvement in that he was able to reduce the amount of heroin he was injecting and started to attend more regularly. He was then able to see that his struggle to fight off the treatment was equivalent to his attempts to fight his drug dependence. He eventually left at the end of four years of analysis, having abandoned his heroin habit and been accepted to university. He still keeps in touch with me and I have seen him once or twice a year since the end of his analysis. It was clear to me that in order to gain his trust and have any hopes of succeeding with him I could not accept his destructive rejection of me and of analysis. It was also obvious that I needed to help him to separate from me and let him take on the responsibility for himself in getting accepted to university and in going forward towards his next developmental stage: adulthood.
In the transference, Alan displayed his highly ambivalent attitude towards the drug, now transferred onto me. As a result of his unconsciously identifying me with the drug, I would become sometimes an enemy, a persecutor to be avoided. The message contained in his need to miss sessions was a mixed one: in one way it represented his attempts to liberate himself from me; on the other hand he was also testing me out to see whether I could contain and survive his aggression. To have interpreted the missing of the sessions only as an unprovoked attack against me would have been a technical mistake that would have ignored his need to defend himself against the imaginary attacks coming from me.
The question of termination of adolescent treatment can be clarified if also approached from the angle of growing detachment and separateness. The wish to feel free from the analyst often appears well before we feel safe about the patient's capacity to make this step. It is important then to differentiate between a state that looks like resistance but which may, at this stage, contain elements of normality and health. Where this is recognized we can see that successful analytic work, where integration had almost been reached, has made it possible for the young person to return to his analyst at a later stage, either to continue work that he felt to have been incomplete or to report on his good experiences and allow his analyst share in them. From such adolescents who return as young adults we can learn a great deal, especially about the problems that they have been compelled to hide from the analyst earlier on, and about the reasons for it.
The transference relationship is always an affective one, for the analysis is not an intellectual but an affective process, and for the analysis to proceed we need what we call rapport. It is only when we make direct contact with the affects by empathy that we can interpret them intelligently and be certain of how the patient is feeling. Accurate empathy is indispensable to sound analysis and the wisdom we need is a combination of intelligent insight with emotional understanding. We have to register and interpret affect in instincts and object relations terms but we also have the further task of analyzing the affects themselves. We must have logical theory but we do not work with theory, we work with living impulses and feelings. This, of course, applies to all patients but it is of the utmost importance to bear this in mind when treating the young addict who not only deals in a very complex way with his feelings, but is also capable of provoking disconcerting and confusing feelings in the analyst who may not always be emotionally ready to deal with them.
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