Excerpts from Must Read Books & Articles on
Mental Health Topics
Books, Part XXXX
Addiction as an Attachment Disorder
Philip Flores (2004)
Chapter 4- Addiction: An Attempt at Self-Repair that Fails
To be ourselves, we must complete ourselves.
Will Durant (1926)
As comprehensive and compelling as Bowlby's work is, his theory fails to thoroughly address all the subtle nuances that make up successful addiction treatment. Because Bowlby's observations evolved from the study of children, his formulations do not always translate easily into direct clinical application. Bowlby's observational data and ethological framework need to be expanded with concepts drawn from other sources if their full potential for addiction treatment is to be realized. The work of the relational models, especially the contributions of self psychology, helps compensate for attachment theory's limitations by placing Bowlby's model within a more practical paradigm that has increased relevance for addiction treatment.
Although there is no evidence that Kohut and Bowlby were openly influenced by each other's writings, they shared a unified allegiance to psychodynamic theory in general and object relations theory in particular. It appears that their individual theories were parallel developments, achieved separately without the other's direct influence. Because Kohut's clinical work was primarily with adult patients (Bowlby collected his data exclusively from children) who demonstrated disturbances in their capacity to maintain narcissistic homeostasis, he added an important perspective that was lacking in attachment theory, especially as it applies to addiction treatment. A brief review of Kohut's contributions illustrates the significance and strength of the relationships between the two theories.
Heinz Kohut's (1972) work with patients whose central disturbance involved feelings of emptiness and depression is in many important ways an extension of Bowlby's observations concerning the difficulties that occur when a child's developmental need for secure attachment is disrupted. Kohut extended psychoanalytic thinking beyond its standard concept of drive theory so that narcissistic vulnerabilities could be better understood as a consequence of the patient's inadequately formed or damaged sense of self. Like Bowlby, Kohut emphasized the critical importance of parental responsiveness in the development of internal mental structures for self-control and the eventual emergence of individuality and the capacity for mutuality. Kohut stressed that a child's nuclear self is formed during infancy and embodies the fundamental self-esteem, ideals, and ambitions of the child. The nuclear self is bipolar, organized around two anchor points of ideals and ambitions. In his final book (1984), Kohut added a third constituent of the self, which involves the maturation of the alter ego or twinship needs.
Attachment with a primary caregiver allows the various agencies, drives, and conflicts of the mental apparatus to become unified into an integrated sense of self. Kohut (1977) defined the self as "a unit, cohesive in space and enduring in time which is the center of initiation and a recipient of impressions" (p. 99). However; the formation of the nuclear self does not take place in relation to overt praise and rebuke. Rather, it is the empathic, nonverbal, intuitive responsiveness of the mother to her child's needs that validates healthy striving for autonomy and identity. The atmosphere the parent creates either integrates or fragments the nuclear self. It is not so much what the parents do as much as who they are that determines developmental outcome.
Sarah had entered treatment because of her husband's threat "to divorce me and never let me see the children again if I don't do something about my drinking." It quickly became apparent during the first few sessions that the only attachment figures in Sarah's life were her children. The threat of losing them was a far more powerful motivating force than the pull of the compulsion to drink. She readily agreed to meet once a week for psychotherapy and attend AA meetings. Although Sarah was an elegantly attractive, intelligent, and educated woman, she never worked outside of the home and described her relationship with her husband as "empty and cold." Her drinking had always been solitary; she consumed wine or vodka only after her husband had gone to bed at night or the children were safely at school during the day. Despite her friendly smile, quick wit, and pleasant demeanor, she had no close friends. When asked why, she replied, "I don't think most people find me very interesting."
Therapy limped along for months. Sarah's attendance was sporadic. Many sessions were dominated by long periods of painful and uncomfortable silence. Encouragement to attend AA meetings was met by weak protests that "the people there didn't seem friendly or inviting."
All of this dramatically changed one day during the middle of a session, after her therapist had cautioned her again that her isolation was not good for her recovery or her depression. She uncharacteristically flared at him angrily. "What's wrong with you? Can't you see what I am?" She threw her arms open wide. "Look at me. Do I look like someone that you or anyone else would find interesting?" "As matter of fact, I do," her therapist replied.
She stared at him, dumbfounded. Uncertainty washed over her face. "Well, it's all an act; nothing but smoke and mirrors. I can only maintain this on a superficial level. Eventually, like everyone else, you'll tire of me and see me for what I am."
Following this confession she burst into tears, buried her head in her hands, and sobbed. Her therapist waited for her crying to stop before he leaned forward and gently assured her. "Sarah, I see this is painful to face, but it's important you let yourself speak to it and feel what this brings up for you. I understand that you feel what you say is true about yourself, but that's not been my experience of you. Where does this feeling come from?"
Sarah leaned back into her chair and wiped the tears from her eyes. A loud sigh escaped from her chest. "You know, I haven't thought of this for years." She sat up and looked into the therapists' eyes. "I don't think I ever told this to anyone, but when I was a young girl ... about 5 or 6, 1 use to hide behind this big chair we had in the living room, so no one would find me or see me. I'd close my eyes and try to make myself disappear. I did this for years.
Sarah proceeded to describe in painful detail an emotionally barren home that was in stark contrast to her parents' high-profile social standing in a small rural community in southern Mississippi. Her father owned the only movie theater in town and her parents were prominent members of the small community, loved and respected by all who knew them. Sarah was the polite, precocious only child they would parade out for the towns folk to admire like a porcelain china doll. At home, the climate was much different. Her father found her to be an embarrassment because she was an unplanned child who was born when he was in his early fifties and her mother was in her early forties. Her parents provided her with all the finest clothes, education, and trappings that money could buy, but both felt awkward and uncomfortable in her presence. Her father especially found her early childhood exuberance intrusive and annoying because it interfered with his tranquil and somewhat stately lifestyle. Sarah frequently overheard him complaining to her mother, "Can't you keep your child quiet, she's an embarrassment to me." Most evenings were spent at their large country home, which sat in the middle of ten acres of isolated farmland, with her parents sitting together on the front porch, engaged in quiet intimate conversations over cocktails, while Sarah played quietly and alone in her room.
Following this important revelation, therapy progressed more rapidly over the next few months as Sarah came to alter her internal working model, which included a strong component along the lines of "there is something lacking in me that is capable of provoking love from anyone." Her relationships with her therapist deepened, and her friendships, both inside and outside of AA, became richer and more satisfying. As people became an increasing source of emotional regulation, her need to drink became less of a driving compulsion.
From the perspective of self psychology, a child needs empathic attunement from parental figures in order to develop a cohesive self. A cohesive or "bipolar self is a developmental achievement of transforming the archaic grandiose self in self-assertive ambitions and the idealized self into mature values and ideals" (Stone 1992, p. 335). Minor or sporadic emphatic failures are not deleterious. In fact, periodic lapses facilitate the crucial process of transmuting internalization. Optimal frustration within the context of a holding environment provided by a "good-enough mother" actually facilitates the building of psychic structure and the internalization of functions previously provided by external objects. Since Kohut attributed the lack of empathy and attunement as a primary contributor to psychopathology, he reasoned that the use of empathy as a therapeutic tool was crucial in the restoration of the self. Empathy or "vicarious introspection" becomes the primary mode of data gathering for self psychologists. The therapist's task is to identify the selfobject functions that the patient requires, which are activated and demonstrated in the transferential relationship. Since it was the parents' original failure to adequately serve this function that initiated the child's misdirected search for regulation through dysfunctional channels (e.g., alcohol, drugs, sex, etc.), one key element in the repair of the developmental arrestment can be provided if the therapist makes him- or herself available as a selfobject.
One of Kohut's primary contributions to psychoanalytic theory is a change in the way narcissism is conceptualized. Kohut legitimated narcissism as a normal developmental process necessary for a healthy, age-appropriate need for object relatedness and attachment. Classical drive theory regarded narcissism more as selfishness or stubborn self-centeredness, reflective of an individual's unwillingness to delay gratification. The insistence that "I must have everything my way" is very similar to AAs position when it warns its members of the dangers of the alcoholic's inflated ego. From Kohut's perspective, narcissistic needs are not regarded as selfish, but reflective of a disturbance in the relationships between the self and its most significant others or selfobjects. Narcissism can be viewed as a roundabout way of attempting to provide for oneself what was not provided by others.
Another person "is a selfobject when it is experienced intrapsychically as producing functions that evoke, maintain, or positively affect the sense of self" (Wolf 19F5, p. 271). A selfobject is neither a self nor an object; rather; a selfobject is a subjective aspect of a function performed by a relationship. Selfobject transferences, like substance use, are really attempts at selfrepair. The vulnerable individual is attempting to complete a process initiated in childhood but uncompleted. Kohut believed that we never give up the hope for completing ourselves. In a similar fashion, Paul Ornstein (personal communication, 1982), speaking to the importance of maintaining the therapeutic frame and the therapeutic alliance added, "The self is always searching for the right environment to complete itself."
Kohut made the important distinction between healthy and pathological narcissism. Phase-appropriate, empathic responsiveness to the child's selfobject needs is essential for the cohesion and development of the self and leads to healthy selfesteem. Without the idealizing or mirroring selfobjects, a child is likely to grow up with narcissistic vulnerabilities leading to disturbance and difficulty with affect regulation, increasing the potential for addictive behavior: Consequently, the vulnerable individual is left without the internal structure necessary to manage the emotional injuries and disappointments (affect disregulation) that are sure to follow later in life. As Bacal (1985) writes, "The defects in the self produced by faulty responses of self objects lead this individual to establish what Kohut called transference like states, where he looks for self objects in his later life to provide him with the responses which he missed in order to repair the self" (p. 488). From this perspective, Bacal is suggesting that transferential relationships are essentially attempts at self-repair. Bacal's position is similar to the selfmedication hypothesis of Khantzian (1982). Both Khantzian and Kohut postulated that the use of substances and archaic selfobject relationships share a similar function: each is a compensatory driven behavior reflecting desperate and futile attempts to shore up the defective self.
SELFOBJECT RELATIONSHIPS AND TRANSFERENCES
Evidence gathered by Kohut and others (e.g., Stolorow et al. 1987, Wolf 1988) over the years in their work with patients suffering from narcissistic vulnerabilities has led to the identification of seven common selfobject tranferences:
1. Mirroring: A response that confirms the child's innate sense of vigor, importance, and uniqueness. It is the "gleam in the mother's eye" as she is empathically attuned with the child's feelings and interests. From this experience, the child develops healthy narcissism and grandiosity. This results in healthy self-esteem with an
appropriate sense of assertiveness and drive for mastery and achievement.
2. Idealizing: If the child is presented with a strong, soothing selfobject who allows and provides idealization, the capacity for healthy ideals, values, and principles is internalized.
3. Alterego or twinship: A firm sense of self, resulting from the optimal interactions between the child and selfobjects makes up this third constituent in relation to the first pole (mirroring), from which emanates the basic strivings for power and success, and the second pole (idealizing), which harbors the basic ideal goals and values. The core of the personality is determined by the tension arc in the intermediate area of basic talents and skills, which is established between ambitions and ideals. The selfobject requirement consists of the need to belong to something greater than oneself, a human among humans, and is the antithesis of alienation and isolation. It reflects the desire to be part of a community.
4. Adversarial: The need to compete and exert one's full potential without fear of destroying the other person. For a child, it's the need to be able to play aggressively without fear of destructive retaliation. For an adult, it is the confidence that the other person will tolerate your anger and work through disagreements without the relationship being destroyed. The experience helps the person develop resiliency.
5. Efficacy: The experience of having importance and significance in relation to another person. It is the feeling that one's presence, responses, and actions can have a positive impact on another person, that one can be of help and of importance to someone.
6. Self-delineating: A relationship with an object that promotes individuation and the separation of the self without the threat of loss of attachment. Often, it is a relationship that allows the other person to be who he or she is, without undo pressure to behave in a certain way in order to maintain the attachment relationship.
7. Witnessing: The need for a selfobject to be a witness and provide emotional understanding for the injustices or wrongs that were inflicted on the individual. This relationship is especially important for trauma survivors.
AA AND SELFOBJECT FUNCTIONS
Self psychology's concepts of mirroring, idealization, and another person serve the function of a transformational or corrective twinship and provide alternative ways to explain how AA is helpful to its members. Mirroring takes place when members feel they are seen for who they truly are and when they have a positive influence on others. Those suffering from deficits in this area (mirror-hungry personalities) will often have their previously unmet needs for healthy grandiosity, exhibitionism, and respect gratified by the attention that their continual sobriety brings. Idealization, whether of a sponsor, the group, or of one's higher power, is in evidence when members tell of feeling bolstered by identification with some greater source of strength and wisdom. Members with longer periods of abstinence and sobriety serve as important role models that spur others on to emulate. Twinship is operating when members speak of the healing effect of belonging to the group and finding peers with similar experiences. Many of the other selfobject functions are provided through continual twelve-step work (helping others) and sponsorship.
After his parents died, Cecil was raised by a series of aunts and uncles who lived in a rural area of the Midwest. At age 17, he promptly joined the Navy and spent the next four years traveling the world until he was honorably discharged at the age of 22. He began drinking in the Navy and continued throughout his adult life without any suggestion of problems for the next twenty years. Two failed marriages left him cautious about committing to any woman again, even though he had a long string of short-term relationships over the last ten years. He worked for the airlines and his job required that he move every few years.
Cecil showed up at a therapist's office one day complaining of "depression and lack of meaning in my life." He quickly announced that he had gone to a few AA meetings since being transferred to the city and concluded he was an alcoholic. In fact, an AA member had given him the therapist's name and had urged him to set up an appointment. Antidepressants were promptly prescribed and Cecil agreed to enter an outpatient therapy group.
During the course of the next few months Cecil religiously attended both AA and the group. With continual sobriety, he was able to identify a pattern to his drinking. "I never felt comfortable with my father or with men unless I was drinking with them." He proceeded to paint a picture of a man who surrounded himself with drinking buddies and for whom the local tavern became the one place where he felt he could count on connecting with others.
Eventually, AA began to serve a very similar function to that of the local tavern. He found a "home group" and a bunch of men that he admired and looked up to. Cecil developed a relationship with a sponsor and began to faithfully work the steps of the AA program, frequently reading the "Big Book" and "the daily meditations." He admitted, "You know, I never did get into this God thing that my aunts and uncles tried to force down my throat, but this higher power and spirituality make sense to me."
A few months later, he excitingly announced to the group that a "bunch of doctors and lawyers at the meeting invited me out to have coffee with them. They were asking me what they should do about working the steps. One of the lawyers even asked if I'd be his sponsor."
THE REPARATIVE APPROACH
In an attempt to explain the importance of self psychology as a treatment approach, Howard Bacal (1992) wrote, "One simply cannot apply unmodified classical drive theory in the clinical situation and expect that the patient will feel understood" (p. 56). Bacal challenged the "considerable discrepancy between what effective classical theorists preach and what they practice" (p.56). His criticism has relevance because it is an attempt to bring classical psychodynamic theory in line with the practicalities of treating the addicted patient. Self psychology helps accomplish this task because it offers a unique perspective, not only for addiction, but also for all psychopathology. Self psychology departs from Freud's classical drive theory with its emphasis on intrapsychic conflicts and moves the focus of attention to relationships and the age-appropriate developmental needs that were unmet, which leads to arrested emotional development. Until this is repaired through the restoration of psychic structure, individuals will remain susceptible to seeking external sources of gratification because their internal self structure is unable to provide this needed capacity.
Ormont (2001), writing from a modern analytic perspective, convincingly argued that since the developmental failures (parenting figures did not provide needed maturational input, creating a gap that leaves the child with developmental personality deficits) occurred before the maturation of language, preoedipal patients cannot respond to words or interpretations. Characterological change does not take place through interpretation, but through experience, "microinternalizations" of the therapist's functions as a selfobject. No further psychic growth, Ormont contends, is possible without these experiences.
Therapy from this perspective needs to be geared to preoedipal patients' developmental arrest, which leaves them with the inability to use feelings as signals and the incapacity to regulate their emotions. Developmentally arrested patients require a corrective emotional relationship to repair the deficit in their psychic structure. Therapy, from this perspective, takes on a goal very similar to that of the transformational experience that AA requires of its members if sobriety and recovery are to be achieved. Ormont (2001) writes about the importance of such a treatment approach:
Like the child, the patient has a maturational need to internalize the admiration of a nourishing figure who derives pleasure from the pursuit of mastering challenges and overcoming obstacles. The child-patient has a need to merge with the idealized parent surrogate, to share in the security, standards, and calm of the analyst. The movement is from narcissistic need to a capacity to take care of oneself. [p. 345]
THE RESTORATION OF HEALTHY SELF-ESTEEM
Healthy self-esteem is the end product of sufficient age-appropriate responsiveness and parental emotional attunement. Healthy parental role models provide the other necessary component of idealization that leads to healthy narcissism, which is basic to emotional health and consists of a subjective sense of well-being and confidence in one's self-worth. People who feel a balanced valuation of their importance and potential and can relate in mature ways to others will usually have a sense of meaning and know how they fit in the world.
In contrast to this, even though the majority of cocaine addicts and alcoholics appear to be very successful and are high achievers in their professional lives, those who work with these patients on a consistent basis are struck by how fragile their basic sense of self-worth has been. Despite their exaggerated striving for financial and intellectual success, their need for approval and acceptance leaves them consistently vulnerable to injury, rejection, shame, and humiliation. Kohut and Wolfe (1978) state:
Individuals whose nascent selves have been insufficiently responded to will use any available stimuli to create a pseudo excitement in order to ward off the painful feeling of deadness that overtake them. Adults have at their disposal an even wider armamentarium of self-stimulation--in particular, in the sexual sphere, addictive promiscuous activities and various perversions, and in the non-sexual sphere, such activities as gambling, drug and alcohol induced excitement, and a lifestyle characterized by hyper-sociability. If the analyst is able to penetrate beneath the defensive facade presented by these activities, he will invariably find depression. [p.418]
HEALTHY AND UNHEALTHY NARCISSISM
Self psychology has consistently viewed healthy narcissism or mature narcissism as reflective not of the decrease of emotional investment in one's self but of a person's inability to establish mutually satisfying relationships with others in which giving and receiving are balanced. As Ornstein (1981) writes, "When ... the self attains the capacity for becoming a relatively independent center of initiative ... it is then also capable of recognizing the relatively independent center of initiative in the other" (p. 358). In the case of healthy narcissism, the person can hold a healthy respect for his or her uniqueness while at the same time being able to be in reciprocal resonance with the unique qualities and independence of another. Such a person can give as well as take and does not need to be one-up or one-down in a relationship.
In contrast, pathological narcissism requires either the presence of an idealized other (e.g., "My worth is enhanced by your power") or a mirroring selfobject (e.g., "My worth is confirmed by your admiration of my power") in order for the afflicted individual to maintain narcissistic homeostasis. Selfobjects in both categories occupy precarious positions, prone to devaluation or contempt if they should fail to provide their required functions. True reciprocal mutuality in a relationship is usually too taxing, overwhelming the narcissist's capacity for acceptance of imperfections in self and other. Consequently, the give and take that is part of healthy mature relationships cannot be maintained.
The narcissistic individual is like the magician in the circus sideshow who is constantly employing sleight of hand as a distraction to get others to pay attention only to what he wants them to see so that they do not notice what is being hidden. Grandiosity as a defense should not be confused with grandiosity as a healthy component of psychic structure. As Bacal (1992) suggests:
Grandiosity, in my view, is not always an appropriate designation for the self state that it refers to. I believe that what Kohut meant by this term would better be separated into two ideas. The one would reflect the sense of personal conviction of one's unique importance. This would be a self-percept that presumably arises out of optimal experiences of mirroring by selfobjects. It is affectively toned in a healthy way. The other, which would be closer to the traditional notion of grandiosity, Would reflect a self-percept that is inflated beyond what the individual would normally experience. This may properly be regarded as a pathological self state; and it is associated with a disavowed sense of low self-esteem. [p. 72]
Narcissism from this perspective ceases to be a source of healthy self-respect and self-esteem and becomes a defense--a false self or grandiose self that guards against painful feelings of shame and low self-worth. As Morrison (1989) convincingly demonstrated, shame or humiliation is always the underbelly or driving force behind a narcissistic defense. AA has long recognized that the alcoholic's grandiosity or self-centeredness and lack of humility are the most important obstacles that have to be modified if sobriety is to he maintained. Using technically incorrect terms drawn from psychodynamic concepts, AA nevertheless captures the essence of the problem that must be addressed in recovery. Long before Kohut's theoretical formulations of grandiosity and narcissism, early pioneers in the treatment of alcoholism were writing of the necessity of "the surrender of the inflated ego" in an alcoholic's recovery (Tiebout 1954). Bateson (1971) wrote that the biggest obstacle to alcoholics' recovery was their reluctance to relinquish their "false pride." While the terminology may be different, the basic premise is similar. Early theorists recognized that narcissistic features such as grandiosity were a primary corollary in the addiction process.
False pride, inflated ego, and grandiosity are consequently viewed as defenses against feelings of inferiority and inadequacy. As Tiebout (1954) suggested, there has to be a reason why one has a need to inflate oneself. If an alcoholic or addict felt or believed these defenses were enough, there would be no need for inflation of self or false pride. From this perspective, if a person possessed a firm sense of self-esteem, confidence, pride, or healthy narcissism, there would be no need for grandiosity.
When individuals suffer from an absence of healthy self-esteem, they are left with an intolerable affect state often referred to as shame. Morrison (1989) writes, "The self's experience of shame is so painful that the narcissistic constrictions of perfection, grandiosity, superiority, and self-sufficiency are generated to eliminate and deny shame itself.... Shame, then, can be viewed as an inevitable feeling about the self for its narcissistic imperfection for failure, for being flawed" (p. 66).
The cycle of remorse, shame, and self-loathing that substance abusers experience the morning after a humiliating night of chemical abuse spurs them to make the false promises and vows to never let something like this happen again. Attempts at control inevitably fail, exacerbating the self-loathing and contributing to the rigidity of the defenses. Because of repeated failures, shame and remorse become intensified. Substance abusers are forced to combat the painful affect with their only available resource, namely, alcohol or drugs.
Khantzian (1994) believes that AA is corrective for the alcoholic because the program is able to penetrate the narcissistic defenses of false pride. The primary reason alcoholics suffer, according to Khantzian, is because they cannot control their drinking and they cannot control themselves. Unable to admit their vulnerabilities, they remain isolated, alone and cut off from others and themselves. What they need to do (admit their vulnerabilities to another), they cannot do because of the shame and their characterological grandiose defensive posture. AA works because once initiation into the program occurs, contact with others is sustained, and through continued interaction with others alcoholics are able to alter the dysfunctional interpersonal style that up to now has dominated their life. Khantzian explains that only through this maintenance of contact with others can the disorders of the self be repaired. He identifies the four aspects of the disordered alcoholic as (1) regulation of emotions, (2) self-esteem or a lack of healthy narcissism, (3) mutually satisfying relationships, and (4) self-care. He agrees with Kurtz (1982) and other interpreters of AA that it is shame that makes the engagement and attachment difficult, if not sometimes impossible, for many practicing alcoholics.
A NEW DEFINITION OF ADDICTION
The treatment of narcissism has many similarities to and applications for the treatment of addiction--especially if addiction is viewed as an epiphenomenon of narcissistic defenses against shame, fear, and other painful affect. Narcissism, like addiction, is a retreat into a grandiose-self or false-self personality organization as a way of avoiding the need for attachment. Addiction from this perspective is the result of unmet developmental needs, which leaves certain individuals with an injured, enfeebled, uncohesive, or fragmented self. Vulnerable individuals are unable to regulate affect and in many cases are even unable to identify what it is they feel. Unable to draw on their own internal resources because there aren't any, they remain in constant need (object hunger) of self-regulating resources provided externally "out there." Since painful, rejecting, and shaming relationships are the cause of their deficits in self, they cannot turn to others to get what they need or have never received. Deprivation of needs and object hunger leaves them with unrealistic and intolerable affects that are not only disturbing to others, but also shameful to themselves. With few other options open to them, substance abusers turn to alcohol, drugs, and other external sources of regulation (e.g., food, sex, work, gambling, etc.).
Consequently, addicted and alcoholic patients are always vulnerable to compulsive, obsessive, and addictive behavior, constantly substituting one addiction for another until the vulnerabilities in the self structure are repaired and restored. Repair and restoration of the self can be accomplished only within a healing and healthy relationship. The patient needs a consistent, nurturing, mirroring, and holding environment that can contain and manage negative, destructive impulses while giving the patient the opportunity to identify, internalize, and incorporate a healthy set of introjects and internal object representations.
However, once the psychic structure is repaired and restored, it can be maintained only if, like any living organism, it is provided with an environment where it is continually nurtured, fed, and allowed to flourish and grow That can be accomplished only if substance abusers learn how to establish and maintain healthy intimate interpersonal relationships outside the therapeutic milieu. Since relationships can also become compulsive and addictive, substance abusers need to experience themselves in relation to others to fully understand how they contribute to their difficulties within the interpersonal sphere. Until that is accomplished, the absence of continued satisfying relationships in the substance abusers' lives always leaves them with an internal feeling of emptiness and a susceptibility to search for external sources of gratification.
SELF PSYCHOLOGY AS A DEFICIT THEORY
Some may have difficulty with the generalization and the lumping of all addictions under one category. While there are many addictions and they each have their own special characteristics, all the addictions have their genesis in common endopsychic sources. An important aspect of any theory is its ability to identify and unite complex and seemingly unrelated phenomena into one simple singular truth. Self psychology and attachment theory do this. Kohut (1977) postulated that all addictions share a singularly underlying similarity: they are all misguided attempts at affect regulation and self-repair generated by inadequate psychic structure. Until psychic structure is built, the addict and alcoholic will have difficulty establishing intimate attachments and be inclined to substitute a vast array of obsessive-compulsive behaviors that serve as distractions from the gnawing emptiness that threatens to overtake them. Consequently, when one obsessive-compulsive-type behavior is given up, another is likely to be substituted unless the deficiency in self structure is corrected. Kohut stated:
Vulnerability of the self is the consequence of developmental failures and early environmental deprivation. The absence of secure attachment leads to ineffective attachment styles, which perpetuate through adulthood. Substance abuse, as a reparative attempt, exacerbates dysfunctional attachment styles because physical dependence and chemical use toxicity exacerbate the deterioration of existing physiological and psychological structures. Prolonged stress on existing structure leads to exaggerated difficulty in the regulation of affect, which leads to inadequate modulation of appropriate behavior, poor self-care, and rigidly ingrained patterns of object relatedness, which lead to increased character pathology. Kohut (1977) clarified the relationship between addiction and psychic deficits:
The explanatory power of the new psychology of the self is nowhere as evident as with regard to these four types of psychological disturbance: (1) the narcissistic personality disorders, (2) the perversions, (3) the delinquencies, and (4) the addictions. Why can these seemingly disparate conditions be examined so fruitfully with the aid of the same conceptual framework? Why can all these widely differing and even contrasting symptom pictures be comprehended when seen from the viewpoint of the psychology of the self? How, in other words, are these four conditions related to each other? What do they have in common, despite the fact that they exhibit widely differing, and even contrasting, symptomatologies? The answer to these questions is simple: in all of these disorders the afflicted individual suffers from a central weakness, from a weakness in the core of his personality. He suffers from the consequences of a defect in the self. The symptoms of these disorders, whether comparatively hazy or hidden, or whether more distinct and conspicuous, arise secondarily as an outgrowth of a defect in the self. The manifestations of these disorders become intelligible if we call to mind that they are all attempts--unsuccessful attempts, it must be stressed--to remedy the central defect in the personality. [1977, p. vii]
The calming or stimulating effect which the addict obtains from the drug is ... impermanent. Whatever the chemical nature of the substance that is employed.... No psychic structure is built, the defect in self remains. It is as if a person with a wide open gastric fistula were trying to still his hunger through eating. He may obtain pleasurable taste sensations by his frantic ingestion of food but, since the food does not enter that part of the digestive system where it is absorbed into the organism, he continues to starve. [p. viii]
SELF-MEDICATION HYPOTHESIS AND AFFECT REGULATION
Building on the early theoretical observations and formulations of Kohut (1977), Khantzian (2001) provides an alternative explanation for the addiction process that not only is compatible with the disease concept, but also expands it while providing useful and practical theoretical formulations that can enhance an addict's and alcoholic's treatment and recovery. The self-medication hypothesis has important implications for psychotherapy. It not only provides an explanation of why substance abusers have a propensity to switch addictions, it also complements the way AA and other twelve-step programs treat chemical dependency.
In his earlier work with narcotic addicts, Khantzian (1982) first recognized that opiates were the drug of choice for certain individuals because of the drug's specific pharmacological effects. Khantzian discovered that heroin addicts prize their drug for its antiaggressive effects. It helped them soothe and calm their intense feeling of rage. He eventually discovered this to be similar for other drugs that reduce anxiety, depression, or other painful affect states. Chemically dependent individuals are in a sense acting as their own uncertified physicians to fix or repair what they are missing. Consequently, Khantzian hypothesized that it isn't pleasure so much that addicts are seeking; rather, they are attempting to regulate their emotional selves and escape, even momentarily, from the constant feelings of deprivation, shame, and inadequacy that dominate their lives.
In his later work, Khantzian found that all substance abusers were predisposed to abuse or become dependent on a particular drug because they suffered a particular impairment in affect regulation. He hypothesized that addicts were drawn to a certain drug because it matched their idiosyncratic deficits in regulating specific feelings. Although most addicts have experimented with many different drugs, they learn that a particular drug has a special appeal for them because of the drug's ability to regulate troublesome affect states. For instance, narcotic addicts are drawn to opiates because of their ability to relieve states of dysphoria associated with aggression, anger, and rage. Chronic depression, bipolar illness, hyperactive syndromes, and attention deficit disorder (ADD) are symptoms highly represented in cocaine addicts. Addicts who felt bored, empty, dead inside, or that life was meaningless were frequently drawn to stimulants. Later experience showed Khantzian that counterdependent, restricted, and inhibited individuals were likely to be drawn to alcohol and sedatives. Highly anxious and fearful people suffering from chronic anxiety are prone to use the benzodiazepines and likely to become dependent on minor tranquilizers like Valium and Xanax, while the more isolated and schizoid individuals were attracted to marijuana and the hallucinogens. As Khantzian (1982) wrote, "This self-selection is related to the distinctive psychoactive actions of various drugs.... In the course of experimenting with different drugs, an individual discovers that the action of one drug over another is preferred" (p. 587).
The self-medication hypothesis has proved to have important implications for treatment even though many of its earliest assumptions have not been substantiated by later research. The recognition of the self-medicating function of abused substances helped shift the focus from a pleasure-seeking to a pain-relieving approach to understanding why alcoholics and addicts abuse substances. This shift enabled clinicians to engage in a more positive, compassionate psychotherapeutic relationship.
AFFECT REGULATION THEORY
Affect regulation theory carries with it the implication that everyone, not just addicts and alcoholics, needs selfobjects to help provide affect regulation. Certain individuals, because of genetic and environmental variables, are more vulnerable to disruption because they suffer more severe deficits in this capacity. Vulnerable individuals are more dependent on outside sources or do not have the necessary interpersonal skills to obtain regulation the way our species is genetically hardwired to get it--through other people.
Because of Kohut's and Khantzian's persuasive reasoning, affect regulation theory helped shift psychoanalytic thinking about addiction from the more classic drive or instinct theory to the relational models (Fairbairn 1952, Guntrip 1974) with its greater emphasis on adaptation, developmental arrest, and deficits in self structure. Building on the early theoretical observations of Kohut (1977), Khantzian provided an alternative explanation for the addiction process that is not only compatible with the disease concept, but also expands it while providing useful and practical theoretical formulations that can enhance the substance abuser's recovery and treatment. Attachment theory, with its emphasis on the psychobiological aspects of the attachment experience, helped legitimize many of the aspects of affect regulation theory. Both attachment theory and affect regulation theory challenged a formerly unspoken bias that dominates our culture and the mental health model: dependency is bad.
DEPENDENCY AND PATHOLOGY
Bowlby cautioned therapists about their tendency to confuse healthy attachment needs with dependency. Too often, clinicians use the term attachment to explain adult pathology (West and Sheldon-Keller 1994). A person's need for reassurance, comfort, and understanding, especially during times of distress, must not be construed as pathological or regression to immature behavior, especially when someone is threatened by loss. Many therapists are too quick to impose these views or agree with patients' self-assessment when patients admit with embarrassment that they are "too needy." These value judgments are built into the idea of dependency. They are often reflected in a therapist's appraisal, which are reinforced by a culture that equates independency with maturity and mental health. In the rush to combat the demon of dependency, patients are often retraumatized, feeling much as they did when their critical parents shamed them for seeking comfort or assurance.
To be dependent on someone is not the same as being attached. Attachment is an emotional bond that forms over time with caregiving, familiarity, and continuity. Someone can be attached and not dependent. Consequently, it is also possible to be dependent and not attached, which is what codependency is all about. As attachment theory implies, dependency not only is a confusing and pejorative term, but also reflects a strong bias in our culture toward an obsession with autonomy and independence at all costs, which is not in line with the biological realities of our species.
David had sought therapy because of complaints of depression related to a deteriorating marriage and recent job loss. An active member of AA for nearly four years, David feared his crisis at home and his difficulties finding a new job might jeopardize his recovery. A similar pattern with both his marriage and job were quickly identified. He was a bright, good-looking, energetic man who had little difficulty finding either new relationships or new employment. However, he had extreme difficulties maintaining either beyond six months. David would quickly become disappointed and critical of his boss, often perceiving him as inadequate or undependable. Similar reactions would get played out with the women in his life. Observations to this effect by his therapist were quickly rejected. Attempts to show how these patterns were related to a father who abandoned him as a child and left him in the care of a physically disabled and incompetent mother whom he could not trust to provide for his basic needs were initially dismissed as "pure coincidence." Just as progress was being made toward him developing some clarity about this pattern, he abruptly terminated therapy.
Six months later, David called back, "to meet just a couple times for a little tune-up." During the meeting, the therapist encouraged him to join a therapy group. The therapist hoped that the transference intensity related to David's fear of dependency on one person might be diluted by shifting and spreading it out to the other members of the group. David reluctantly agreed, and over the course of the next few months, he quit two more jobs because of "incompetent management." The group gradually began to confront him about his pattern. David eventually conceded that "there might be some truth to the group's observations about how I respond to my bosses."
Things proceeded smoothly in the group for a couple months. David eventually started a new relationship with a woman and shortly thereafter announced to the group that he was leaving treatment. Members' comments that he was repeating his six-month cycle were met with denial and explanations that "this is different."
A year and a half passed before David called again to schedule an appointment. He wanted to join another group. He explained proudly that he held the same job now for nearly two years and had just gotten a promotion. His new position provided him with more opportunity "to run my own show. I don't have anyone that I have to keep running things by for approval." However, his relationships with women had not improved. When encouraged that he directly deal with his dependency fears if he entered another group, David balked. "I don't want to be tied down to any commitments."
The therapist did not hear from David again. However, a year later, a close colleague confided in him that he had a former patient of his who was posing a repeated difficulty in a therapy group. Without revealing the patient's name, it was clear that David was in the process of engaging in the same counterdependent behavior he had demonstrated repeatedly with his previous therapist. The mixture of fear and repulsion that dominated David's unmet dependency needs prevented him from tolerating and benefiting from what he needed most--a healthy reliance on other people.
Critics of AA (e.g., Jones 1970, Tournier 1979) often express concern that the addict and alcoholic may become too dependent on the program, and they judge the alcoholic's reliance on AA with concern and suspiciousness. Even if one accepted the premise of this argument, isn't it preferable to have a dependence on an organization that promotes health, sobriety, and helping others rather than a drug that promotes sickness, death, and immeasurable suffering to oneself, one's family, and society? For some reason, many professionals fail to understand how their devotion to their church, tennis club, or professional organization is any less dependent than an AA member's devotion to AA. Weinberg (1975) expresses a similar sentiment:
Even if one accepted the premise (which to be consistent would also seem to rule out devotion to an organized religion or to psychiatric cults such as psychoanalysis), the author is hard pressed to consider this argument as reasonable. Since one cannot deny that alcohol dependency is extremely harmful to the individual, his family, and society, whereas AA dependency means sobriety, stability, and helping others as a result of living the program, what is the alleged harm in substituting the latter for the former? [p. 34]
AA members are in fact told, "You did not get sober just so you could go to AA meetings for the rest of your life." Dependency is actually discouraged in the program. What often gets passed off as dependency by AA's critics is actually the alcoholic's investment of himself in relationships within the AA fellowship. Often, this is the first time that the AA member has engaged in any type of meaningful human contact while not drinking or being intoxicated. Weinberg (1975) stresses the importance of this involvement:
The close ties to an accepting group of peers which are generated over time may serve as a powerful incentive to resist the first drink and avoid facing loss of esteem in the group. Finally, AA groups frequently sponsor social events--picnics, dances, etc.--which help foster group involvement and also provide the alcoholic with an atmosphere which combines fun with sobriety, a combination often unknown to him for many years if at all in his adult life. It is of great importance to learn or relearn such an association, because there is little incentive in staying sober if one cannot have any fun in life without drinking. [p. 42]
It is unfortunate that so many professionals view it as a negative turn of events. A common suggestion is to get the addict or alcoholic to face the world as it really is. In contrast to the accusations that suggest that AA fosters pathological dependency by substituting one dependency for another is the consideration that the emergence of such dependent behavior actually signals an important change in a positive direction. It is fortunate that alcoholics become hooked on the people in the AA program. Such an occurrence is often the first evidence of alcoholics' ability to engage in one-to-one relationships, which allows them to accept their need for help and to find new people with whom they can identify. This process takes time. If this process is not interrupted, the addicted individual will eventually develop a healthy capacity for mutuality and secure attachment.
Closely related to this principle of healthy dependence on others is the maturation of narcissistic needs for selfobjects and affect regulation. Kohut differentiated between archaic needs for selfobjects (which is a reparative process that involves the building of psychic structure) and mature needs for selfobject responsiveness (which involves the mutual regulatory process that goes on between two healthy individuals who provide the type of regulation that keeps each other functioning at an optimal level). Early in recovery, alcoholics and addicts typically need archaic selfobjects. Their reliance on the excessive use of grandiose defenses is intertwined within the fabric of values expressed by the drug and alcohol subculture. Recovery and abstinence interfere with the narcissistic fixations of their chemical-using lifestyle. Treatment works best when it provides a course for recovery that facilitates the maturation of healthy narcissism. Sometimes this may require that the individual develop an idealized attachment to the program.
An idealized attachment to a program allows an individual's narcissistic needs to be met in a healthy fashion. It can be a reparative experience if the substance abuser internalizes the admired values expressed in the philosophy of the program. Since AA's values are often enthusiastically held by its members, they represent a direct confrontation with the tenets held by the drug and alcohol subcultures. By idealizing the values of the AA program, alcoholics and addicts not only become less enamored with drinking and drug use, but also develop a healthy dependence on those they idealize. Since these new objects of admiration are more dependable and far more empathic than their previous drinking or drug-using friends and earlier parental figures, alcoholics and addicts are more willing to risk relying on another human being. It is within this climate that a sense of hope can be generated, a beginning faith that personal change is possible, that with the help of new objects for identification a more adaptive patterning of relationships can emerge.
SELFOBJECT TRANSFERENCES: IMPLICATIONS FOR TREATMENT
As a result of insufficient selfobject responsiveness, the substance abuser lacks self-worth and suffers from chronic feelings of poor self-esteem and shame. It is within the matrix of environmental responsiveness and emotional attunement that a specific process of psychological structure formation develops. Structure building cannot occur without a previous stage in which the child's mirroring, twinship, and idealizing needs have been responded to efficiently. Structure is laid as the consequence of minor, nontraumatic failures in the responses of empathic selfobjects. Specifically, structure is built when the ruptured bonds between the self and the person providing selfobject functions is restored (Harwood 1998). Resolving disagreements in an ideal atmosphere of optimal frustration permits the self to gradually internalize the functions previously provided by the selfobject. Optimal frustration reflects the ideal environmental situation within which these minor, nontraumatic failures occur.
Empathic failures, within the context of optimal frustration, lead to a gradual replacement of the selfobject functions by the individual's developing capacity to soothe and calm oneself. Kohut called this process transmuting internalization. If affect regulation and self-soothing are internalized, the person will be less dependent on external sources for gratification. The more the holding environment provides opportunities for empathic failures to be worked through and repaired, the greater the frequency that ruptured bonds with the caregiver will be reestablished, and subsequently the stronger the structure formation will be (Beebe, 1993).
Dorothy was sober for more than two years and active in AA when her female therapist referred her to a mixed group of men and women to give her an opportunity to work on her issues with men. The only daughter in a family of four sons and a father who was a major in the Air Force, Dorothy was the constant recipient of ridicule and mockery. Since the therapy group was co-led by a man and a woman, Dorothy was able to align herself with the women in the group and use them as a buffer as she dealt with her male siblings in the group. However, her biggest challenge came from her dealings with the male leader in the group. Any failures, imagined or real, on his part to defend or understand her were met with emotional storms of protest and outrage. With the group, and especially the women, serving as a bulwark against overwhelming fears of retaliation, Dorothy received the encouragement and support she required in order to work through all injuries as they occurred. With the male therapist's consistent patience, each repair allowed psychic structure to be established, providing her with a greater capacity not only to stand up for herself, but also to tolerate shortcomings in men without viciously attacking them.
Psychic structure, from a self psychology perspective, is not an entity or an agent, but a capacity, indicating a class of psychological functions pertaining to the maintenance, restoration, and consolidation of self-experience. Psychic or self structure represents the capacity or ability to integrate and organize fragmenting affect into meaningful experience. Structure formation--the acquisition of patterns and meaning--is developed out of the internalization of functions previously provided by external objects and reflects the ability to take over these functions without relying excessively on selfobjects. The deficits in psychic or self structure that require external augmentation are usually the result of developmental failures related to unmet age-appropriate attachment needs. Conversely, the successful formation and establishment of self structure is a developmental outcome reflecting the capacity for affect regulation.
In treatment, optimal frustration should not be confused with deliberate attempts on the therapist's part to frustrate the patient. Frustration naturally occurs in any genuine ongoing relationship. Optimal refers to the climate established in the holding environment that most favorably allows for the reestablishment of ruptured bonds in an atmosphere of optimal responsiveness. If a proper treatment environment is created, structure formation will be the natural by-product of the spontaneous interactions that occur within the therapy relationship.
PARALLELS BETWEEN PSYCHIC STRUCTURE
AND INTERNAL WORKING MODELS
There exists a complementary relationship between Kohut's definition of psychic structure and Bowlby's internal working model. Following Kohut's work on selfobject transferences, substance abusers are viewed as having been deprived of the opportunity to adequately internalize the admiring, encouraging, valued, and idealized qualities of good-enough parental figures. Absence of this experience inhibits further developmental growth, interfering with the gradual internalization of the selfobject function. Until these capacities become internalized, vulnerable individuals--through the force of the repetition compulsion--will continue to re-create their past in the present. Attachments to external bad objects (e.g., a cold and critical mother, drugs, alcohol, etc.) in the external world are extremely difficult to relinquish until internalized object and self representations are worked through or modified. Ogden (1983) states:
Resistance is understood in terms of the difficulty the patient has in giving up the pathological attachments involved in his unconscious internal object relations.... This tie is based on one's need to change the bad object into the kind of person one wishes the object were.... The second category of the bond to a bad internal object ... takes the form of a crusade to expose the unfairness of, coldness of, or other forms of wrong doing on the part of the internal object. [p. 236]
The attachment to the tantalizing, internalized, split-off, good object and self representations is the collected bond that fuels the addictive process. The needy but undeserving good self representation is a bottomless pit that can never be satisfied, and the tantalizing good object can never fulfill its promise of perfect love, acceptance, and complete nurturance without any limits or disappointments. The overindulgent, overgratifying, and inconsistent mother can be as damaging to the child's development as the cold, critical, and rejecting mother. In the former case, frustration tolerance is never internalized and impulse control is never mastered. Ogden states, "One type of tie to a bad internal object is the attachment of the craving self to the tantalizing object. The nature of the tie to the object is that of the addict for the addicting agent and is extremely difficult to relinquish" (p. 236).
Disturbances in attachment during the formative years of development increase the potential for psychopathology and establish an internal working model that impacts future attachment styles. In a similar fashion, attachment-oriented therapy can be defined as a way of eliciting, exploring, integrating, and modifying internal working models. It is helpful to think of all interpersonal interactions as operating on two levels. There are the observable interchanges occurring between individuals in the external world, and the internal exchanges of self and object representations occurring within each person's internal working model. Each level of interaction influences the other. Just as a person's external behavior is modified by interactions with others, adaptations in internal self and object representations are also occurring. This approach to treatment operates on the principle that internal structural change is necessary if external behavioral change is to be long-lasting and something other than compliance.
LIFELONG NEED FOR SELFOBJECTS AND AFFECT REGULATION
Bowlby (1979) saw the need for healthy relationships that provided mutual affect regulation as an integral part of human behavior "from the cradle to the grave." Kohut agreed, and said that we never outgrow our need for selfobjects, and that therapy is only complete when the person can form healthy attachments outside of the therapeutic milieu. Another very important aspect of attachment theory and self psychology is their compatibility with AA. Each perspective defines addiction as failed attempts to regulate affect and repair deficits in psychic structure. Developmental failures leave the vulnerable individual with an inadequate capacity to form intimate attachments, leading alcoholics and addicts to substitute things and substances for people. Both theories view the disease concept as a metaphor and provide alternative explanations for why AA works and why abstinence is required. However, as attachment theory reminds us, regardless of our age or emotional development, we will always require some degree of emotional regulation from others. The denial of the need for others is what leads individuals to seek gratification (e.g., drugs, alcohol, food, sex, work, gambling, etc.) outside the realm of interpersonal relationships.
AA AND NARCISSISM
Viewing addiction as a disorder of the self and narcissistic phenomena as the problematic expression of the need for selfobject responsiveness helps provide an alternative explanation for why AA and other twelve-step programs work as they do for the chemically dependent individual. Self psychologists hold many basic tenets that they believe are essential if narcissistic disturbances are to be repaired. Kohut viewed the narcissistic disorder as the expression of a reaction to injury of the self, and regarded the experience of the bond between the self and the selfobject to be crucial for psychological health and growth. Kohut is implying that there is an inverse relationship between individuals' early experience of positive selfobject responsiveness and their propensity to turn to alcohol, drugs, and other sources of gratification as substitutes for these missing or damaging relationships. Conversely, if they are to successfully give up these misguided attempts at self-repair, they must learn how to substitute healthy interpersonal relationships in which needs for selfobject responsiveness (mirroring, merger, and idealization) are satisfied in a gradual, gratifying way.
AA and other twelve-step programs accomplish this in a number of ways. First and foremost, AA provides a predictable and consistent holding environment that allows addicts and alcoholics to have their selfobject needs met in a way that is not exploitive, destructive, or shameful. Because of unmet development needs, addicts or alcoholics have such strong and overpowering needs (object hunger) for human responsiveness that they feel insatiable and shamed by their neediness. Through their identification with other alcoholics and addicts, they come to accept in themselves what they could not previously because they believed their badness was unique.
This principle was brought home clearly one day at a conference led by John Bradshaw, the noted author, lecturer, ordained Protestant minister, and self-proclaimed recovering alcoholic. Bradshaw was speaking on one of his favorite topics--toxic shame--when he told the audience about his personal experience when he first entered AA. "My alcoholism had gotten so bad that I was forced by the shear humiliation of my situation to attend an AA meeting. Halfway through the meeting I was so overwhelmed by the shame that my drinking had caused in my life that I was compelled to stand up and tell everyone all the horrible things I had done in the last few years of my drinking. I must have carried on for over fifteen minutes with an outpouring of every despicable, disgraceful act that I could remember that I had committed while under the influence of alcohol. When I stopped talking and forced myself to look around at the faces in the room, I expected to see people pulling away in disgust."
Imagine Bradshaw's surprise when the other alcoholics in the room did not reject him like his congregation did or abandon him as his church had done when they discovered all those horrible truths about him. "Instead," Bradshaw announced, "of running away from me in repulsion, everyone ran toward me, gave me their phone numbers, and told me to call them anytime I needed to."
Addicts or alcoholics can only tolerate acceptance at this level of emotional vulnerability because they feel understood on a very basic, empathic level. Empathy and emotional attunement are not only the cornerstone of treatment for self psychology, they are also the foundation from which chemically dependent individuals can begin to feel the kind of responsiveness and gratification they had been missing and were previously unable to tolerate in their lives.
As Kurtz (1979) has eloquently argued in his book, Not God, alcoholics must come to terms with their narcissistic defenses and quit playing God:
"Not-God" means first "You are not God," the message of the AA program.... The fundamental and first message of Alcoholics Anonymous to its members is that they are not infinite, not absolute, not God. Every alcoholic's problem had first been, according to this insight, claiming God-like powers, especially that of control. But the alcoholic at least, the message insists, is not in control, even of himself: and the first step towards recovery from alcoholism must be the admission and acceptance of this fact that is so blatantly obvious to others but so tenaciously denied by the obsessive-compulsive drinker. [p.42]
Kurtz says it's the alcoholic's denial of his need for people that leads to his eventual denial that he's an alcoholic. Consequently, recovery is dictated by reversing this process. First, the alcoholic must admit that he is an alcoholic and then he must ultimately admit he needs people. In an existential sense, the confrontation between what substance abusers tried to be and what they really are (not God) results in their ceasing to live their life in bad faith (i.e., alcoholic) and become more authentic ("Hello, I'm Joe, a recovering alcoholic"), with all the limitations that authentic life imposes on them. As archaic ways of getting one's needs met are gradually relinquished for more mature ways of establishing close human contact (removal of character defect by working the program), the alcoholic or addict is able to internalize more self-care and monitoring of affective states (transmuting internalization). The central issue in this process is the acceptance of one's self as one is, which requires dealing with shame about the self that was previously hidden.
AA, as a holding environment, also becomes a transitional object; a healthy dependency that provides enough separation to prevent depending too much on any single person until individuation and internalization are established. Gradually, alcoholics or addicts are able to give up the grandiose defenses (narcissism) and false-self persona for a discovery of self (true self). As David Treadway (1990) points out, the self-help movement is, regardless of its successes or failures, driven by people's attempts to regain the "lost spirit of community."