Cohen, Peter (1990), Is heroin dependence pathological?. In: Peter Cohen (1990), Drugs as a social construct. Dissertation. Amsterdam, Universiteit van Amsterdam. pp. 32-43.
© Copyright 1990 Peter Cohen. All rights reserved.

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IV. Is heroin dependence pathological?[1]

Peter Cohen

Table of contents

IV.1 Critique of a psychological a-priori

The psychological a-priori in scientific discussions of addiction to heroin, as well as addiction to other substances, consists of two separate assumptions:

  1. that becoming addicted is best described as a psychological process within a particular individual, and that such a description can also serve as the basis for its explanation;
  2. that addiction is a psychopathological phenomenon within an individual which necessitates change and that the description in psychological terms serves as the basis for a therapeutic intervention.
Logically, 1 and 2 do not go together. But in everyday practice they are inseparable. In this article, which deals mainly with heroin addiction, both are taken as equally important. However, from the addict's point of view and certainly in our own dealings with the so called heroin problem, the idea that every regular heroin user, let alone every addict, is a pathological case is especially important. Several 'theories' are used to label addictions as a pathological aberration. I will indicate four of them, but undoubtedly more could be found in the vast literature on this subject.

A. Addiction is pathological because addictive behaviour reflects a developmental disorder.

Within psychoanalysis this vision is paramount. Addictions are either based on an oral fixation1 or on an anal one, or even on both.2 In this reasoning the actual addiction is a regression which has to be dealt with by removing the regression. This idea has remained almost undisputed within psychoanalysis even though it has long been known that addiction is extremely hard to 'cure' by psycho analytical methods.

B. Addiction is pathological "because it is characterized by an abnormally high intensity of craving for satisfaction and by a strikingly low susceptibility for modification of the need for that satisfaction."3

This way of describing addiction makes quantity rather than quality the basis of the pathology. One might remark here, that this type of description could easily encompass many behaviours which we do not normally consider pathological (for example, ambition, sex or the need for company).

C. Addiction is pathological because of the function it fulfils within some pathological syndrome.

For instance Kuiper says that not only affective problems, but also other illnesses can lead to addiction. Thus for Kuiper emotional inhibitions can provide the motivation underlying addiction to disinhibitors like alcohol or stimulants; depression or dysphoria can give rise to addiction to alcohol or opiates; anxiety can lead to addiction to alcohol, opiates or hypnotics; and tension, depersonalization and derealization can result in addiction to substances that counteract these affects. Chronic depersonalization and emotional emptiness give rise to chronic use of cannabis.5,6 Here the addiction is functional within a pathology, and thereby becomes pathological itself. It is a secondary pathology.7

Authors like Mijolla and Shentoub8 fall into this category. For them addiction is a symptom of the impossibility of enacting satisfactory object relations. The addictive substance replaces the human object, and the relation to the substance replaces a relation to the human object.

D. Although the following theory of the pathology of addiction is similar to that given by Mijolla and Shentoub, I present it separately because of its rigour. For Kohut, some cases of addiction occur because people do not have sufficient psychological structure "to soothe themselves or to go to sleep".9 Later he states, in a generalizing context, that "the addict craves the drug because the drug seems to be capable of curing the central defect in his self".10

This looks like pathology in extremis. Kohut's view could also have been considered under the first heading, in which addiction is seen as a developmental disorder.

This short and certainly incomplete excursion through the theories which define addiction as pathological behaviour on the basis of a psychological understanding of the phenomenon, leaves us with a strong sense of disquiet. If we are to believe the quoted authors, there is a lot wrong with addicted people.

But strangely enough, authors can be found who describe addiction as pathological without linking it to specific qualitative or quantitative characteristics. I should mention Van Dijk, who concludes with regard to alcohol addiction, that "for the person who gets addicted there is no indication whatsoever of specific personality characteristics".11,12 The American investigator Craig has enriched the literature with a thorough review of all empirical studies of personality characteristics of heroin dependents.13,14,15 He concludes that there is pathology, but not a specific one, and that particular personality characteristics of heroin dependents cannot be found. We might be tempted to react to all this with a very modern conclusion. In the current climate, with its preference for multi-causality, multi-functionality and even for multi-disciplinary research we have to accept that different psychological theories may apply when analysing or treating a case of addiction. I do not support this conclusion, because it leaves veiled the a-priori I mentioned at the beginning of this article.

At this point I would like to turn for a moment to a completely different so-called problem area, homosexuality. In the Netherlands we have almost completely passed out a period when we considered homosexuality to be a mental disorder, a psychopathological state. A great variety of theories and scientists were preoccupied during this period with the 'problem' of homosexuality, without ever being able to reach a more or less homogeneous view of its causes or its treatment. But nevertheless, homosexuality was by common consent seen as a pathological disorder, either moral or mental, and mostly as both.

This point of view has changed considerably. In fact, as homosexuality has reached a level of social acceptance and integration, so the matter has been dropped. As a result, its earlier problematic content -- translated into a scientific problem -- has petered out.

During certain periods psychologists and psychiatrists seem to make observations and design theories about assumed pathological phenomena, in which they probably do little more than provide scientific rationalisations for social conventions. What is the plausibility of the hypothesis that our present theorizing in relation to addiction (in particular heroin addiction) takes as point of departure the a-priori which we have seen in the case of homosexuality?

"Impossible," -- a therapist will remark -- "in my own work I have seen addicts who are as mad as a hatter. I really cannot see such people as constructions of my phantasies nor myself as promulgating invisible social prejudices. These people cry for help. So I need adequate psychological theory on which to base my therapies".

Our imagined therapist is right. Some addicts show incontestable pathology. I want to ask two questions here.

  1. How often does this occur? Or, in other words, how representative are heavily disturbed people (psychotic or prepsychotic) of the total population of drug dependents?
  2. Can we find a theory, maybe even for psychotic drug users but certainly for the mass of drug users or misusers, which does not explain drug use or misuse primarily in terms of psychopathological processes?
For an answer to the first question I will refer not only to empirical research, but also to practical experience. At the time of writing (June 1983) the local government of Amsterdam is considering the enabling of the Health Authority to maintain a small group of addicts on prescriptions of morphine. For the members of this group a completely new word has been coined: EPD. This stands for Extra Problematic Drug-user. In a recent unpublished report by the Health Authority the size of this group was estimated to be 120 people. An EPD is characterized by severe psychiatric disorder with concurrent physical and social neglect. We may assume that the other heroin dependents in Amsterdam (about 8000[2]) do not belong to the EPD-group. This assumption is consistent with what is generally accepted in the literature about (the range of) the proportion of heavily disturbed people among drug dependents.16 But let us for a moment broaden our concept of pathological dependence to include all people we call junkies. They are the more conspicuous of heroin users, and in Amsterdam they are estimated to number 1200. Junkies are defined by their full time involvement in obtaining their prefered drug and if this is not available in finding a substitute.

Not all of them look badly neglected, not least because many shoplifters, chequeforgers, and in particular prostitutes, cannot afford this.

For an answer to the second question I will turn to the work of Norman Zinberg, an American analyst and psychiatrist. Zinberg tries to show how we construct the pathological and individual psychic source of junkie behaviour. He is not soft in his description of junkies who "look a lot alike: they are usually thin, their clothing shabby and their person somewhat unkempt. Initial conversations reveal their almost total preoccupation with heroin or its replacements and the life-style that surrounds its compulsive use".17

Furthermore they demonstrate a clear negative identity, they naively believe in all kinds of magical processes, they are paranoic and their deterioration of super-ego functions is dramatic. If something goes wrong, others are guilty. They cannot reason logically and their memory is bad.

This is not minimal. But still Zinberg does not stop. He adds that their "everyday psychological state seems compatible with a diagnosis of borderline schizophrenia or worse".

According to Zinberg, it follows that for a psychologist or a psychiatrist it is very attractive to use all these observations to construct psychological explanations of drug dependence. That is, explanations in which drug dependence is seen as being grounded in psychic characteristics which are evidently pathological and -- this is essential -- which were already present in the pre-morbid person before he got drug dependent.

But Zinberg is not convinced. He asks what evidence we have that the personality state in which these drug dependents present themselves to us, has anything to do with the psychic structure of the person before the onset of his drug dependency. According to him no such evidence is available and he finds it unacceptable to 'explain' the mental characteristics of heroin dependents by means of postulated unsolved mental problems which predated the addiction. This is a type of explanations he calls "retrospective falsification".

Let us go back to Craig now. He concludes his review on the literature about personality characteristics of heroin dependents with many research recommendations. Craig's conclusion, that "it is impossible to ascertain if traits found in heroin addicts, predated addiction or were the result of it" brings him to recommend longitudinal studies that will answer this question.l0a Elsewhere he states that "we are in desperate need for longitudinal studies concerning changes in personality over time".l0c Craig does not move away from the psychological a-priori, although I consider the massive lack of evidence for a psychological explanation of heroin dependence the most essential part of his findings.

Stanley Einstein has worded his doubts about the psychological a-priori in the following way: "What are the implications of relating to a dynamic living person -- a drug user -- from the theoretical perspective of a closed system stereotype?"

In addition he states that we see the drug user as somebody who "differs significantly from us and others in our life space in a negative sense", a view he calls the theoretical dehumanization of the drug user.18

One could justly interpret these words as a combined criticism on both the psychological a-priori and the social conventions behind it. But in this case the argument is not elaborated.

IV.2 Social determinants of addict behaviour

Now we do have a problem. When we agree with Zinberg and Craig, and accept that at least we make a highly unfounded judgement on the pathological content of something within an individual that makes him into a drug addict, how then can we explain the modes of behaviour we so often see in heroin dependent people.

And if it were true that the strikingly uniform ways in which junkies appear to us are not to be connected to a set of definite personality traits, do we have to leave the realm of psychology altogether in our search for explanations?

To deal with these questions I would like to return to Zinberg and in addition introduce some criminological notions as expressed by Leuw.

Zinberg's response to the problem he himself helped to create is worded in both psychoanalytic and sociological terms. His opinion is that the social situation in which heroin users find themselves after a period of regular use creates a condition which he defines as stimulus-deprivation.

Because of severe disapproval and in many cases rejection by parents, wider family and long standing social contacts, heroin addicts increasingly lose essential sources of stimuli. It is precisely these stimuli which enable a person to maintain a measure of continuity and structure as a person. Referring to Rapaport, Zinberg assumes that the relative ego autonomy in relation to the Id and the environment is harmed or disturbed by this deprivation of social stimuli. Out of that condition emerges the process of 'junkieization' of heroin users. Junkie behaviour is not seen as arising from pathological traits within a pre-morbid person but from strong environmental forces which exclude people from standard forms of social relations by labeling them as extremely deviant or even dangerous. This might be compared to banishment to a public Siberia. Few could remain "normal" under such circumstances. I could even add here that a high degree of "normality" has to be assumed in order to account for sensitivity to stimulus deprivation.

Zinberg's reasoning does not leave the domain of psychology at all, but it does end the primacy of psychological theory when trying to explain junkie behaviour.

And now Leuw. He published a clear and outstanding analysis of the social construction of the so-called heroin problem, but it is outside the scope of this article to summarize it adequately. I will draw only on a few details that supplement Zinberg's view.

Leuw adopts much of the criminological theory of stigmatization, in which a distinction is made between primary and secondary deviance.

In the case of heroin use primary deviance consists of consuming a substance that is socially seen as devilishly dangerous. Although it is quite possible to use heroin inconspicuously in a perfectly integrated life style, primary deviance almost always develops into a secondary one. For a host of reasons primary deviance creates repressive or rejective social reactions. The expulsion of the heroin user and his concurrent social retreat instigates the process of secondary deviance. In this process deviance becomes the "all defining characteristic of somebody", "for himself as well as for his surroundings"19

Also for Leuw it is social rejection that not only diminishes the range of adaptive behaviour but also seems to be a strong determinant of its content.

The difference between Zinberg and Leuw lies in the greater psychological detail which Zinberg uses, but for both it is neither the substance heroin nor the assumed psychological disorder within individuals that explain junkie-behaviour. For both, the explanation has to be found in a complex interaction between a person and several levels of the environment. A completed process of junkieization results in a heroin user who lives at the margIn of society, driven there by his friends, his parents, the police, social assistance or whatever. The heroin-using culture is the only environment where he is allowed to function. "The moral rejection and the (legal) repression did not only ban him from 'normal' society, they also convicted him to live in a psychologically very destructive milieu".14

In summary, we have seen that psychology or psychiatry offer a great many explanations of addiction. The supply is so large that almost any part of human development, of emotions and the pathology thereof can be causily connected to the emergence of addiction. Little wonder that empirical research cannot support an assumption that specific personality traits can be made to explain heroin addiction any more than was the case with alcohol addiction.8

We may quietly consider it plausible that in a great many cases of addiction, psychology by itself lacks the competence to explain them. Denial of this involves what I have called a psychological a priori. The means by which this a-priori is usually maintained was given the name of "retrospective falsification" by Zinberg. Of course psychology must play a role in a theory of addiction and addict behaviour, and so must psychopathology. But neither can play more than an auxiliary role within the broader social scientific theory of the addictions.

What conclusions should psychiatrists and psychologists draw from these arguments?

I hold the view that both groups of professionals are functional in preserving some of the important social factors that together cause the extreme rejection of heroin dependence. Note that I do not say that these professionals create this reality or the dependents by their strong labeling actions. This would be a naive and even nonsensical view because the social factors that uphold the rejection of heroin use are many. The view that regular heroin use or heroin dependence is pathological is one of these factors and may have the function of creating an ideological foundation of quasi-scientific status. However, even without this foundation social rejection would occur, probably because it has very important societal functions. I have discussed these elsewhere.20

I do see, however, a role for the psychotherapeutically busy in the political process of changing the present misery of heroin use. I will discuss this later on in this article. Now I want to go back to the authors and their definitions of the pathology of heroin dependence to which I referred in the beginning. How can we fit their observations into a broader social scientific view of addict behaviour?

Those who see substance dependence solely as a developmental disorder cannot be very useful for such a theory. But those who look upon addiction as a quantitative aberration are already closer to a contribution.

One might reason that the 'abnormality' of the intensity which is hypothesized in the craving for drugs does not necessarily have a disruptive function in the social development of a person. This is valid even for heroin dependency under present conditions of severe illegality. The intensity in itself could be without social (and thus personal) consequences if the drug user could keep his use secret, or contain the secrecy within a circle of trustees and if the user were able to prevent his conscience from fulfilling the role of an external rejecting agent.

But for many heroin users these preconditions do not exist. The financial burden of obtaining the illegal substance gives them away, and the consequences of being socially known as a user of forbidden substance take their inevitable toll. Subsequently, the pharmaceutical and subcultural consequences of substance use become dominant in such a way that substance dependence as a normal adaptation is hidden from view. In Mulder's words. this dominance becomes the "abnormal intensity" of the need for satisfaction.

An additional problem is that current social judgement of heroin use are in part shared by most heroin users themselves, belonging as they do to the same dominant value system. The pain associated with this self-rejection adds to the intensity which, according to Mulder, is abnormal. This might explain the higher than average suicide rate found amongst heroin users, as was the case with homosexuals at the height of their persecution.21

This way of reasoning can also be applied to the evaluation of the psychological theory which looks upon addiction as a defense against very intense affects or the lack of them. Depression, depersonalization, great fury, apathy, emptiness: as adaptations to the many stages of a career into a social outcast they are not so strange. One could even empathize with them. This is also valid for the reported feeling of not being a person or in Kohut's words, a lack of psychic structure or self. I do not want to be misunderstood to be holding the view that these affects or states always develop after the onset of forbidden substance use. We should be fully aware, however, that what we call "pathological" emotions can have principally different etiologies. When we find them in heroin dependent people, the incidence of these emotional states alone is insufficient to locate their etiology in mental processes dating from before the consequences of illegal heroin use became operational.

The observations of these affect-theoreticians have remained useful. However, the theoretical framework in which they can find a place has changed. Where we should seek the explanation of addict behaviour is not the individual in which some pathological process has taken place, but in a polymorphic social interaction between a rejecting environment and a person who happens to like an illegal substance very much.

For normal people it is this interaction which is pathogenic and which gives rise to the heroin addiction problem as we know it now.

What I am saying, in essence is that the run-of-the-mill junkie has some characteristics which could be described as pathological, but which are better described as enforced emotional adaptations of normal persons. Extraordinary psychic pathology does exist in some heroin dependent people, but to use this picture as a generalization for all heroin users or addicts is very bad science.

However, this way of reasoning does not explain why some people get addicted and some do not. This is indeed a challenge created by rejecting the psychological a priori.

IV.3 Subculture

In their essay on possible causal relationships between psychopathological processes and non-medical drug use, Schuster, Renault, and Blaine argue that there is no reason to assume that the use of opiates cannot be normal human behaviour. Their problem is to explain why in our cultures it is seen as abnormal. They suggest that social factors transform opiate use into an exception, and they recommend research to clarify these factors and their operation.22

One could ask, agreeing with Schuster et al. how it is possible that the social factors of which they speak are in a great many cases, mitigated or neutralized. Fortunately "becoming deviant" is a research topic in criminology. Matza even looks into the concept of pathology in this context.23

The concept of subculture is of central importance here. In his study "Drug use and Subculture" Cohen shows how subcultural influences ease the emergence of behaviour which is looked upon as deviant or even criminal by others outside the subculture.24 The drug scene provides participants with a different selfconcept, different ideology, ways of defensive communication, warning systems against invasions of the subcultural sphere, rituals, forms of magic and last but not least, with attractive new personal relations.

Clearly the emergence of subcultures explains much concerning why some people get addicted and others not. Matters like proximity are vital here, and possibly chance plays some role.

More important, the emergence of subcultures is not arbitrary. Subcultures are specific reactions to broad social developments that sensitize either one -or an other social substratum into creating them or being attracted to them.

At the present moment opiate use is clearly bound up with specific youth subcultures, in contrast to the opiate use of some 60 years ago when it was called the illness of the better classes.25,26 The similarity in primary deviance between such completely different groups is in itself a very interesting theme.

But the challenge of explaining why some people get addicted and others not, although all belong to the same social strata, may not be completely met by the concepts of deviance and subculture. It is worthwhile focussing research on this problem, without falling back upon the psychological a-priori.

IV.4 Conclusion

The habit of psychologists and psychiatrists of connecting use and misuse of drugs primarily to psychopathological processes in individuals helps to maintain the present heroin problem. This may be sad, but the consistent failure of the greater part of therapeutic work with drug addicts and the history of our drug policy allow no other conclusion.

The real help that these professional groups could give to heroin dependents is to cease every intervention that confirms the drug addict in his role of social outcast and failure. Therapists have to make a conceptual and ideological 'volte face' by accepting the drug dependency of a person.

This actually implies their leaving the field of the drug-issue altogether but for the time being this is not very likely. But as long as they are involved in drug problems, they should help addicts to function in spite of social rejection, by supplying drugs in a pure form, and by encouraging the emergence of better regulated ways to consume them. The goal is not abstinence, but amelioration of the social position of the drug addict as much as possible. A consequence of this might be that a body of generally accepted rules emerges for dealing with opiates, as is already the case regarding the way we deal with alcohol. According to Hunt and Zinberg, these rules play an essential part in the (self) regulation of drug use.27 Maybe it will eventually be possible to make a contribution towards changing the relationship between users and non users of opiates so that the pathogenic interaction between these two groups becomes less oppressive, and thereby less risky for both. I strongly oppose the use of psychotherapy in the bulk of drug dependence cases, even if the addict himself asks for it because of his addiction. For, is psychotherapy here not the quasi-scientific treatment of the suffering from social prejudice, a prejudice the addict himself has not been able to escape, alas?

References chapter IV

  1. Fenichel, 0.: Impulse neuroses and addictions, in Fenichel, 0.: The psycho-analytic theory of neurosis. London 1946, page 369
  2. Glover, E.: Alcoholism and drug addiction, in Glover, E.:The technique of psychoanalysis, N. Y. 1963, page 215
  3. Mulder, W.: Een probleem van lichaam en geest, in: Verslaving, Cahier van de stichting Bio-wetenschappen enMaatschappij, Dec. 1976, page 11
  4. Idem, Verslaving, Amsterdam 1969, page 132
  5. Kuiper, P.: Hoofdsom der psychiatrie, Utrecht 1979, page 326-330
  6. Idem, Neurosenleer, Deventer 1978, page 206-207
  7. Wurmser, L.: Mr. Pecksniff's Horse? Psychodynamics in compulsive drug-abuse. In: Blaine, J. and Demetrios, J. eds.: Psychodynamics of drug-dependence. NIDA research Monograph 12, 1977, page 38 ff
  8. De Mijolla, A. et Shentoub, S.: Répères theoriques et place de l'alcoholisme dans l'oeuvre de S. Freud. In:Revue Francaise de Pychoanalyse, 1972 (1), page 43-83
  9. Kohut, H.: Introspection, empathy and psychoanalysis (1959) In: Ornstein, P. The search for the self, selected writings of Heinz Kohut: 1950-1978. N. Y. 1978, pages 224-225
  10. Idem page 846
  11. Dijk, W. van, Alcoholisme, een veelzijdig verschijnsel. In: TADP, maart 1976, page 28
  12. Geerlings, P. en Wolters, E.: Verslaving, een handboek voor arts en hulpverlener. Utrecht 1980, page 20-21
  13. Craig, R.: Personality Characteristics of Heroin Addicts: A review of the empirical literature with Critique. Part 1. International Journal of the Addictions, 1979, 14 (4), pages 513-532
  14. Idem. Part 2. Int. Journal of the Addictions, 1979, 14(5) pages 607-626
  15. Idem. Personality Characteristics of heroin Addicts: Review of Empirical Research 1976-1979. In: The international Journal of the Addictions, 1982, 17(2), pages 227-248
  16. Cf. the review by Khantzian, E. and Treece, C.: Heroin Addictions -- The diagnostic Dilemma for Psychiatry. In: Pickens, R. and Heston, L. eds.: Psychiatric Factors in Drug Abuse, N. Y. 1979, page 28
  17. Zinberg, N.: Addiction and Ego-function. In: The p. a. study of the child, 30, 1979
  18. Einstein, S.: Editorial, International Journal of the Addictions 1981, 16(4), pages iii/iv
  19. Leuw, E.: Een criminologische visie op deviant druggebruik. In: Goos, C. en Wal, H. van der, eds.: Druggebruiken, verslaving en hulpverlening, Alphen 1981, pages 77-106
  20. Cohen, P.: Maatschappelijke aspecten van de perceptie van het heroineprobleem en het beleid daarop. In: heroineverstrekking, verslag van de heroineconferentie 13 mei 1982, Amsterdam. Stichting Uitgeverij de Oude Stadt, 1983
  21. Lettieri, D. (ed.) Drugs and Suicide. Beverly Hills 1978
  22. Schuster, C. Renault, P., Blaine, J.: An Analysis of the relationship of Psychopathology to Non-medical druguse. In: Pickens, R. and Heston, L. eds.: Psychlatric Factors in Drug-abuse. N. Y. 1979, pages 1-19
  23. Matza, D.: Becoming Deviant, New Jersey 1969
  24. Cohen, H.: Druggebruik en Sub-cultuur. In: Dijk, W. van en Hulsman, L. eds.: Drugs in Nederland, Bussum 1970
  25. Bijlsma, U.: Chronische morfinevergiftiging, psychiatrisch gedeelte. In: Bijlsma, U. et al. Opium en Morfine, Leiden 1925
  26. Kits van Heyningen, A. van,: Over het opium en het Opiummisbruik. In: Indië en het Opium. Een verzameling opstellen betreffende het opiumvraagstuk, Batavia 1931, Uitg. Kolff
  27. Hunt, L. en Zinberg, N.: Heroin Abuse: A new Look. Drugabuse Council IS7 9/76

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