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Hindawi Publishing CorporationISRN AddictionVolume 2013, Article ID 250751, 6 pageshttp://dx.doi.org/10.1155/2013/250751

Review Article�e�cits o� A�ect �entali�ation in Patients �ith �ru� Addiction�Theoretical and Clinical Aspects

Svetoslav Savov and Nikola Atanassov

�e��rt�e�t �� itive �cie�ce �� c��l�� ew ��l��ri�� iver�it�� tevi�e� ��lev�r�� l��ri�

Correspondence should be addressed to Svetoslav Savov; [email protected]

Received 24 August 2012; Accepted 15 October 2012

Academic Editors: A. M. Barr, L. Janiri, and P. Mannelli

Copyright © 2013 S. Savov and N. Atanassov. is is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Traditionally treated with wariness, drug addictions have provoked a serious interest in psychodynamically oriented cliniciansin recent decades. is paper discusses the development of contemporary psychodynamic conceptualizations of addictions,focusing speci�cally on mentalization-based theories. e concept of mentalization refers to a complex form of self-regulationwhich includes attribution of psychological meaning to one’s own behavior and affective states, as well as those of the others.We hypothesize that drug-addicted patients have severe impairments in mentalizing, associated with developmental de�cits,characteristic for the borderline personality disorder and psychosomatic conditions. Psychodynamic models of mentalizationand their corresponding research operationalizations are reviewed, and implications for a contemporary understanding ofdrug addictions and psychotherapy are drawn. e authors propose that mentalization-oriented theories provide an adequateconceptualization, which is open to empirical testing and has clear and pragmatic guidelines for treatment.

1. Introduction

We know that the onset of drug addictions is determined bya complex combination of constitutional (biological), social,and psychological factors. Physiological components play acrucial role in the maintenance of psychological anxiety,associated with physical abstinence, but they are not the oneand only etiological factor behind this disorder and they cannot entirely explain the motivation for subsequent relapses[1]. It is clear that every psychoactive drug induces a speci�cstate of intoxication, but individual psychopathology largelyde�nes the sub�ect’s reaction towards the pharmacologicaleffects [2].

Bearing in mind these assumptions, we review a seriesof developments in the understanding of substance abusestarting with classical psychodynamic approaches based ondrive/con�ict models. en, we present comprehensive the-ories of affect regulation which we see as a starting pointfor the transition to modern mentalization-based concep-tualizations. We describe the shi from the initial empha-sis on instinctual grati�cation to the investigation of egodevelopment and pathology. We show how contemporary

psychodynamic clinicians and researchers can increasinglyrely on mentalization based theories to explain personalitypathology. We outline some of the implications of this shifor evidence-based practice.

ere is clear evidence supporting neurobiological andneurocognitive adaptations to speci�c drug exposure, thenatural history of addiction involving “spontaneous recov-ery” with minimal intervention, consideration of now copi-ous evidence from other therapeutic interventions such asmotivational interviewing that appear to also emphasizethe interpersonal environment in treatment. However, theseissues are beyond the scope of the current article. Ourmain aim is to examine the evolution of psychodynamicapproaches to addictions which we see as parallel to thegeneral development in psychodynamic clinical theories.

2. Classical Psychodynamic Approaches toAddictions

Many psychoanalytic pioneers were interested in the problemof substance abuse and addictions. Abraham [3] tried to

2 ISRN Addiction

conceptualize this form of pathology from the point of viewof the libidinal theory, that is, as a symptom of regress to oral�xations and striving for “orgasmic” experiences. Rad� [4]was the �rst to point out that not the toxic agent itself, but theimpulse to use it, de�nes addictions. Fenichel [5] underlinedthe deep-seated depression and anxiety in addicts.

In general these authors understood substance abusefrom the point of view of euphoric-pleasurable experiencesand believed that the symptom has a “hidden” meaning (e.g.,symbolizing an orally gratifying object). Glover [6], however,made an important breakthrough with his hypothesis thatthe psychoactive substance could be used “progressively”not only for regressive satisfaction, but also for protectingthe subject from primitive (destructive and self-destructive)impulses or even psychosis.ese ideas would later serve as abasis for Khantzian’s work on the self-medication hypothesis[7].

3. Affect Regulation

e next generation of psychodynamic models comeslargely from the ego psychological tradition. e maindifference between ego-psychological theories and classical-drive�con�ict models is that ego psychologists shi the focusfrom the symptom to the personality de�cits of addicts andtheir incapability for coping with traumatizing anxiety. Druguse is related to speci�c ego pathology manifested in quickshis from depressive states to intensive arousal in con�ictualrelations with important others [8]. Addicts react to situa-tions of crisis with affect regression (totalization of feelings),which is dealt with by splitting unacceptable parts of internalor external reality and denying their existence. However,only when these series of operations are pharmacologicallyreinforced, a sense of mastery and raised self-esteem can berestored [9].

is generation of psychodynamically oriented cliniciansconcentrates on the clinical reality that patients with drugaddiction complain of being either overwhelmed by intoler-ably painful affects or cut off from their emotions. Referringto these characteristics of the affective life of addicts, Wiederand Kaplan [2] de�ne drugs as “prosthesis” helping patientsto regulate their impaired affective life.

e problem with drug addicts is that the primitivedefense mechanisms they employ do not efficiently pro-tect them from excessive anxious and depressive states.Consequently, addicts present not only interpersonal dif-�culties, affect storms, and impulsive behavior, typical forpatients with borderline personality disorder, but their wholeemotional life is in a way much more easily “somatized”and driven around bodily sensations. us, impaired affectregulation comes into focus as a central diagnostic feature ofthis disorder. is term denotes a qualitative transformationof affective states with modi�cation of their intensity and�orduration [10]. It encompasses an interaction between neuro-physiological, motor-expressive, and cognitive-experientialareas. Constant defensive blocking of affectivity leads to astate in which emotions are treated as physiological attackssetting vicious circles such as “I am afraid to be afraid.”

We can safely generalize that the contemporarypsychodynamic approach to drug addictions abandonedaltogether early conceptualization of pleasure seeking andsymbolic importance of the drug. Instead, leading authorslike Khantzian [7] see the motivation behind substanceuse as an attempt for “self-medication.” He observes thatpatients addicted to opiates rely on the antiaggressive effectsof the substance which block disorganizing and threateningaffective states of anger, pain, shame, and loneliness.Khantzian convincingly shows that regressive aspects of thepsychopharmacological effect have been excessively stressed,leading to a neglect of its “progressive” functions, that is,blockage of primitive psychic states and reinforcement of egodefenses—drug addicts do not just search for an “escape” or“euphoria.” ey actually need a shield that protects themfrom excess in anxiety.

We are naturally interested in the developmentalorigins of these affective disorders. Krystal [11] points thatonly when the small child is protected from exposure tocontinuous trauma in early relations, it can develop affecttolerance during latency and adolescence. He makes itclear that primary self-regulation de�cits in drug addictsencompass a tendency for affective regress, de�cientcapability for using anxiety as a signal, and impairedtolerance for painful emotions, especially the primitive affectof undifferentiatedanxiety and depression .

ese de�ciencies showing failure in the desomatization,verbalization, and symbolization of affective experiences arequite oen observable in psychosomatic conditions charac-terized by the state of “alexithymia” (from Latin, “no wordsfor emotion”) [12]. Addicted patients oen share some of thefollowing basic components of alexithymic functioning: (1)difficulty in identi�cation and differentiation of feelings andbodily senses in a state of emotional arousal, (2) difficulty indescribing feelings, (3) limited imagination and poor fantasylife, and (4) cognitive style focused on external reality [13].

Without having a good enough understanding of theirmental states, these patients cannot modulate emotions andinstead show tendencies for direct discharge of anxiety inbehavior or somatizations. Interpersonal disappointmentseasily trigger rapid changes in mood, which an individualwith certain predispositions would try to regulate by phar-macological means. Interestingly, alexithymia—a concepthighly applicable to addictions, is also one of the roots ofcontemporary mentalization-based theories.

4. What Is Mentalization?

e concept of mentalization was introduced by PierreMartyin the 70s as an extension of the research into psychosomaticphenomena [14]. Classically it refers to the quality andquantity of psychic representations, their verbalization, andconnections with affectivity. From another point of view thatof modern developmental psychopathology Fonagy [15, p. 4]de�nes mentalization as “… a form of mostly preconsciousimaginative mental activity, namely, interpreting humanbehavior in terms of intentional mental states (i.e., needs,desires, feelings, beliefs, goals, purposes, and reasons).” is

ISRN Addiction 3

conceptualization integrates the notion of “theory of mind”in cognitive developmental models with attachment theory[16]. It is based on the following threemain assumptions [17]:(1) the feeling of the self as agent is rooted in the experience ofbeing attributed psychic states by a signi�cant other, (2) thiscapability is a function of the interaction between the caring�gures through a process of mirroring, (3) its developmentcan be impaired by traumatic experiences.

Attachment is seen as the main factor in the developmentof mentalization and the formation of internal representa-tions of affective states. Secure attachment is a preconditionfor good enough affect regulation and guides the transitionfrom coregulation in the mother-infant couple towards self-regulation of the child [10]. e child internalizes mother’sempathic expression and this type of “intersubjectivity” is amilestone in the relation between attachment and affectiveself-regulation. Using language, children can name theirfeelings, receive verbal and emotional feedback about theiradequacy, and thus become supported in the effort to thinkabout themselves and others [13].

Bateman and Fonagy [18] understand borderline person-ality disorder as a result of inadequate mirroring in earlydevelopment. According to them, patients with borderlinepersonality disorder have difficulty in mentalizing mainly ininterpersonal and intimate situations, when they are mostvulnerable to excesses in anxiety. De�cits in mentalizationprevent them from having a good enough “buffer” fromaffects and trigger “�ght or �ight” mechanisms. ese obser-vations are relevant for the conceptualization of addictions,having in mind the high percent of comorbidity with border-line personality disorder [19].

Allen et al. [20] describe a two-way interaction betweensubstance abuse and mentalizing. Intoxication impairs men-talization of own emotional states as well as those ofthe attachment �gures. De�cits in mentalization on theother hand contribute to an inclination for substance abuseunder emotional stress caused by interpersonal con�icts withattachment �gures.

Contrasting, but also complementing Fonagy’s model,Bouchard and Lecours [21] present a theory of mentalizationfocused on the development of thinking through binding ofinstinctual pressure in representative networks. is theoryhas roots in the psychosomatic research done by Marty[22], Krystal’s theory of emotions [11, 23], and Piaget’s con-ceptualization of the child’s intellectual development fromsensor-motor activity towards formal verbal thought [24].Bouchard and Lecours describe a complex process of psychicworking throughwhich prevents direct discharge into actionsor somatizations. Affects are here conceptualized as positivelyor negatively valanced psychological phenomena with asomato-motor tendency for action. is tendency is “deso-matized” by a complex process of psychic working through.e authors assume that representative de�cits lead to anexcess of excitation, which has not been transformed intoa psychic con�ict, that is, anxiety has not been mentalized.Forms of impulsivity, addicted behavior, and somatizationare interpreted from this point of view as an expression ofaccumulated drive impulses with no attributed psychologicalmeaning.

Bouchard and Lecours [21] describe mentalization asa continuous process, functioning as “immune system” ofthe psyche, because it modi�es external and internal pres-sures. Normally, mentalizing contributes to the coherent andmeaningful experience of one’s own psychic states. Insteadof acquiring this tolerable distance from direct affectivepressure, drug addicts oen suffer from severe anxiety anddepression. ese conditions are triggered by the deepconviction that the individual is helpless in regulating notonly external reality but also his or her emotional states.Substance abuse is the coping mechanism which replacesmental processing of helplessness, apathy and emptiness, andthus brings back temporary control.

5. Empirical Research onMentalization inAddicted Patients

A considerable body of research on disorders of affectregulation has been accumulated. Bateman & Fonagy [25],for example, point that patientswith alexithymia usually growin families characterized by high levels of negative affect,difficulties in representation, and impaired recognition ofemotional expressions, aswell as scant discussion of emotionsin the parent-child relationship.

Haviland et al. [26] present more speci�c data about therelationship between alexithymia and substance use disor-ders. In a sample of 204 patients (72 treated for alcoholism,79 for drug addiction, and 53 for double addiction) 41.7%were diagnosed as alexithymic, the percentage of alexithymiabeing signi�cantly higher among women (50%) than thecorresponding �gure among men (35.8%). High levels ofalexithymia in substance use disorders contrast low levels (9%and 12%) among male adults and students in norm, and 8%and 12% among women, respectively.

ere is also a growing body of research supportingthe foundations of mentalization theory in various clinicalgroups and ages. High mentalizing functioning is shownto protect the child from early traumatic in�uence [25].MacBeth et al. [27] �nd data supporting the associationbetween mentalization and social functioning in patientswith psychosis. Taubner et al. [28] show that depressedpatients tend to have lower re�ective functioning scoresconcerning issues of loss compared to healthy controls. ecited research fails to show the relation between re�ectivefunctioning and symptomatology in depressed or psychoticpatients. However, Lecours and Bouchard [29] present datathat the severity of symptoms in the borderline personalitydisorder is associated with low level of mentalization intwo distinct areas depressive and aggressive affects. Further-more, traumatized individuals are likely to meet the DSM-IV criteria for borderline personality disorder only if theyhave de�ciencies in mentalizing [30]. It is clear that thecomplex links between severity of symptoms and quality ofmentalization should be further explored.

From the point of view of the relation between mental-ization and stress, it is becoming clear that relative calmnesssupports mentalization, while excessive anxiety contradictsit [15]. An evident parallel exists with addictions, where

4 ISRN Addiction

an inability to contain affects, which is a basic componentof mentalization, could be used as a key psychodiagnosticcharacteristic.

Looking at this promising line of investigations, it issurprising that there is hardly any published research ondrug addicted patients’ mentalizing functioning. Levy andTruman [31], however, report data showing that cocaine-using mothers’ maternal mentalization mediates associationsbetween maternal substance abuse and children’s psychoso-cial development. Improvement in mentalization in responseto a mentalization-based parenting intervention was associ-ated with improvement in maternal caregiving behavior andincreased regulation in children between 24 and 36 monthsof age. Ostler et al. [32] examine children exposed to parentalmethamphetamine abuse and �nd that those with highermentalization were less prone to underreport symptoms,had fewer mental health problems, and were rated by theircaregivers as more socially competent.

e apparent scarcity of empirical research onmentaliza-tion in addicted patients stands in contrast to the fact thatthe presented models have already been operationalized suc-cessfully. e most widely used instrument for mentalizationassessment is the Scale for Re�ective Functioning in theAdultAttachment Interview (AAI) [33]. Low results on that scaleare registered if the subject demonstrates poor access to themotivational origins of behavior.

e Grille de l’Élaboration Verbale des Affects (GEVA)[34] offers an alternative empirical approach. It measuresverbal affect working through by segmenting and codingaffective units in narratives. It consists of two orthogonaldimensions depending on the level of mentalization: fourchannels of affect expression (somatic and motor activity,imagery and labeling verbalization) and �ve levels of affecttolerance and abstraction (disruptive impulsion, modulatedimpulsion, externalization, appropriation, andmeaning asso-ciation). ese are a total of 20 possible forms (4 channels ×5 levels) of affective expression. ey are used to calculate anaggregate score for the quality of affective mentalization.

6. Implications for Treatment

ere is a common agreement that the treatment of drugaddictions has to offer an encompassing range of ser-vices—medical, social, and psychological. e place of psy-chotherapeutic work is without doubt central because it isdirected at changing the psychic functioning of the patient. Itis assumed that this happens through a gradual process whichdeepens the understanding of the place of addiction in one’sown life.

It is well known that early attempts at psychotherapeuticwork with addicted patients offered no base for optimism.We are familiar with these individuals’ proneness to fall intorelapse and drop out of therapy, as well as low tolerancefor psychic pain combined with tendency for self-destructivebehavior. Contemporary psychodynamic forms of treat-ment of personality disorders, however, show a promisingapproach, focused on the current mental states of the patient.Aiming to create a network of representations of these

internal states, mentalization-based treatment (MBT) [25]follows a different path from the traditional psychoanalytictechnique. It does not aim at interpreting “deep” unconsciousfantasies but works instead with easily accessible content.etherapist’s goal is to restore mentalizing by creating repre-sentational coherence and integration of mental states. eapproach that Bateman and Fonagy offer is well structuredand focused on enhancing the working alliance and payingattention to the immediate interaction between the patientand the therapist. e therapist is �exible to the speci�csof the pathology (impulsiveness, interpersonal difficulties,self-destructive behavior, etc.) by being relatively active andencouraging a strong relation of attachment which makesit possible for both participants to explore and overcomecurrent failures in mentalizing.

MBT explores the relationship between affect andbelief and has some technical features similar to cognitivebehaviour therapy, which explores the relationship betweenmaladaptive schema and dysfunctional cognition or prob-lematic feeling and has been widely used to treat drugaddiction. Of course, to the extent of focusing on the “hereand now” patient-therapist relationship, and of placing anemphasis on transference (albeit not interpreting it actively),MBT is still psychodynamic psychotherapy.

is approach has already been extensively studied in sev-eral randomized control trials with patients with personalitydisorders. Bateman and Fonagy [18], for example, report an8-year followup of 41 patients with borderline personalitydisorder in partial hospitalization. MBT is associated withsigni�cant improvement in all measured areas (depressivesymptoms, suicidal and self-destructive behavior, numberand duration of hospitalizations, social and interpersonalfunctioning, and use of psychopharmacological medication).e improvement is sustained 5 years aer the end of therapy,while patients in treatment as usual show limited change oreven deteriorate during the same period.

is data should be considered having in mind thatMBT requires relatively little additional training on top ofgeneral mental health training, and has been implemented inresearch studies by community mental health professionals,primarily nurses, with limited training given modest levelsof supervision. is is an important aspect from the pointof view of delivering cost-effective interventions. However,studies of the efficacy of this approach with drug addictedpatients still have to be carried out.

7. Discussion

�isorders of affect mentalization in drug addicts �nd differ-ent explanations in the light of the “con�ict-de�cit” dilemma.Authors like Khantzian stay closer to the mentalizationmodels and see the lack of self-regulatory functions as an egode�cit, that is, a function that was never established, while,according to Krystal, self-caring is “forbidden” by archaicparental �gures. In that sense, Krystal’s position is analogousto the classic psychoanalytic perspective, explaining addic-tions as a result of unconscious con�icts.

ISRN Addiction 5

Following Fonagy’s work and staying more closely withKhantzian we understand low abilities for mentalization inaddicted patients as a personality de�cit related to early envi-ronmental failures. From this point of view mentalization-based theories stress predominantly the relational aspectsin the functioning of the patients against the intrapsychicdimension of the traditional psychodynamic theories. Usu-ally these individuals share a history of interaction witha caregiving �gure, which had not provided good enoughmirroring or it was discontinued due to a trauma. is focuson the direct interpersonal environment, typical for Fonagy’stheorizing, however, has been criticized for an underesti-mation of complex object relations which modulate affectactivation [35]. Indeed, de-emphasis of the unconscious is acentral feature in Fonagy’s theory. At the same time, as Dia-mond andKernberg also point out, Fonagy and his colleaguesshow signi�cant empirical evidence that mentalization isestablished in the context of secure attachment and is blockedin insecure attachment and/or severe trauma.

Choi-Kain and Gunderson [36] add several critiquesto the mentalization theory based on the idea that thisconcept is too broad and multidimensional. However, itscore measure�the Re�ective Functioning Scale, yields onlya single score and it is time-consuming to administer.e authors propose that research should focus on morelimited concepts for which self-report measures have beendeveloped (i.e., theory of mind, mindfulness, empathy, etc.).Another limitation, according to them, in the Fonagy modelis emphasizing process over content.

Other authors (i.e., [37]) have been trying to answerthe question whether the concept of mentalizing is just anew word for well-known phenomena. It becomes clear,however, that it offers a pragmatic integration of clinicalobservations, developmental psychopathology, and attach-ment experiences. It is also a useful explanatory frame-work, connecting affect regulation and clinical symptoms.Last but not least, mentalization combines psychodynamichermeneutics with evidence-based practice and is open toadvances in contemporary neurocognitive theories.

Strength in Fonagy’s mentalization model and the clas-sically oriented model of Bouchard and Lecours [21] canbe regarded as genuinely integrative theories uniting theintersubjective-relational approach with the drive/con�ictperspective. An important point of distinction, however, isthat Fonagy’s theory underlines the interaction with a realobject attributing meanings to the child’s affective states,while Bouchard and Lecours focus primarily on the role ofrepresentative mechanisms in verbal affect mentalization. So,although the two perspectives are not completely contradic-tory, fundamental in Bouchard and Lecours’ theory are theorganizing structures of unconscious subjective experience.

Looking at the empirical evidence, we can see thatthese two approaches are distinct but also overlapping [38].High levels of re�ective functioning or elaboration of affectcontribute to a basic feature of mentalization the capacity totreat behavior as driven by internalmental events and not justexternal stimuli.

8. Conclusion

Affect processing is a basic component of mentalization.De�cits in capabilities for affect representation and mod-ulation manifested in drug-addicted patients point to sim-ilar psychogenetic origins of mentalization disorders withpsychosomatic conditions. Better clinical understanding ofthis form of pathology is a key ingredient in the assessmentand clinical work with drug-addicted patients. Based on acoherent understanding of personality organization, mental-ization models offer promising potential for psychodiagnos-tic accuracy and therapeutic efficacy. eir correspondingoperationalized instruments can be used as valuable toolsfor assessment of change in psychic functioning resultingfrom treatment. Further work is recquired on distinguishingbetween different subgroups in the addicted population(i.e., a comparison of speci�c impairments of the re�ectivefunction and pathways to addiction in opiate and stimulantusers).

Acknowledgment

is paper was supported by a Grant from the InternationalPsychoanalytical Association.

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Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Documents

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