Classical Psychoanalytic Approach to Substance Use Disorders

Very interestingly, although Freud did not specifically speak of addictions or substance use disorders, he was no stranger to addiction in his personal life. Given that most drugs which are considered illegal by today’s standards could be prescribed or obtained over-the-counter in the late 1800s, Freud thought he had discovered a cure for depression and fatigue when he began using and prescribing cocaine for his patients. He chronicled his findings in the well-known monograph he had written aptly named, The cocaine papers (Freud, 1974 [1884]). Over time, it became clear to his family and colleagues that Freud was himself addicted to cocaine, in spite of his being an advocate for the drug. Freud also concluded that cocaine could be used as a “cure” for morphine addiction. It was not until the death of his friend and colleague, Ernst von Fleishel-Markow, whom Freud had attempted to detox using cocaine, that he began to change his opinion of cocaine. Apparently, von Fleishel-Markow had become addicted to morphine after suffering an infection sustained while doing an autopsy and was subsequently prescribed morphine to lessen excruciating nerve pain. Freud eventually concluded that cocaine was a dangerous drug with highly addictive qualities. It was also well known from biographical accounts (Jones, 1957) that Freud smoked upwards of ten cigars a day. He eventually developed cancer of the jaw/mouth which resulted in his death on September 23,1939. When Freud left Vienna, partially in response to Kristallnacht on November 8— 9, 1938 (in which the Nazis destroyed all Jewish prayer houses, synagogues and Jewish-owned shops/businesses) and partially in response to the urgings of his followers, he secured safe passage to live in London, England. In addition to obtaining passage for his family, Freud was also able to secure passage for his personal physician, who was prescribing pain medication that allowed Freud to function on a daily basis (Jones, 1953, 1955, 1957).

If we go back to the earliest formulation of psychoanalytic theory, we can find some description of how addictions may develop from the Freudian perspective. In Freuds theory of psychosexual development, he outlined the various stages that children go through from birth to around age 12 (you may recall these as the oral stage, anal stage, phallic, latency stage). Each stage carries a primary source of “gratification” although it’s important to remember that Freud defined sexual gratification in a very broad sense. For example, the oral stage which takes place from birth to around 2 years old, is marked by oral gratification being the primary source of gratification. Therefore, the sucking reflex and the pleasure derived from sucking and food intake is considered to be the primary source of “sexual gratification.” However, if the infant is either understimulated or frustrated in the feeding process or if they are over-stimulated, then something Freud referred to as fixation could result. If one were to become orally fixated, he or she could go on to develop addictions to food, smoking, drinking (alcoholically), as a means of continued attempts for oral gratification. Although this theory has some intuitive appeal, it’s very difficult to determine what wouldbe considered under-stimulation versus over-stimulation, or who would become fixated versus those who would not.

Later, Freudian theory evoked another, albeit, lesser known theory of substance use disorders, in which addictions were derived from death instincts or a form of slow suicide (Khantzian, 1980). Indeed, substance use disorders were described by the famous psychiatrist, Karl Menninger (1938) as “suicide on the installment plan” (borrowing from the title of a book by Ferdinand Céline in 1938) because of the progressive physical, psychological, emotional and spiritual deterioration that many individuals with substance use disorders often experience. Just as the id is thought to strive for pleasure and operates according to the “pleasure principle” or “eros,” Freud hypothesized that an opposite drive referred to as the death instinct which operate according to “Thanatos,” which is an expression of the death wish or death instinct.