Case Studies - Clinical Schizophrenia & Related Psychoses ( 2022) Volume 0, Issue 0
The Role of the Family Dynamic in Addiction: Trigger and Psychotherapeutic Ally
Jihene Mrabet, Department of Clinical Psychology, American University in the Emirates Dubai, United Arab Emirates, Email: firstname.lastname@example.org
Received: 03-Jan-2022, Manuscript No. CSRP-21-44758; Editor assigned: 06-Jan-2022, Pre QC No. CSRP-21-44758 ; Reviewed: 25-Jan-2022, QC No. CSRP-21-44758; Revised: 28-Jan-2022, Manuscript No. CSRP-21-44758 (R); Published: 04-Feb-2022, DOI: 10.3371/CSRP.MJ.020422
Introduction: What narcissistic foundations can we hope for when a child is born? What future hope for the evolution of his subjectivity prey to a fantasy experience of submission, domination and affective ambivalence? What place to seek for in a family dynamic that rise the older brother to the omnipotent status? What recourse to adopt in order to survive the destructiveness of internal objects, threatening and barring the road to the hallucinatory realization of the desire.
Methods: These are the questions we asked ourselves when we encountered the Addiction; When we encountered Miss A in our office and started running a psychodynamic therapy.
Results: The importance of object relation in addiction was highlighted through the therapeutical process. Indeed, deficient maternal countenance, distorted oedipal structure, incestual and fratricidal unconscious desires play a fundamental role into drug addiction.
Discussion and Conclusion: Object relations precarities may expose the teenager to substance abuse and a deeper interest on the precocious family relationships would enhance the understanding of addiction and therefore a more efficient therapeutically approach.
Adolescent; Addiction; Substance abuse; Family; Object relation
The Addiction generally describes the pathological relationship that a subject has with a substance or behavior resulting in a constant and irrepressible urge to perform a certain behavior despite efforts made to counter it. Addiction relates as much to the use of licit products (tobacco, alcohol, psychotropic drugs) and illicit (cannabis, opiates, cocaine, amphetamines, etc.) as to repetitive behaviors (such as pathological gambling or compulsive buying, sports addiction, sexual addiction. According to Rozaire,et al. the process of installation of the addictive behavior is quite similar regardless of the type of addiction. Usually, it starts with an unbearable anxiety of emptiness that would be accompanied by a feeling of incompleteness. The subject feels the urge to feed certain needs and identifies a substance and/or a behavior that could satisfy his hunger. Then follows an inability to stop the behavior with a transition to the repetitive act allowing the momentary reduction of anxiety;feeling of relief which will very quickly be replaced by a more or less structured depressive discomfort.
In some other cases, drug use is voluntary, satisfying and controlled, motivated by curiosity or as part of a social mimicry. According to Koob  substance’s effects will gradually fade and the person will need to increase the drug doses aiming to match similar effects. This is when the person completely loses control and finds herself adopting increasingly dangerous and sometimes desperate behaviors in order to alleviate the devastating anxiety related to the lack of the substance. Psychiatric comorbidities are also often identified and that could explain a much higher addictive risk in some people, such as mood disorders, anxiety disorders and personality disorders. It should also be added that genetic and sociological factors make a major contribution in the establishment and sustainment of addictive behavior.
Theories of addiction
There is a variety of theories addressing the addiction phenomenon. Some of these approaches focus on the biological aspect, whereas others highlight either the psychological or the sociocultural sides of the problem. According to the American Psychiatric Association and Bevilacqual [3,4]. Addiction is a chronic disorder that imply the three areas together. However, they insist on the role played by genetic précising that studies show that half the risk for addiction is caused by it. Nevertheless, psychologists add that the psychological factors are determinant as triggering elements, could explain the vulnerability of some persons comparing to others and predict the risks of relapse . Moreover, environmental factors are playing an important role in this equation facilitating the exposure to drugs.
The neurobiological theories: The neurobiological theories discuss the drugs’ effects on the brain, the common consequences and the specificities related to the substance itself. Many substances have been identified and classified as per their primary action on the brain and the number of users all over the world. The National Survey on Drug Use and Health published a report in 2019  exposing the most used drugs in USA and its prevalence among the society. The most used drugs were in order, Alcohol, Tobacco, Marijuana, pain reliever, Cocaine, tranquilizer or sedative, Hallucinogens, stimulants, Methamphetamine, Kratom, inhalants and finally Heroin.
Psychological theories: Psychological approaches tend to focus on personality vulnerability, non-adapted behaviors, and models of rational choice and object relation theory. Behavioral theories center their attention on overt behaviors and reinforcement . This is how the drug self- administration model was lunched discussing the chemical, behavioral, instinctual and social reinforcements. Researchers demonstrated that classical conditioning model have played a fundamental contribution in understanding the rise and sustainment of the addiction. Personality theories expose vulnerabilities that are linked people dynamics. Hans Eysenck pointed out that for some persons drug serve as a weakness fulfillment . According to him, three major dimensions are implicated in this process: Psychoticism, Neuroticism and Extraversion. Psychoticism describes the propensity of a person to functional psychosis displaying aggressivity, impulsivity, egocentrism and coldness. Neuroticism describes the propensity to experience mood unbalance such as anxiety, irritability and moodiness . Researches have proved that these two dimensions have the strongest role predicting and maintaining drug abuse . Some psychoanalytic theories state that the drug abuser is most of the time suffering from a narcissistic crisis and an impaired self-concept . According to Graham, et al.  the reason behind substance abuse is a disturbed object relation characterized by the defeat of the separationindividuation process. Failing to internalize comforting good objects, the drug abuser will look for external substances that would be incorporated instead.
Sociological theories: Many researches were interested on identifying the environmental factors behind the installation of the addictive behavior [13-15]. The findings suggest that antisocial personality is frequently resorting to substance abuse. The results also highlighted the vulnerability of children with anxiety or depressive symptoms to early substance use. For this reason, the peer environment was deeply investigated as the primary source of influence on drug use behavior since this is where usually all start. Another important outcome is the role played by family’s dynamic in facilitating or protecting the children from falling into addiction . Indeed, if a family member is already inscribed in substance use or are permissive towards the use of drugs by their children, they will be more tempted by it . Another important element to mention is the nature of family relationships. The risk of addiction is more important if there is a conflictual family dynamic, low level of bounding, lower socioeconomic state and troubled parental educational style.
Addiction and adolescence
To tackle the addictive problem in adolescence is to question the paradox of this age group. Between the infantile and the genital, between body and psyche, between construction and destruction, between repetition and symbolization, between life and death, and finally between passivity and activity . At the heart of the emotional problematic, we find the problematic of the body as a scene where the intimate and the social are played, where the unrepresented in search of meaning. Is it necessary to interpret addiction as a form of acting, testifying to the failure of symbolization or, on the contrary, as an attempt to link the infantile and the genital; of what has been traumatic and not symbolized? Can it be understood as what Sigmund Freud called in 1920 "the compulsion of repetition" in his work "beyond the pleasure principle" . An active repetition which re- enacts a painful event, a suffering in the hope of taming and diminishing it. Morgenstern  state that adolescence could be defined as a period of paradox: Perhaps adolescence consists in experiencing such paradoxes, in developing patience and tolerance in the face of to the suffering that results, until these paradoxes find little by little, with the entry into adulthood, if not their resolution at least their acceptance. It is thus that suffering often tries to annihilate itself in self-destruction, in addictive risk-taking, in the provocation of these episodes of small deaths after each drug consumption . Addiction would be according to an attempt to cling to external reality and the perceptual world to compensate for the failure of the internal world .
Miss A is a 22-year-old young woman, of bosniac origin resident in America. She introduces herself to me with a request that already grabbed my attention when reading the information paper that she filled before the clinical interview. I can read these words on the paper: “I need help understanding why I’m so sad all the time and why I do the things I do”. Her request suggests her emotional distress in the face of the passivity felt as destructive…facing this irrepresentable in search of meaning. Miss A sits in front of me; she is embarrassed and avoids looking to my eyes. She tries to maintain herself and displays a forced smile. When I ask her to explain the reason of her visit, she admits that the main reason is that she suffers from a drug addiction that has made her lose her job, the respect and trust of her family and especially the love of her big brother (who is one year older than her). She explains that it all began when she was 15 years old when her friends started using cannabis. She tried and admits that she liked the effect it provided; the well-being she felt: "It allowed me to be less sad I think". Her use of this substance was occasional, according to her. On a trip to her home land with her mother and brother, she meets Mr. S,a friend of his brother, and falls in love with him. Miss A states that she was seduced by the way he spoke to her, the exclusive interest he had in her and the love his family had for her. This last reply suggests the precariousness of her environment that is responsible for the development of the primary and the secondary narcissism. Narcissism is closely related to the family capacity representing a base of security essential to the psychic development of the person. Mr.S was a big cannabis smoker and both of them locked themselves in a double enjoyment that was both life-giving and destructive. Little by little, he led her to use Xanax and fentanyl which caused an effect of excitement and euphoria. She also adds that drugs made her forget her problems with her parents. I ask her about the nature of the problems. She hesitated, and then revealed what seems to be the source of her psychic vulnerability: a deficient maternal relationship. Miss A describes her mother as cold and distant. When I asked her what might be the reason behind such attitude, she replied ironically: "It's not like she wanted me". She told me that her mother was always happy to have only one child, her oldest son, whom she considered as a golden boy, and that getting pregnant one year later was neither programmed nor desired. That's what her mother told her one day out of anger because Miss A came home late". My older brother has always been a perfect child, when I was a kid I always felt like I had to live in his shadow and do everything I could to satisfy my mother. But the more I grew up the more I realized that I would never be like him and I would not be treated like him". Through the speech of Miss A, we distinguish a very strong feeling of jealousy toward her older brother that is narcissistically invested by the maternal desire, the one she was deprived from this absent mother, does not stimulate her child and does not fulfill her containement functions as first stated by Wilfred and Françoise [22,23]. Miss A is then in the grip of an excessive excitement overflowing her capacities of connection and elaboration of the ego creating what pirlot, et al. [24,25] call a pathological envelope that does not guarantee the construction of a sense of continuity in the person. This system of shielding from excitement as it is called Isabelle Martin-Kamieniak  would be the very foundation of narcissism. At the advent of adolescence, our subject is confronted with narcissistic-object antagonism;how to build oneself in a completely autonomous way when one's self is filled with others, others invasive or abandoning. The identification with this other meaning to be introjected in order to guarantee the development of the adolescent at the stage of psychic maturation is here hindered by the porosity of the limits of the narcissism of Miss A. Our subject feels the identificatory movements as dangerous and invasive that must be rejected at all costs. Since the beginning of her adolescence, our patient has tried to contradict the parental speech and to test the limits of her parents. The conflicts of Miss A were accentuated with her mother in particular raising the inequality of treatment compared to her brother, the one to whom everything was allowed. The father interfered only when it was necessary to raise the tone or when it was a question of physical correction. This only exacerbated her jealousy towards her older brother, a brother so much hated but also deeply loved. Speaking about her brother, Miss A said that her brother is her best friend and then clearly admitted that she has been always jealous of him. She envied his ability to remain indifferent to the judgment of others and therefore his ability to handle external elements threatening his inner tranquility. She admits that she never knew how to control neither what penetrated her but also what emanated from her. She adds that her brother represents everything for her and she described to me nostalgically the moments they had spent together, the places they visited, the games they shared and the music they listened to. Her voice intersects and she adds "He does not want to talk to me anymore ... I feel I lost him forever". Her brother is angry after her because of her addictive behavior. A silence settles and I perceive the necessity to offer her a time of internal reflection. Then she looks up and tells me the story of the best friend of her brother who died after an accident three years ago. She and his sister were also very close. She looks at me and says in a broken voice: "my brother's best friend stopped talking to me two weeks before he died." when I ask her about the link between this episode and her current state, she answers: "We must never stay in conflict with someone we love because we never know if we will be able to talk to him again". The link between this memory and the current episode between her and her brother is transparent and I perceive this incestual identification which must imperatively be annihilated by the fratricidal desire. This brother inscribed in the desire of the mother and who manifests himself as an idealized object, even supplanting the father, is indeed the father in the Oedipal Freudian triad. The brother becomes the object of desire of Miss A. The fraternal closeness is apprehended as an incestual desire that became obvious when later Miss A will confess that she contacted her brother and that she asked him about their kids (two ferrets that they are taking care of). After some interviews, Miss A realizes that her relationship with her boyfriend is based on a need for narcissistic reassurance, narcissistic identification, because just like her, he was psychologically vulnerable. The drug addiction was reinforced and it is called relational addiction .Miss A opens more and more to therapy and the process of reflection and symbolization gradually begins to weave a backdrop for the management of unconscious fantasies that were once experienced as destructive. Questioning the real nature of the relationship with her boyfriend, Miss A asks me what she should do. Should she stop this relationship in a radical way or is it possible for her to continue talking to him from time to time on Facebook. I referred the question to her meaning that the decision is hers. It was a way to also explain to her that the therapy space is a healthy place to enjoy her individuation process without being penetrated by the external environment that has always been disappointing (sometimes deficient and sometimes invasive and dangerous). Miss A is astonished and says: "everyone around me keeps telling me that I should not see him again or talk to him !! ". "And what do you think? I think they probably have their reasons and they are valid but what I would like is that you can elaborate your own reasons and that you can think about it". When Miss A is back for her next session, she shared with me a dream that she had: "I was swimming in the open sea in my home land but I did not feel safe, the sea was dark. Suddenly something grabbed me from underneath and tried to drown me in the depths. I looked up and saw a hand reaching out to me as if to save me. I grabbed it and it was you. I remember that I stared at you before waking up. The symbolism of this dream seems transparent to us, depicting the transferential experience of Miss A during the course of the therapy in an attempt to repair her first object relation through the relationship with the therapist. Miss A seeks my maternal countenance, she recourses to me as a transitional object, in the Winnicottian sense, to fix the relationship with her mother and to repair her narcissistic failures. Miss A's addiction seems to be a "means of containing an object relation of dependence and maintaining a sufficiently secure narcissistic-object gap" as conceived by Corcos and Jeammet . It would also be an attempt to free the emotional dependence on libidinal objects but would also allow the maintenance of another form of dependence as self-destructive as the first .The nature of Miss A's object relationship was marked by the absence as in the case of her mother and father (father who by saying does not appear anywhere in the patient's speech, which It also seems likely to indicate his non-existence in the maternal desire). This father is replaced by the older brother who is erected as a pedestal and elevated to the rank of Oedipal desire object. The reactivation of fantasy scenarios in adolescence undermines the equilibrium the patient's fragility and hinders her attempts to individuation. The addiction then presents itself as a form of self-medication that allows to overcome an unpleasant phenomenon, provoking relief, suggesting a form of pleasure constrained to repetition and positioning itself in the most of the cases to a unique solution that subjugates the psychic life of the individual. Miss A takes control of herself, decides to confront her internal “demons” and face her responsibilities (towards her family but also towards the law the patient has had trouble with the law because she benefited from her position in a bank for steal money in the cashier). She decides to finally end her relationship with her boyfriend, writes an open-heart letter to her brother and then to her parents. At the last session, I invited Miss A's mother to join us. She came to spend a few days with her sister and then to go back with her daughter to America. Miss A's mother seems to be very anxious, proud of the progress her daughter has made in therapy but also dreading relapse.
Miss A manages to verbally express for the first time the love she has for her mother and thanks her for all the sacrifices she has made for her in order to get her out of her addiction. The mother looks at her and said: "I have always been afraid that you would fall into adversity, I know more than you about life and I know that a woman is an easy target, I wanted to educate you the hard way to strengthen you, to provide you with a carapace that can handle the blows of life. I always hoped that one day you'll be better than me, stronger, more beautiful, more independent ... that's all I wish you my daughter ... "On these beautiful words, the two women embrace each other, respectively wiping the tears in a gesture of extreme tenderness. I stared at Miss A and said, "Now you know why your mother gave you that name." This replica was a small nod to the first session when I asked Miss A to explain to me the meaning of her name and who chose it for her. She told me that it was her mother who named her and that this name meant "hope". At that moment she could not yet interpret the unconscious symbolism of her mother's choice [30,31].The eyes of the two women shined, they hold hands as if to signify the advent of a new chapter in their lives, an emotional revival long feared but ultimately so desired. Desire can then be part of the reality lightened from the weight of the past.
Results and Discussion
In the current study, the relevance of object relation for cannabis addiction was discussed through based in terms of the therapeutic process. The study revealed that deficiency of maternal countenance, distorted oedipal structure, ancestral and fratricidal unconscious desires have causal effect into drug addiction. The study emphasizes that object relations precarities have the potential to expose the teenager to cannabis abuse while precocious family relationships could magnify perception of addiction requiring more efficient therapeutic approach. The emotional stability of the drug abuser is pivotal to the rehabilitation process. The prevalence of cannabis abuse has been increasing in United States particularly among the adolescents. Cannabis use disorder has several family and psychosocial consequences. Cannabis use disorder treatment options are limited and therefore, the psychotherapeutic approaches such as motivational enhancement, cognitive behavioral and contingency management are expected to produce effective results. Cannabis is in fact the most widely used illicit drug in United States. Young people are mostly affected by its abuse and there have been very few reports on the treatment option available. However the anecdotal experience, uncontrolled trials and randomized controlled trials are available for treatments (Table 1).
|Prevalence of drug disorder|
|Age (18 to 25 years)||39%|
|Percent user ship|
|Prescription pain medication||31%|
|Marijuana (Cannabis sativa ) constituent and its usage|
|Age (>18 years)||48.2 million|
|Usage (2018-2019)||Increased by 15.9%|
|Cannabis disorder prevalence||30% among Cannabis users|
Psychotherapeutic approaches have certain limitations with differences in mode of action, time to effect, symptom alleviation and target symptoms. Similarly pharmacotherapies also have different efficacies. The cognitive and behavioral therapies and motivational therapies were found to be effective as per several randomized clinical trials with good compliance and effectiveness. There forms of treatment are cost effective. There are no drugs for the treatment of cannabis dependence due to lack of scientific or clinical evidence. The treatment option for cannabis addiction is growing all over the world. The psychosocial interventions methods for the treatment of psychosocial interventions have challenges in terms of long term outcomes. In a study comprising of mindfulness based psychotherapy and based on tolerability and therapeutic feasibility as assessed by retention rates, adverse events, and clinical worsening and abstinence rates it was found that a substantial number of patients achieved abstinence. The mindfulness training is tolerable and feasible for extension to the individual psychotherapy for treatment of cannabis dependence.
Addiction is a scourge that continues to spread and wreak chaos in everyone's life. It’s threatening most specifically children and teenagers because it’s targeting them at a their most sensitive developmental stage. It arouses curiosity and when barely approached, it turns into a death trap. In this study we highlighted the importance that object relations precarities play in exposing the teenager to substance abuse and therefore we recommend a closer focus on the precocious family relationships in order to understand the phenomena of addiction and to provide a better therapeutically approach. The emotional stability of the drug abuser is a master key to his rehabilitation process.
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Citation: Mrabet, Jihena."The Role of the Family Dynamic in Addiction: Trigger and Psychotherapeutic Ally.� Clin Schizophr Relat Psychoses 16S (2022). Doi:10.3371/CSRP.MJ.020322
Copyright: � 2022 Mrabet J. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.