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Commentary on Understanding Addictive


Vulnerability
a

Clifford Yorke
a

Hon. Consultant Psychiatrist, Anna Freud Centre, London.


Published online: 09 Jan 2014.

To cite this article: Clifford Yorke (2003) Commentary on Understanding Addictive Vulnerability, Neuropsychoanalysis:
An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 5:1, 42-53, DOI: 10.1080/15294145.2003.10773408
To link to this article: http://dx.doi.org/10.1080/15294145.2003.10773408

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42

Neuro-Psychoanalysis, 2003, 5 (1)

Commentary on Understanding Addictive Vulnerability


Clifford Yorke

SOME REFLECTIONS ON ADDICTION

The target paper


I read Professor Khantzians target paper with some
disappointment, and I was unhappy when I was
asked to be a discussant.
His observations cover a great deal of ground but
do not, to my mind, make an appropriate basis for an
exchange of views between psychoanalysts and
neuroscientists on the vexing question of addiction.
Indeed, his psychodynamic perspective seems to
minimize some crucial psychoanalytic concepts.
Unconscious mental functioning receives scant, if
any, attention, outside the following sentence:
Contemporary psychodynamic theory in application to SUDs paralleled developments in modern
psychoanalytic thinking by laying less emphasis on
drives and unconscious conflicts, but placing
greater emphasis on appreciating the importance of
affects, on the development of ego and self structures, and on the quality of and capacity for relationships and connection to others.

Less emphasis could well be read as little


emphasis without doing any disservice to the general purport of the text. (SUDSsubstance-use
disordersseems the preferred term to drug addicClifford Yorke: Hon. Consultant Psychiatrist, Anna Freud Centre,
London.

tion nowadays, but seems to me insufficiently explicit.)


The point about affects calls for immediate comment. Freuds views on affects have been effectively and cogently discussed in this Journal by
Solms and Nersessian (1999); also, the point that,
without a concept of drives, there is no psychoanalytic concept of either thought or affect has been
emphasized by others, including the writer (Yorke,
1999a, 1999b). For Freud, a drive can only be
known through its mental representatives, of which
the quantitative aspects are perceived as affects (the
qualitative ones are thoughts). In psychoanalytic
thinking there can be no affects without drives,
about which Khantzian borders on the dismissive.
And what is meant by self structures? If
Khantzian means self-representations, these are
conceived, psychoanalytically, as complex mental
organizations, conscious and unconscious, to which
all parts of the personality make contributionsa
statement equally true of object representations.
The latter are not mentioned in spite of their ready
interaction with, and reciprocal influence upon,
self-representations. Whatever Khantzians psychodynamic theory is, it is clearly not based on
psychoanalytic thinking, modern or otherwise.
That said, it is gratifying to observe in the paper
one significant point with which I am in agreement:
when discussing drug addiction, we are not concerned with a homogeneous group of disorders. But

Understanding Addictive Vulnerability Commentaries

it is doubtful, to say the least, whether these conditions can be properly considered in terms of painful emotions that cry out for control, and the drug
of choice used to this end. But Khantzian is firmly
of the opinion that drugs act in specific ways that
make them especially suited for specific purposes.
Opiates, he avers,

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are very effective in countering and muting intense


anger and rage and appeal to individuals who endure such feelings, and/or suffer with psychiatric
conditions in which such affects dominate. (High or
obliterating doses of alcohol can have similar effects on the basis of a hypnotic action.) . . . Depressants in low to moderate doses have appeal to
individuals who are tense and anxious. . . .

Khantzian does not base his entire understanding


of inappropriate drug use entirely on these suppositions, but they provide an essential basis for his selfmedication hypothesis. Our neuroscientific
colleagues will no doubt have some very helpful
contributions to make on this subject. In my experience, Khantzians generalizations are not altogether
justified. They take no account of the fact that,
although any given user may have a preference for a
particular drug, multiple-drug use is commona
heroin addict may take amphetamines and other
drugs such as cocaine as well. The point is exemplified by a young salesman who progressed from
hashish via skin popping with physeptone to
main-lining with methedrine and heroin and who
told his psychiatrist: I dont like myself, but on
meth I liked my own company. On meth I was
the me I wanted to be. He thought he was too
retiring and shy, but, on methedrine, I was able to
sell my goods with a good deal of confidence
(Richard, reported by Radford, Wiseberg, &
Yorke, 1972, p. 175).
There are, quite simply, too many exceptions to
the authors assertions. Certainly, there are heroin
addicts, for example, for whom the drug intensifies
or even liberates anger or rage, people who otherwise inhibit aggressive inclinations. But, in others,
heroin may sharply reduce aggressive behavior. One
mainline heroin addict stated, in interview after
detoxification: Until I took up drugs I had very
little control of my violent feelings. They would
burst out all over the place. Since Ive been taking
drugs, Ive felt more at easeI just dont get so
aggressive (Ronald, reported by Wiseberg,
Yorke, & Radford, 1975). But another patient who,
before taking drugs, was very timid and could not
show a degree of aggression adequate for normal
adaptation found that, under the influence of heroin,
though not stoned, he could be constructively
forceful (Paul, reported by Wiseberg, Yorke, &
Radford, 1975). In higher doses these responses are

43

obliterated as stupor approaches or supervenes. And


if what Khantzian says of depressants is often true, it
is also true that reduction of anxiety is an effect of
other drugs, possibly dependent on the source of the
anxiety. Some heroin addicts whose anxieties have
been aroused by their libidinal urges find their libido
sufficiently damped down by the drug to obviate
these anxieties; and when sexuality is a source of
shame, the taking of the drug heightens their selfesteem and feelings of well being (Wiseberg,
Yorke, & Radford, 1975, pp. 107108). There is,
quite simply, no consistent response in different
patients.
Wiseberg, Yorke, and Radford (1975), discussing the undoubted harmpsychological and physicalof addictive drugs, put the question: Why do
people use dangerous drugs?1 They pointed out
that, when the use of such drugs did boost selfesteem, this might well be felt by some to outweigh
the dangers, especially so by those who have a
defect in reality testing, however circumscribed, and
who, on that account, do not fully appreciate the
danger to which they subject themselves. Those
whose egos are weak in other respects may also
discount or set aside the danger (Wiseberg, Yorke,
& Radford, 1975, p. 107). But in some of their cases
there were no indications that the use of the drug
had any such effect on self-esteem. In other cases,
where there was an apparent rise in self-esteem, the
reasons for this were not consistent from case to
case. They did not simply function as a source of
narcissistic supplies. In addition to the examples
given there are other ways in which the use of
heroin may appear to enhance self-esteem. The
modification of critical superego functioning, temporary changes in the defensive organization, redistribution of drive energy, the approval of
drug-taking peersall these may increase the addicts self-esteem, at least while the drug is operative.
There are many other reasons for taking drugs
for kicks and sexual gratification among themand
for addicts of this kind the buzz is what really
matters. And for some mainline users the injection, the use of the needle, is of special importance.
To exemplify:
I think the needle and syringe are as important as
the drug. I like to flush a great deal and I do it over
and over again. I am sure this is sexual. Its like
masturbation. I always tried to put off the orgasm as
long as possible. If I felt one coming on, I would
stop and start again and swear by something holy.
[Gianetta, in Wiseberg, Yorke, & Radford, 1975,
p. 104]
1
Freud referred to the problem of why people take morphia, cocaine, etc. in 1930.

44

Clifford Yorke

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I get a kick out of giving myself injections, and


didnt like it much if someone else injected me. I
enjoyed the routine, finding a vein, filling a syringe,
and flushing. . . . I would flush and flush and flush
until I couldnt continue because it clotted. Having
injected all the H, I would flush in and out the
ordinary blood. I dont know whyit was a sort of
compulsion to make the fix last longer. I couldnt
bear to pull the needle out. [Sarah, in Radford,
Wiseberg, & Yorke, 1972, p. 164]

Here, again, the masturbatory quality is evident, and


it reminds us of Freuds early opinion that masturbation was the primal addiction (see later).
What Khantzian considers attempts at self-correction are not, however, meant to be restricted
to affect regulation but include what he calls disordered self-care and two contributory factors in
the addicts personality: disordered self-esteem
and disordered relationships. I take disordered
self-care to refer to various forms and degrees of
self-neglect including neglect of the bodily self,
often stemming from impaired self-esteem. I have
already made brief reference to self-esteem in relation to drug effects, but it is a complex matter, and
more will be said about it, as well as self-neglect, in
relation to the part played in addiction by selfdestructiveness. Disordered relationships are a
common companion of almost anyone with severe
psychopathology and are, as we know, protean in
form. The phrase is imprecise.
One last word about self-correction. Even if the
self-medication hypothesis had the general significance that Khantzian believes it to have, he does
acknowledge that these attempts at self-correction
ultimately fall short (p. 12). Indeed, he refers to the
long-term effects as devastating, and few would
disagree with him.
Addictions not intrinsically involving drugs
Before proceeding, a brief digression at this stage
about the nature of psychic conflict may be helpful for those neuroscientific readers who may not be
too familiar with the psychoanalytic concept of
drives in relation to conflict. (I hope those who feel
at home in the field will bear with me.) Conflict
with the external world is universally acknowledged
and easily understood, and in the absence of introspection (rare among neuropsychologists) may be
the only type of conflict to be readily recognized.
The Freudian concept of drive organization linked
with erogenous zones (e.g., oral, anal, urethral,
phallic) is also well known to those who take any
interest in psychoanalysis, and conflicts arising during those developmental stages are generally understood, whether or not Freuds specific formulations

are accepted. But psychoanalysis also recognizes


that instinctual life involves the operation of internal and inbuilt forces, complementary but in opposition to each other: masculinity/femininity, love/
hate, activity/passivity. All of these are operative in
everyone throughout the history of the mental organization and can be found in the developmental
phases centered on the different erotogenic zones.
One such pair of conflicts is clearly exemplified in
active looking (voyeurism) on the one hand, and its
opposing complementthe wish to be looked at
(exhibitionism)on the other. We speak of phallic
exhibitionism, for example, but anal exhibitionism
is familiar to us, perhaps most commonly thought of
in the popular imagination in terms of an offensive
gesture.
In approaching the problem of addiction from a
psychoanalytic point of view, it may first be useful
to remind the reader that addictive behavior is not
restricted to taking drugs. An understanding of it,
then, is unlikely to be based on the effects of drugs
alone. That said, a working definition of addiction,
however rough and ready, seems an advantage.
Certain points seem generally agreed. The addictive substance or the addictive act is compelling,
and difficult, if not impossible, to resist. The need
for it is a majoroften the majormental preoccupation, and the addict is prepared to do almost
anything, including steal and lie, to satisfy his/her
craving. There are, necessarily, limitations on the
lengths to which any given person is prepared to go
to achieve this end, but those limits may become
increasingly elastic as addiction takes greater hold
and internal resistances loosen. An indispensable
feature of addiction is that its satisfaction is shortlived and demands repetition. (In the case of many
drugs habituation may demand increasing doses to
achieve a comparable effect.)
Addiction is driven. A factor common to all
addictions, then, would seem to be a powerful and
imperative need, an appetitive striving, that threatens the addict with Unlust [unpleasure] if gratification is not to be had. Unpleasure, in this
context, is used in a rather wide sense and has both
bodily and mental connotations. The psychoanalyst
regards appetitive strivings as manifestations of
drive activity and, in this, will consider sexuality, in
its widest psychoanalytic sense, as well as aggression, of prime importance. But, since it is undisputed that powerful addictions do not necessarily
involve drugs, can the role of sexuality in these
disorders be of similar significance?
Freud was the first psychoanalyst to approach
this question (cf. Fenichel, 1945), but he first did so
by way of alcohol addiction. Writing of dipsomania
in a letter to Fliess dated January 1897, he took the
view that drinking was a substitute for an associated

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Understanding Addictive Vulnerability Commentaries

sexual impulse and, later in the same letter, made


the suggestion that a similar substitution might be a
basis for gambling. In another letter to Fliess on
December 22 of the same year, he referred to masturbation as the primal addiction, for which the
use of alcohol, morphine, and tobacco were substitutes. He did not stress, as he would have done later,
that masturbation is inexorably tied up with the
fantasies that go with it, the content of which is both
various and varied. Although people often speak of
guilt over masturbation, analytic investigation repeatedly reveals that the guilt stems from the fantasies, largely unconscious, that accompany the
practice (e.g., the forbidden incestuous fantasies of
early childhood). And when we reflect on the fact
that masturbation fantasies can be of the most perverse kind, we are not surprised that many perversions have an addictive quality.
Freud did not return to the subject of gambling
until 1928, when he wrote his paper on Dostoevsky
and Parricide. Apart from the historical importance
of the paper and the murderous fantasies of the great
writer, the compulsive masturbatory tie to the addiction involves unconscious guiltor rather the need
for punishmentas a motivating factor. That factor
may be of great importance in the persistence of the
addictions, as indeed it is in a great deal of crime. (It
is striking how often crime and gambling go together.)
Certain addictions are quite overtly and unambiguously sexual. Flashing is a common-enough
example: the flasher repeatedly risks arrest and
imprisonment by his compulsion but is not deterred
by his knowledge of that danger. Cottagingthe
roving lavatorial promiscuity of some practicing
homosexualsis another clear example: although
its mode of gratification is different from flashing, both seek an anonymous object and, in both,
voyeurism and scopophilia are important components. In both, too, reciprocity is an aim, though
rarely achieved in the case of flashing. The anonymity is of some interest: the sexual interchange is
without a persona.
Of other addictions that are unmistakably sexual,
stalking is a striking example, and one in which
looking and the wish to be looked at play an important part. Here the aggressive component is every bit
as plain as the sexual. That is unambiguously the
case with the predatory stalker intent on rape, as it is
when a resentful stalker pursues a former spouse or
lover bent on revenge (the typology adopted by
Mullen, Path, & Purcell, 2001, and Mullen et al.,
1999). In one well-known type that may achieve
publicity when the victim is well-known, the perpetrator bombards his prey with love letters and
follows her every movement, and, if indeed she is a
celebrity, his infatuation drives him to read every-

45

thing he can about her, see every show she appears


in, or read every book she has written. When, as is
all too likely, he repeatedly fails to get any kind of
response other than hostility, love may give way to
the hate that is never very far beneath it, and a
dangerous animosity supervenes. The more sinister
aspect of this type of stalker is what normally marks
the difference between stalking and a teenage crush.
The double-sided nature of the attachment is revealed, though the hostile component could perhaps
have been inferred much earlier as an obsessive
infatuation turns to determined pursuit and a relentless, tormenting persecution that is not to be shaken
off.
Not that the perpetrator is always a man or the
victim a woman, and not that every teenage crush is
simply that and no more. And the stalking may not
always be consciously sexual and persecutory, at
least to begin with. A colleague is analyzing the
intriguing case of a young adolescent girl who is
unable to stop herself spying on two teenage girls
friends of each other, though not of hers. The stalker
feels she has to know everything about the objects
of her compulsive fascination and everything they
do, separately or together. She watches them from
every possible vantage point, often, though by no
means always, in secret. She repeatedly calls them
by telephone, though she says nothing when her
victim lifts the receiver.2 She too bombards her
victims with letters and emails, but unlike her spying, declares her identity. She begs for recognition
and reciprocity, but the girls refuse her advances,
complain to their mothers, and finally tell the police.
A good deal of analytic work was needed to uncover
the homosexuality, but it is only intermittently recognized. (It appears to be linked with an aggressive
incestuous attachment to an uncaring mother.)
There is a penetrating curiosity to see inside the
girls and, even perhaps, to see (and recover?) the
(stolen?) penis. But there are only hints of this, and I
hope that, when the analysis is finished, the patient
will one day be written up if problems of confidentiality can be overcome. It would, I believe, be highly
instructive: there are many puzzling and unanswered questions.
In cases of stalking, the object of attention
unlike that of the flasher or cottageris rarely
anonymous. All these perverse activities are carried
out and recalled without shame. (Shame, after all,
normally brings with it a wish to hide. Fear of being
found out is a different matter.)
If we are inclined to attribute powerful voyeuristic/exhibitionistic impulses to flashing, cottag2
Note the similarity with those addicted to making chillingly silent
calls to women they do not know, or alternatively try to talk dirty to
them.

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46

ing, and stalking, we need to acknowledge that


other component instincts are by no means excluded
from these perversions, any more than they are from
the normative. The rapid reversal from love to hate
in stalking is nothing if not striking (it has led to
murder), and conflicts between masculinity and
femininity always need to be looked for. That may
seem obvious in the case of the young female teenager stalking other teenagers, but, by its nature,
analysis looks beneath the surface. When a marriage
breaks up, passionate love may be followed by
equally passionate hate.
It seems worth recalling that Freud regarded the
libidinal and aggressive drives, under normal circumstances, as fused, so that the libidinal drives can
modify the aggressive and destructive onesor, in
different terms, that love can modify hate (Freud,
1923). Conversely, defusion of the drives would
liberate aggression from the moderating influence
of libido. Normal sexual intercourse calls for a
degree of healthy and facilitating aggression, and
this seems in accord with the concept that preoedipal contributions to the drive organization, including the sadistic elements, are brought under the
control and synthesis of the growing maturation of
the drive organization as the oedipal phase is negotiated and adolescence continues the task. Defusion3
of the drives opens the way to all degrees of cruelty.
These few summarizing sentences cannot convey
the complexities of these processes, but may give
some idea of the psychoanalytic understanding of
the underlying switch in such perversions as stalking as well as the process of falling out of love.
Of the addictions in which perverse sexuality is
conspicuous, pedophilia and child pornography receive a good deal of public attention. Interestingly,
pedophiles keep quiet about their practice to avoid
criticism from outsiders, but as a rule they have
no feelings of shame about it. (The question of
superego functioning in addictions is a complex one
and is touched on briefly below.) And although
multiple murders have always attracted attention,
the recent case in the United Kingdom of Harold
Shipman raised, starkly, the addictive nature of his
actions, though details of motivating influences
have never been known. The list of addictive
behaviors is far from complete: readers will have no
difficulty compiling their own. Food addiction is so
widespread it must be mentioned, but before introducing the next section of this paper with a few
words about it, some comments on kleptomania may
be in order.
Shoplifting may or may not be compulsive. There
are many different personal backgrounds to this
3
The history of Freuds views on the fusion and defusion of drives
is a long one and is summarized by Strachey in his introduction to
Civilization and Its Discontents (Freud, 1930, pp. 5963).

Clifford Yorke

common type of theft. It may simply be a transient


phase in the teens; it may be part of more sustained
criminal activities; it may be used to ward off depressive feelings and produce a sense of triumph
and exhilaration: the causes are many. Its diversity
is reflected in the literature. Menninger (1968) is
mostly concerned with its frequency in women during the involutional period when an increase in
sexual drive is the rule. But it must be remembered
that addictive thieving is common at other ages:
many teenage girls shoplift, though not necessarily
compulsively. Certainly, it can provide kicks.
Abrams (1996), for example, has discussed the case
of a boy who insisted he was a girl, laid claim to
feminine accoutrement such as jewelry and high
heels from early in his second year, and was shoplifting cheap jewelry by the age of 4 years. Certainly
what Freud called the compulsion to repeat (see, in
particular, Freud, 1920) is operative in this case, as
it is in addictions generally. Unlike shoplifting,
the term kleptomania points to the compulsive
factor but embraces addictive thieving of all kinds.
It is particularly common in teenage girls.
In this connection, Blos (1957) underlined the
fact that delinquency follows separate pathways and
is essentially different in males and females. This
reflects the divergent psychological development of
boys and girls during early childhood and the influence this has on the structure of the ego of the
different drive organizations, subject to different
vicissitudes, in male and female. The girl is in close
proximity to the perversions in a way not true of the
boy and, furthermore, lacks the destructiveness to
both person and property common in the young
male delinquent. The girl delinquent inclines, far
more than the boy, to kleptomania, vagrancy, sexual
waywardness, and provocative and impudent behavior in public. In the girl, it can be said that
delinquency is an overt sexual act, or, rather, sexual
acting out. In the girl, the aims of the pregenital
drives dominate delinquent behavior and thus relate
it to the perversions.
As Blos (1957) understands it, kleptomania is
closely linked with penis envy, but underlying it is
an accusation that the mother has willfully withheld
the expected gratification vital to overcoming her
oral greed. The penis or fecal symbol is obtained by
robbery, stealing, and deceit. The connection between kleptomania and both revenge and restitution
has been emphasized by others, including Ornstein,
Susan, and Bogner (1983).
The link between kleptomania and penis envy
had long been emphasized by others, notably
Abraham (1922), Chadwick (1925), and Friedlander
(1945). The relationship with fetishism in the male,
in which the female garment symbolizes a penis, is
well known, but its very rare occurrence in the

Understanding Addictive Vulnerability Commentaries

female has been recorded by Greenacre (1953) and


Zavitzianos (1971).
Lastly, Frosch (1990) is surely right in classifying kleptomania, pyromania, pathological gambling, and the drug and sexual addictions as impulse
disorders.

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Drug addiction
Self-damaging bulimia notoriously takes on an addictive form in which the compulsion is hated and
condemned as forcefully as the compliance from
which it is inseparable.4 Its relationship to drug
addiction is of considerable interest. Benedek
(1936) described a woman with a polyphagia who
consumed large quantities of food, alcohol, ether,
aperients, and other medications, though never narcotics. Elsewhere (Yorke, 1970), I suggested that
such a case might provide a bridge between alcoholism and the so-called food addictions. In this connection, it seems worth recalling some comments of
Anna Freud (1965). There, in a brief discussion of
addiction, she referred to a quantitative increase in
otherwise normal tendencies that gave an impression of perverse behaviour (p. 201). She then
turned to children who have an overwhelming
craving for sweets superficially similar to adolescents and adults addicted to alcohol or drugs. Like
adults, the satisfaction of their need acts as an
antidote [to] anxiety, deprivation, frustration, depression, etc., and, just like adults, they will lie and
steal to get hold of what has become a necessity.
She considered, however, that there were important differences between childrens craving for
candy and the addictions of their elders. The craving
for candy is a straight-forward expression of a
component drive rooted in unsatisfied or overstimulated wishes of the oral phase of development,
desires that have grown excessive and by virtue of
quantity dominate libidinal expression (p. 201). As
the child grows up, the sweet eating may be displaced and be reflected in excessive drinking of
water, overeating, gluttony, and perhaps in smoking (p. 202). They are often reflected in the choice
of relationships with those who sustain and give
comfort.
These outcomes in later life do not, for Anna
Freud, have the character of addictions. She considers addictions to be more complex and add to the
4
It is well known that bulimia may follow a period of anorexia
nervosa. An anorexic patient of mine came into treatment when she was
15, with her weight alarmingly low. After some time, she began to wake
up each night at 2:00 a.m. with severe anxiety. When she reported such
an attack, I suggested that she may have been frightened that, in a wish
for a night-feed, she would get up, raid the fridge, and eat everything in
it. The next night, that is exactly what she didshe was then bulimic.

47

oral needs passive/feminine and self-destructive


tendencies (p. 202). Accordingly, the addictive
substance is not simply good, helpful, and strengthening like the childs candy. It is also felt to be
weakening and overpowering, emasculating and
castrating, as, in fact, drugs and excessive alcohol
really are. The two opposing drives come together
in the wish for both strength and weakness, activity
and passivity, masculinity and femininity. In these
respects, the benign needs of the excessive candy
eater are very different from the cravings of the
addict.
Anna Freuds reflections, expressed both in her
book (1965) and in discussions at Hampstead, led
me to review (Yorke, 1970) the existing psychoanalytic literature on drug addiction. Rosenfeld (1965)
had already done this, but he seemed to me to treat
the many contributions to the literature as if there
were some degree of accordance between them, and
as if each emphasized different aspects of a mutually recognized pathological mental structure and
functioning. To my mind this was far from the fact
of the matter.
It seemed to me that a careful reading of the
literature showed only confusion, ambiguity, and
contradiction (cf. Wiseberg, Yorke, & Radford,
1975). Indeed, many authors failed to acknowledge
or perhaps even recognize the views and opinions of
others.
I ended my 1970 review by drawing attention to
some of the difficulties underlined by the study. The
problem of definition was one, but there were a
number of others. Not all writers distinguished between the psychological effects of taking a drug and
the psychic consequences of its pharmacological
actions. More disquieting, perhaps, was the conclusion that idiosyncratic viewpoints can sometimes
obscure otherwise useful clarifications of existing
knowledge; that too many papers fail to supply
convincing clinical evidence to support their assertions; [and] that, overall, there is a good deal of
diagnostic disarray (p. 156). This could sometimes
be traced to an unfortunate tendency on the part of
some writers to equate depressive affect and its
relief with manic-depressive states and, of others, to
mistake the compelling character of addictions for
obsessive-compulsive states. And, in summarizing
those conclusions elsewhere, a further ground for
criticism was emphasized: namely, the remarkable
refusal of a number of writers to acknowledge the
contributions of their colleagues and predecessors
and even less to make use of them (Radford,
Wiseberg, & Yorke, 1972, p. 157).
Reflecting on this unhappy state of affairs, we
took the view that a substantial impediment to serious study lay in the fact that the many investigators
had failed to apply to their patients any consistent

48

Clifford Yorke

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method of diagnosis. From the psychoanalytic point


of view, a diagnosis ought to be a psychoanalytic
diagnosis or, more strictly, a metapsychological diagnosisthat is, a diagnosis in terms of the way the
sufferers mind works. And in this respect Anna
Freuds diagnostic investigations had provided the
diagnostician with an extremely useful and sophisticated tool: the diagnostic profile (A. Freud, 1962,
1965). As she herself had explained:
Fact finding during the process of assessment produces a mass of information made up of data of
different value and referring to different areas and
layers of the childs personality: organic and psychic, environmental, innate and historical elements;
traumatic and beneficial events; past and present
development, behaviour, and achievements successes and failures; defences and symptomatology,
etc. Although all the data that are elicited merit
careful consideration, . . . it is basic to analytic
thinking that the value of no single item should be
judged independently, i.e., not without the item
being seen within its setting. [1965, p. 138]

The profile schema allows the diagnostician to organize information available at the diagnostic stage
into a comprehensive picture of the patient in metapsychological terms5that is, in terms of dynamics,
structure, economics, and genetics. A profile of this
kind can only be provisional, since it is based only
on the information available at the time the assessment is made. A patient who subsequently enters
psychoanalytic treatment will, little by little, reveal
much more information, some of which will no
doubt confirm and enlarge on the initial assessment,
while some of it may cast doubt on some of the
initial conclusions. But, for all its limitations, the
profile is the most efficient instrument we have for
psychoanalytic diagnosis at the stage of assessment.
It has the considerable merit of examining, as
closely as current information allows, the relevant
contributions of a large number of variables, not
only to the presenting clinical picture, but to the
personality in which that picture is embedded.
Many psychoanalysts who are concerned with
the importance of clinical research have overlooked,
in this respect, the strength and value of the profile.
It offers a standardized structure within which available data can be brought together and expressed in
metapsychological terms. And
since this structure is known and reproducible by
psychoanalytically trained clinical research workers anywhere, the Profile can be checked and
rechecked wherever the original data are available.
Furthermore, practiced users of the Profile should
5
Nonpsychoanalytic readers of this Journal should note that
metapsychology simply refers to a psychology that looks beyond consciousness.

have a high standard of consistency from case to


case; and there should, in addition, be reliable
comparisons between the work of one group of
investigators and another. Research workers are
free to delineate points of comparison between one
patient and another and between groups of patients.
[Radford, Wiseberg, & Yorke, 1972, p. 158]

We pursued the argument further:


The Profile thus becomes a systematic method for
investigating problems of personality development
and function. From the standpoint of the behavioural sciences, it affords a method that can be
replicated and reviewed by outside observers.
Within a standardized framework, it opens up the
complexities of normative and deviant personality
development to an investigative method that has a
coherent theorypsychoanalysiswhich is both
its rationale and its organizing and defining basis.
[p. 158]

The use of the Profile offers a distinct advantage


in those patients who, from a descriptive point of
view, are commonly grouped together, but whose
nosological status is, to put it no higher, distinctly
uncertain. In the investigation undertaken at the
time, we undertook the systematic metapsychological assessment of a group of patients generally
described as main-line heroin addicts. As we put
the matter later:
Our current Profile studies were based on detailed
social historical and psychiatric reports derived
from extended interviews carried out by ourselves.
To minimize the number of variables we confined
our pilot investigation to 10 subjects who were
regularly mainlining with heroin, whether or not
they used additional drugs. All were seriously addicted to their drug to a point at which their craving
for it and their need to procure it were for each the
major priority; and all were physiologically as well
as psychologically dependent on it.

All these patients were members of an inpatient unit


for the treatment of addiction along therapeuticcommunity lines, though in carrying out this study
we had no responsibility for the treatment program
or the hospital care. All patients had been withdrawn from drugs for some weeks before they were
assessed, though one or two had minor lapses. We
restricted our choice of patient to those cases where
an independent early history was availablea necessary but further restriction on the range of patients
assessed. Commenting on this limitation, we asserted that had we restricted our studies to addicts
serving prison sentences [for example], our findings
might well have been different (Wiseberg, Yorke,
& Radford, 1975, p. 100). (It should perhaps be
noted that two patients were in the addiction unit as
conditions of probation.) In considering the limitations of the study, we had to bear in mind that all

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Understanding Addictive Vulnerability Commentaries

these patients were engaged in group treatment


under a special inpatient regime and had already
been selected by the staff of the unit on the basis of
their suitability for such a setting. Addicts who were
unprepared for such measures were necessarily excluded, and many more of the seriously delinquent
addicts would not be found in such a sample
(Radford, Wiseberg, & Yorke, 1972).
If the results of the investigation had pointed to
significant psychopathological factors common to
all the cases under investigation, the sampling
method (described in the Khantzian paper) would
not have justified extending the conclusions to all
addicts. But since this was not the case (the findings
were striking for their inconsistency), it was hardly
credible that, in a sample chosen differently, the
psychopathology would have shown greater uniformity.6 It was extremely difficult, if not impossible, to point to factors common to manyindeed, to
allof the patients studied. It is not difficult to
demonstrate the differences even within the restrictions of particular kinds of disorder. Let us take two
features of drug addiction mentioned by Anna
Freud in addition to what she called the satisfaction
of oral needsnamely, passive/feminine and
self-destructive tendencies. It seems likely that in
referring to passive, feminine features she only had
males in mind and that, in female addicts, bisexual
inclinations would be revealed in masculine trends.
The sexual organization of three females in our
sample of ten addicts showed that all were polymorphously perverse, though in one phallic/narcissistic
trends were uppermost. Yet for all that, the differences between them were substantial. The sexual
organization in two of them is briefly mentioned
below, while that of the third was as wildly disorganized as that of any young woman I can recall.
The sexual organization of five casesin terms
of sexual preferencesis touched on below, with a
few quotations from each published report, and a
little is said about each patients aggression. In each,
some preliminary remarks may serve to identify
them as real people. In no sense are these comments
case histories: they are simply concerned with the
extent to which Anna Freuds two points apply to
these cases. Since the persistence of such trends
indicates a failure to negotiate the oedipal phase,
comments on this were recorded in each report. And
if the reader wonders why, for illustration, I go back
so many years, I would say there are two good
reasons. The first is that the reader can turn to the
published reports for further details; the second is
that, to the best of my knowledge, these diagnostic
investigations of drug addicts are the most thorough-going of any yet published.
6

Effectively, this view belies our conjecture about a prison sample.

49

But in reading what follows, it may be helpful to


bear in mind that Freud discussed the use of the drug
as a love-object, though in this respect his comments were restricted to alcohol. In his second contribution to the psychology of love (1912), he
compared the relationship between lovers to that of
a drinker to his wine. In a passage that borders on
the poetic, he drew an impressive picture of a drinkers love affair with his favorite beverage. The
extent to which the addictive drug replaces human
relationships is an important question for the diagnostician.
Sarah (age 20)

The wanted first child in a respectable upperworking-class family, from the age of 3 or 4
years Sarah was Daddys girl until her puberty.
From that time on she was openly contemptuous
of her father, perhaps on account of incestuous
wishes. The mother was timid, unadventurous,
and of narrow and rigid outlook. At interview
Sarahs dress was untidy, though her hair was
beautifully kept. She talked well enough, if a
little discursively, and her affect was humorous
but unvarying. She was mildly euphoric, giggly,
rather histrionic, and a little flirtatious.
(a) There were clear homosexual tendencies in
her makeup: I went through a lesbian phase
from 11 to 14 . . . imitation lovemaking in bedrooms with a number of girlfriends, each pretending to be a boy and swapping roles. There
was kissing and mutual masturbation between
them. Although she mentioned fantasies of men
in such situations, there was a continuous inclination toward homosexual practice beyond the
age of 14 and, indeed, up to the present time. I
appreciated a womans body. There was a girl at
school I fancied when I was 16. . . . In prison
butch lesbians fancied me, and if a woman had
made advances I just would have gone with her.
This homosexuality was uninfluenced by the
drug taking, and it can therefore be said that she
failed to resolve the re-emergence of the negative oedipal (phallic) phase in adolescence. The
wish for the narcissistic possession of a penis
was evident.
Her close relationships were need-fulfilling and
constant while they lasted. They were chosen on
a narcissistic basis of an altogether unusual degree. She said of her former girl friend: I cant
say much about her except we were the same sort
of person. We were terribly alike; we used to
think the same sort of things were funny. She had
black hair, the same length and color as mine. We
always had it cut and grew it at the same time.

50

Clifford Yorke

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She was the same height as me. We got into the


same difficulties at school. . . . It was like knocking about with oneself. Her longest relationship
was with a male drug addict, again remarkably
like herself: We viewed the world in pretty
much the same way; we were just like one person, not like two people courting; we adapted to
each other immediately and had no other
thoughts. Its the common bond in junk.
(b) Sarah was clearly aware that her timidity
(which fluctuated a little) was defensive: Im
inclined to be aggressive, but when I was younger
I didnt know it very much, but would burst into
tears, crying hysterically for hours. But she went
on to say: If someone else was spoiling for a
fight, Id lay into them, otherwise Id bottle it up
until my next outburst. After I was 8, when I got
into a temper, I would yell and scream, attacking
them with words but never physically.
Her fights with her father in early puberty have
been mentioned. As for her mother, for whom she
expressed contempt, it was not always easy to
differentiate her aggressive from her sexually
sadistic behavior: Mother was always so very
long-suffering. I felt malicious trying to get her to
show some hurt; she never did.

stemmed less from fears of aggression than from


his feminine attitude. He expressed a great deal
of curiosity about what it would be like to experience homosexual relationships, but said he always avoided them.
Latent wishes to be a passive, feminine partner
with men stemmed from competition with his
mother for her partners, as well as from his
relationships with surrogate fathers. . . . His subsequent relationships with men had marked
homosexual implications, and his fear of homosexuality made him leave the Merchant Navy. . . .
Ive never wanted it, but I thought about it,
thought what it would be like, what it would be
like with a man, any man.
(b) Despite his passivity, his aggression was under normal control and was at the service of his
personality, working life, and sublimations. He
stood up for himself well in the rather tough
world of the Merchant Navy. His attitude to
aggression was summed up in his own words: I
had normal quarrels and arguments, but I avoided
fights. Thered be no sense in it. If anyone bashed
me I would bash them back, but if they only
insulted me Id walk away.
Gianetta (age 23)

Richard (age 20)

Richard was an illegitimate only-child brought


up by his mother and maternal grandparents until
his mother married when he was 2 years old. He
was displaced from his mothers bed. Severe
night terrors began and continued till the age of 7.
Though a contented and healthy baby, his mother
wished he had been a girl. Cleanliness, tidiness,
and quiet behavior were enforced. He was expected to behave like a good girl. When he
went to school he was dressed prettily and was
bullied. He was enuretic until 13. His mother
liked his passivity. But he became rebellious, lost
interest in schoolwork, and began to truant. He
became aware that both parents were having affairs.
He joined the Merchant Navy to train as a ships
cook and did well. He disliked the attentions of
active homosexuals but was at ease with passive,
feminine ones. He gave up after six months,
found work in a shop, did well, and was put in
charge.
(a) Richards sexual relations were limited. His
most lasting relationship was with a girl who
refused to have sexual intercourse with him. Furthermore, he was always attracted to girls who
had some physical disability. His passivity

Gianetta was strikingly good-looking and dressed


with dramatic elegance. Of superior intelligence,
she was lively, articulate, and relaxed at interview. Working-class in origin, she was at home
with people from every walk of life.
She was the first and only child of a handsome
and well-dressed mother and an alcoholic father.
She walked and talked early. Toilet training was
inordinately quick, but she never regressed. She
developed against a background of continuing
drunkenness and violent scenes. Temper tantrums and nightmares were frequent. The mother
slept with her, apparently to protect her from her
father, but when the marriage broke up when she
was 4 years old she missed her father intensely. A
year later she was displaced from her mothers
bed by a physically cruel and tyrannical stepfather. At school she played truant, forging notes of
excuse ostensibly from her mother. She left
school at the first opportunity.
(a) Gianettas aberrant sexual development began with seduction by an uncle at the age of 3
years and continued throughout childhood. Following her physical maturation, she quickly became pregnant, married, and abandoned the baby
to the father, who left her. She became a wellheeled call girl with impressive apartments in

Understanding Addictive Vulnerability Commentaries

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London and Rome, and she indulged the varied


and perverse tastes of her clients. She had a
number of sexual friendships with both men and
women, with whom she showed her partiality for
humiliating sexual partners. She described one
such encounter as follows: I felt very sexy. I
bought a couple of penny canes. I tied Sam up
and tied his penis in a little bag and beat him.
This was very exciting for both of us. It gave me a
feeling of power.
Drug taking began with LSD and progressed to
barbiturates and amphetamines. She felt weakened, lost some of her drive, and completely gave
up her sexual activity. Once she began mainlining, she was rapidly hooked, and her one
and only interest was in maintaining her supplies
of the drug. She lost her money and lived rough
with junkies, for whom she expressed contempt. She was living in utter squalor.
(b) Aggression against her mental and bodily
self was undoubted, but was far from conspicuous in her social conduct. The self-damage was
most striking in the drug-taking phase, and her
rapid deterioration made her horrified when she
realized the appalling damage she had done to
herself.
Ronald (age 19)

(a) Before he started to take drugs, Ronald was


strikingly passive. Sexually, he was strongly inhibited: although he had girl friends from time to
time, he made no sexual advances toward them.
In terms of drive development, he showed pronounced oral and anal characteristics: these
preoedipal features were insufficiently modified
by weak though definite oedipal trends. He believed in the magical powers of his dominating
mother: she was like a witcha phallic woman.
This belief in his mothers magical powers included a faith in the magic of medication. Whatever was physically wrong with him, there was,
he believed, a medicine to put it right.
At puberty disfiguring acne increased his sense
of worthlessness, and his doctor prescribed phenobarbitone. At 13 he began to take hashish and
amphetamines, and at once his self-esteem rose
dramatically. He moved on to heroin, and was
very self-confident. His dislike of his body dramatically receded (I felt ten feet tall). He
started to dress well: I became a leader of
Carnaby Street fashion. The drug amply satisfied any sexual feelings or needs (he was in fact
impotent and blamed this on his fixing). He
idolized the syringe and took the greatest care of

51

it: People joked about how I carried it around in


a little glass case. It was treated as if it were a
very precious penis.
(b) Ronald felt unloved and unlovable, and the
aggression normally aroused under these circumstances was massively inhibited before he took
drugs. He sought acceptance through compliance. He tried to be good and conforming in
relation to his parents. With his peers he was
whatever they wanted him to be: indeed, he lent a
group of delinquents his mothers car to help
them carry out a robbery. His overriding need to
be loved and wanted made any aggression taboo:
If someone raised a voice, I thought there was
going to be a fight, so I always agreed with
everything. I thought anyway that they must be
right. Once, when he was talking to his girl
friend, a boy rode up on a motorbike and offered
to give her a ride. She accepted, and Ronald did
nothing: I would never fight for a girl.
All this changed when he was taking drugs, and
his use of them escalated. His inhibition of aggression was strikingly reduced. He became quite
openly sadistic toward his parents and became
demanding toward them. There was nothing coincidental about the worry and concern he caused
them: it was quite deliberate. He felt powerful in
relation to his peers, dominated them, and pushed
drugs on them. In spite of this degree of social
success, he still, at bottom, needed approval, and
he took part with a group of delinquents in breaking and entering.
Paul (age 26)

Paul was the unwanted second child and son of


successful middle-class parents, but his mothers
pleasure in feeding him made her feel close: food
became an important part of his life. As time
went by, he went to some lengths to avoid rivalry
with his bright older brother, whom he came to
see as goody-goody.
(a) Girls were either highly respected or denigrated sexual objects. For example, Paul found
himself a girl friend who resembled his mother
and whom he greatly respected and with whom
he had no sexual relations. He told her about his
drug taking, knowing it would force her to abandon him. A woman well over twice his age, on
whom he looked down, met his sexual needs: I
just went to her for pills and sex. Developmentally, he was arrested in the positive oedipal
phase with this common adolescent split. Overt
bisexual features were exiguous. His relations
with male companions when he was in the Mer-

52

Clifford Yorke

chant Navy were good and occasioned no anxiety, and he enjoyed eating and drinking with
them. Drugs excited him sexually. He took part
with other drug users in some bizarre activities,
and some wayward sensual pleasures were reinforced by the use of electric shocks.

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(b) He was inattentive and rebellious at school


and was involved in minor delinquency. At 15 he
was involved in an attack on a school prefect,
who was beaten up and needed treatment in hospital. He took a manual job, got on well with his
fellows, and started taking pot. He was soon
taking heroin and cocaine and became hooked
on heroin: I thought drug taking was rather
glamorous and dangerous. His aggression was
generally under control and was subject to satisfactory sublimations.

Comments on the clinical illustrations


These few, highly selective items cannot, of course,
reflect the complexities of these patients mental
functioning. To do that, they would have to be seen
in the context of a functioning mindsomething a
reasonably comprehensive profile aspires to do.
When attempting to examine sexual orientation and
range and use of aggression, one needs to know so
much more. The superego, for example, plays such a
big part in the regulation of self-regard, the setting
up of aims and social standards, and the role of guilt
as well as self-criticism in personal behaviorincluding delinquencythat without some understanding of its operation a good deal of what has
been said about these patients makes limited sense.
And the superego itself draws substantially on other
aspects of the personality in its structure and functioning. Guilt draws on the aggressive drives; selfapproval on the sexual drives in their degrees of
sublimation. And further reflection on the difference between the male and female superego would
be kept in mind in any general scrutiny of these
cases. It could of course be argued that a very
general common factor would lie in the fact that the
psychological development of these patients was
interrupted. Here, I do no more than point to Anna
Freuds firm understanding that, in assessing mental
functioning, all parts of the personality must receive
their due. That view is remarkably close to Lurias
in his neuropsychological work.
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