Groups and neurobio of addiction

Group Psychotherapywith Addicted PopulationsAn Integration of Twelve-Step

and Psychodynamic TheoryThird Edition

Philip J. Flores, PhD

The Haworth Press®New York

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PUBLISHER’S NOTEThe development, preparation, and publication of this work has been undertaken with great care. How-ever, the Publisher, employees, editors, and agents of The Haworth Press are not responsible for any errorscontained herein or for consequences that may ensue from use of materials or information contained inthis work. The Haworth Press is committed to the dissemination of ideas and information according to thehighest standards of intellectual freedom and the free exchange of ideas. Statements made and opinionsexpressed in this publication do not necessarily reflect the views of the Publisher, Directors, management,or staff of The Haworth Press, Inc., or an endorsement by them.

Special thanks to Jason Aronson Press for their generous willingness to grant permission to use materialfrom a previous publication. Earlier but somewhat different formulations of some of the ideas in this newedition have appeared in the following publication:

Chapters 1, 2, and 4, incorporate some material from “Addiction as an attachment disorder” by PhilipFlores, which appeared in Flores, P. J. (2004). Addiction as an attachment disorder. (2004). JasonAronson Press, Northvale, NJ.

Special thanks also to Haworth Press for their willingness to grant permission to use material from previ-ous publications. Earlier but somewhat different formulations of some of the ideas in this new edition haveappeared in the following publication:

Chapter 13 incorporates some material from Conflict and Repair in Addiction Treatment: An AttachmentDisorder Perspective by Philip Flores, which appeared in Journal of Groups in Addiction & Recovery, 1,(2006), 1-26.

Material from Inpatient Group Psychotherapy (1983) and The Theory and Practice of Group Psychother-apy (3rd ed.) (1975) by Irving Yalom reprinted by permission of Basic Books, a member of the PerseusBooks Group.

Cover design by Marylouise E. Doyle.

Library of Congress Cataloging-in-Publication Data

Flores, Philip J.Group psychotherapy with addicted populations : an integration of twelve-step and psychodynamic

theory / Philip Flores.—3rd ed.p. ; cm.

Includes bibliographical references and index.ISBN: 978-0-7890-3529-5 (case : alk. paper)ISBN: 978-0-7890-3530-1 (soft : alk. paper)1. Alcoholism—Treatment. 2. Substance abuse—Treatment. 3. Group psychotherapy. 4. Twelve-step

programs. 5. Psychodynamic psychotherapy. I. Title.[DNLM: 1. Substance-Related Disorders—therapy. 2. Alcoholism—therapy. 3. Psychotherapy,Group. WM 270 F6349 2007]

RC565.F568 2007616.86'0651—dc22

2007031809

http://www.haworthpress.com/store/product.asp?sku=5995









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CONTENTS

Foreword xvJeffrey D. Roth

PART I: THEORETICAL MODELS

Chapter 1. Interpersonal Neurobiology and Addiction:An Attachment Theory Perspective 3

Interpersonal Neurobiology 4The Neurophysiology of Attachment 7Interdisciplinary Research and Attachment Theory:

A Source for Informing Addiction Treatment 9Contributions from Child Development Studies 10Contributions from the Neurosciences 19Reward Deficiency Syndrome 19Attachment and Animal Research 37Contributions of the Relational Perspective to Group

Psychotherapy 38

Chapter 2. Attachment Theory As a Theoretical Basisfor Understanding Addiction 43

Attachment Theory and Self-Psychology 45Attachment Styles and Secure Attachment 46Ainsworth and the Strange Situations 47Implications for Treatment 48Implications for Addiction Treatment 60Summary of Treating Addiction As an Attachment

Disorder 62

Chapter 3. The Disease Concept and GroupPsychotherapy 65

Abstinence: Is it Necessary? 66Paradigm Shift 74Specific Implications of Group Therapy and the Disease

Concept 81Addiction, Abstinence, and the Disease Concept 84

Chapter 4. Psychodynamic Theory and the RelationalModels 97Character Pathology and Addiction 99Contributions of Object-Relations Theory

and Self-Psychology 101Margaret Mahler’s Theory of Normal Development 106Ego Psychology and Object-Relations Theory 107Mahler’s Stages of Normal Development 112Beyond the Ego: Kohut’s Self-Psychology 126Definition of Terms 134The Self-Medication Hypothesis and Affect Regulation 138Application for Therapy: Corrective Emotional Expression 143Addiction As an Attempt at Self-Repair 152Self-Esteem Vulnerabilities 154The Reparative Approach 160

Chapter 5. Alcoholics Anonymous and Twelve-StepPrograms 163Misconceptions About Alcoholics Anonymous 164Values, Science, and AA 167Philosophy of Science and the Limits of Rationality 173The Self-Help Movement 177Alcoholics Anonymous: Its Historical Roots 178AA—Why and How It Works: An Interpretation of AA 182Pragmatism: Its Influence on AA 185Existential View of AA 188AA—How it Works: A Phenomenological Perspective 196The Self-Attribution of Alcoholism 201Honesty, Denial, and the Need for Others 204AA: A Self-Psychology Perspective 207AA: A Treatment for Shame and Narcissism 209Higher Power As an Attachment Object 214

PART II: ADDICTION TREATMENTIN THE GROUP

Chapter 6. Different Models of Group Psychotherapy 221Some Models of Group Psychotherapy 222Psychological Levels of Intervention 223Specific Applications for Addictions Treatment 250

Chapter 7. Preparing the Chemically Dependent Personfor Group Therapy 257

Selection and Composition 259Implications of Research Findings 261Therapeutic Alliance and Cohesion in Group 262Pre-Group Preparation: Increasing Treatment Retention

and Reducing Dropouts 267Recommendations for Entry into a Therapy Group 269Present and Gain Acceptance of the Contract 282

Chapter 8. Interactional Group Psychotherapy 287

Yalom’s Basic Tasks 288The Model-Setting Participant 291Interpersonal Honesty and Spontaneity 295Establishment of the Group Norms 298The Norm of Self-Disclosure 299Procedural Norms and Antitherapeutic Norms 302Importance of Group 303The Here-and-Now Activation and Process Illumination 305Interpersonal Theory of Behavior 316Sullivan’s Interpersonal Theory of Psychiatry 317Examples of Yalom’s Here-and-Now Focus 324Integration of Modern Analytic Approach 332Conclusion 348

Chapter 9. Modifications of Yalom’s Interactional Model 351

Treatment Considerations and Group Therapy 353Recommendations for Group Psychotherapy 356Protocol 356Early and Later Stage Treatment 361Therapist Attributes and Special Considerations

for Affect Attunement 364Careseeking, Affect Attunement, and Psychotherapy 368Group Therapy and ACOA 370Addiction and the Family 371Common Identified Characteristics of ACOA 372ACOA and Shame 375Alcoholics Anonymous and Group Psychotherapy 376

Chapter 10. Co-Occurring Disorders and GroupPsychotherapy: An Attachment TheoryPerspective 379

Addiction—The Cart or Horse of Mental Illness? 380Cross-Addiction 381The Relationship Between Mental Health and Addiction 384Axis I Disorders 386Axis II: Character Pathology and Addiction 386Borderline Personality Organization and Pathological

Narcissism 388Kernberg’s Borderline Pathology 390Kernberg’s Description of Supportive Psychotherapy 391Narcissistic Personality Disorder 395Dynamics of Multiple Addictions 404Integration of Divergent Treatment Philosophies 407The Relational Models: An Integration 410

Chapter 11. The Leader in Group Therapy 413

Values of the Group Leader 414The Therapist As a Person 417Qualities of the Group Leader 417Guidelines and Priorities for the Group Leader 431Roles of the Group Leader 431Focus of the Group Leader 434Characteristics of the Group Leader 438The Therapeutic Process: Therapists’ and Patients’

Contributions 443The Alliance and Addiction: Special Considerations 452Group Leadership Functions 454The Implications for Conducting a Successful Therapy

Group 456Alcoholism Treatment Outcome Studies 458Patient Characteristics Related to Types of Therapy 460Specific Group Strategies and Requirements 463Recommendations 466Convergence of Therapist and Patient Characteristics 467

PART III: CLINICAL APPLICATIONS

Chapter 12. Diagnosis and Addiction Treatment 473Avoidant Society: Cultural Roots of Impaired Attachment 475Criterion Definitions of Addiction 478Drug Groups 480Drug Dependence and the Drug Groups 481Neuropsychological Impairment 483Stages of Change Model 490Relapse Prevention 492Interpersonal Neurobiology, Motivation, and Stages

of Change Model and Brain Impairment 493

Chapter 13. Early Stage Group Treatment:Confrontation, Intervention, and Relapse 495Special Problems of the Addicted Patient 496The Use of Therapeutic Leverage 498Confrontation 501Intervention 512Relapse and Recovery 525Early Stage versus Later Stage Relapse 528Therapist versus Patient’s Contributions to Relapse 530Later Stage Relapses 532Relapse Prevention 534

Chapter 14. Inpatient Groups and Middle StageTreatment 535Yalom’s Recommendations for Inpatient Groups 544Composition of the Inpatient Groups 547Yalom’s Strategies and Techniques of Leadership 549Agenda Rounds 552Difficulties with Agenda Rounds 557The Special Circumstances of Inpatient Therapy Groups

Within the Hospital 558Leader’s Transparency About Alcohol and Drug Use 559The Group Contract 560Simultaneous Membership in Other Groups 562The Special Problems of Confidentiality on an Inpatient

Unit 564Active Outreach 567

Group Members Who Relapse and Come to Group 568Attending Group Under the Influence 569Summary Recommendations for Inpatient Group Therapy 572

Chapter 15. Late Stage Group Treatment:Conflict, Repair, and Reunion 575Paradigm Shift 577The Concurrent Treatment of Addiction and Character

Pathology 580Later Stage Treatment Strategies 583Yalom’s Model and Self-Psychology 584Treatment of Internal Structural Deficits 587Treatment of Introjections 589Later Stage Treatment: Conflict, Repair, and Reunion 593Attachment, Addiction, and the Working Alliance 597Research and the Therapeutic Alliance 601The Alliance: What Is it and Why Is it Important? 603Attachment, the Therapeutic Alliance, and Negative

Process 608

Chapter 16. Transference in Groups 613Definition of Transference 614Transference Possibilities in Group 618Modification of Transference Distortions in Groups 621Types of Transference in Groups 623Common Types of Acting Out Transference 625Abuse of Transference 631Countertransference 631Projective Identification 636Pathways for Psychological Change 640Addiction and Countertransference 641

Chapter 17. Resistance in Group 647Resistance: A Definition 648Group Resistance and the Work of Wilfred Bion 651The Leader’s Influence on the Basic Assumptions 654Resistance to Intimacy in Groups 658Resistance to Immediacy 663

Resistance to Feelings in Group 665Special Considerations of Resistance to Addiction 669The Group Leader’s Effect on Group Resistance 672

Chapter 18. The Curative Process in Group Therapy 677Yalom’s Curative Factors 679Curative Factors in Group 679Existential Factors 682Curative Factors in AA 687Curative Factors Operating in Different Types

of Therapy Groups 689Mechanisms of Change and Cure in Group Therapy 689The Curative Process 694Working Through with the Addicted Patient 698Stages of Cure in a Therapy Group 699Addiction and Goals of Termination 704Conclusion 707

References 711

Index 737

Chapter 1

Interpersonal Neurobiology and Addiction: An Attachment TheoryPerspective

Interpersonal Neurobiology and Addiction:An Attachment Theory Perspective

The world of addiction treatment and group psychotherapy has evolvedand changed since the first edition of this book appeared in 1988. The grow-ing impact that the neurosciences have had on the way we understand ad-diction and the proliferation of ways addictive behavior now pervades oursociety have been foremost among these changes. Addiction is no longerlimited to psychoactive substances such as alcohol, cocaine, heroin, andother central nervous system (CNS) depressants and stimulants, but hasbeen expanded to include the so-called “process addictions” such as sex,gambling, work, shopping, exercise, and even the Internet (Freimuth, 2005).Because these new addictions have nothing to do with substances that areingested or injected into the body, the “disease model” of addiction must beexpanded, with a new paradigm put forth that better captures the fundamen-tal similarities shared by these diverse conditions. Since it is now recog-nized that addiction has more to do with a person’s habitual and compulsivebehaviors than with the substances introduced into the body, a more thor-ough and comprehensive theoretical perspective is required. Such a per-spective must elucidate the multitude of diverse conditions that predisposesome to become addicted to almost anything, while others use substancesrecreationally but do not develop an addiction. Without inclusion of morerecent discoveries in the neurosciences, outdated genetic explanations areincomplete. Countless twin adoptee studies conducted over the past fiftyyears account for only 20 percent of the variance when predicting whowill become addicted (Goodwin, 1979). Recent advances in the neuro-sciences—along with a complementary allegiance to attachment theory—provide a more thorough and satisfying paradigm for the understanding ofthe dynamics involved in addiction. Most important for this book, these ad-vances also furnish new, cogent reasons why group psychotherapy and thegroup format of twelve-step programs such as Alcoholics Anonymous arethe most potent formats for the treatment of addiction.

Group Psychotherapy with Addicted Populations© 2007 by The Haworth Press, Inc. All rights reserved.

doi:10.1300/5995_01 3

INTERPERSONAL NEUROBIOLOGY

The neurosciences have taught us the astounding fact that the most effi-cient way to change one’s brain is not to give him or her drugs that mimic,block, or substitute for endogenous neurotransmitters, but rather to providethe person with an ongoing opportunity for novel experiences and optimalemotional arousal within the context of a safe, supportive, interpersonal re-lationship and affective bond. In short, if you want to change someone’smind, become emotionally attuned with the individual and talk with him orher in a meaningful, caring manner. State-of-the-art neuroimaging tech-niques have confirmed this to be so. Schore’s (2003a) review of hundreds ofneuroimaging studies demonstrated the importance of the implicit, body-based, nonverbal affective communication that occurs within the criticalcomponent of the intersubjective field of the therapeutic alliance. This criti-cal process accounts for the greatest structural changes in the brain duringeffective therapy. The neurosciences have led the way to an understandingof human behavior that is moving beyond the limits of the mind-body dual-ism, which has dominated medical science for the past 300 years. Thisemerging evidence has prompted Lewis, Amini, & Lannon (2000) to write,“Dividing the mind into ‘biological’ and ‘psychological’ is as fallacious asclassifying light as a particle or a wave” (p. 167).

Brain-mapping studies (Braun et al., 2000), in vivo neurochemistry, andstudies of brain receptors (Insel & Quirion, 2005), and state-of-the-artneuroimaging techniques (functional magnetic resonance imagery (fMRI)and other imagery techniques such as PET scans) make it possible to actu-ally visualize changes in brain function or neuron pathways that are the re-sult of attachment, substance use, dysphoria, satisfaction, and even psycho-therapy. Terms such as cortical rerouting, neurogenesis, intensive operantshaping, and brain neuronal reorganization reflect mounting evidence thatthe brain remains plastic throughout the lifespan. They dislodge the pre-1980s’ notion that the brain is hardwired at birth and not subject to alter-ation in adulthood (Taub & Uswatte, 2000; Morris et al., 2001; Weis et al.,2000). Sharon Begley (2004) captured the implications of these new dis-coveries when she wrote about “the brain’s recently discovered ability tochange its structure and function in particular by expanding or strengthen-ing circuits that are used and by shrinking or weakening those that are rarelyengaged. [Although] the science of neuroplasticity has mostly documentedbrain changes that reflect physical experience and input from the outsideworld” (2004, p. 1), more recent research in the area of meditation hasshown that altering the structure of the brain is not limited to only externalphysical rehearsal. The brain can also change in response to purely internal

4 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS

mental signals, similar to those practiced in meditation. Furthermore, thoseindividuals who have the most practice at it are the ones who demonstratethe most alteration in brain circuitry. “This opens the tantalizing possibilitythat the brain, like the rest of the body, can be altered intentionally. Just asaerobics sculpt the muscles, so mental training sculpts the gray matter inways scientists are only beginning to fathom” (Begley, 2004).

These advancements also provide attachment theory with concrete evi-dence that helps explain not only how the brain becomes addicted, but alsohow it responds to psychological interventions. For instance, single posi-tron-emission tomography (SPET) was used to compare two men with sim-ilar diagnosis and age. One man received psychotherapy for a year while theother did not. Pre-treatment SPET imaging revealed reduced serotonin up-take in the medial forebrain bundle when compared with ten healthy indi-viduals. After a year of therapy, the treated individual’s SPET pattern hadreturned to normal. The untreated patient stayed the same. Preliminarystudies also showed that functional magnetic resonance imaging (fMRI)can predict with high accuracy whether an individual will relapse followingtreatment for methamphetamine abuse (Paulus, Tapert, & Schuckit, 2005).

An equally startling discovery is that this new evidence about the ad-dicted brain does not lead to the need for the development of new treatmentsfor addiction, but actually validates many current methods already beingutilized. The field of “interpersonal neurobiology” has validated the vener-able notion that talking with someone—especially if the encounter is mean-ingful and occurs within the context of emotional arousal, attunement, and astrong emotional bond—will alter neural pathways and synaptic strength.All forms of psychotherapy, from psychoanalysis to cognitive behavioraltherapy (CBT), are successful to the degree to which they accomplish thisand enhance growth in relevant neuron circuitry. The use of communicativelanguage and emotional attunement provides the best medium for neuronalgrowth and integration.

The false separation that exists between biology and psychology is grad-ually diminishing thanks to the contributions of attachment theory and theneurosciences. Research has revealed a number of erroneous conclusionsabout the brain and psychotherapy that should be changed. Recent scien-tific discoveries revealed the following six facts:

1. Attachment and psychotherapy can alter brain chemistry.2. Learning-based experiences alter neuronal connectivity.3. Potentiation requires activation (environmental stimulation), which

alters the strength and autonomous patterns of brain functioning.4. Synaptic strength is an experience-dependent phenomenon.

Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 5

5. Speaking in a meaningful way, paying attention, and attachment altersbrain biochemistry and changes in synaptic transmission, strength, andnumbers.

6. Attachment can alter gene expression.

As Siegel (2006) points out, we are at an exciting moment in the historyof psychotherapy as neuroscience has shown us the way to integrate theclinical field of psychotherapy with the independent field of neuroscience.No longer is the simple “single-skull” view of the mind appropriate sincerecent research findings from the neurosciences have now altered com-pletely how we define the mind. The old reductionistic perspective that themind is nothing more than the end result of the accumulation of the molecu-lar and biochemical functioning of the brain is clearly outdated. This obso-lete view fostered the belief that the best way to change someone’s mindwas to give the person a pill or alter synaptic connections in some way. Themind is much more than just the activity of the brain. The mind uses thebrain to cultivate itself or as Siegel (2006) says, “The brain is the playthingof the mind.” No longer is the mind viewed as a singular encapsulated organenclosed within an individual. The new perspective reconciles this miscon-ception when it defines the mind as the flow of energy and informationwithin the brain as well as the flow of energy and information betweenbrains. The interpersonal neurobiological perspective enables group thera-pists to embrace the findings of the neurosciences and use these findings tounderstand how the mind is altered through group psychotherapy, primarilythrough the experience of being with others.

The mind develops as the genetically programmed maturation of thebrain is shaped by ongoing experience, and the experience that sculpts thebrain the most is not drugs, but relationships. As Siegel reminds us, one ofthe most powerful relationships is a properly conducted and managed ther-apy relationship (2006). No form of psychotherapy is effective unless itchanges the brain, and long-lasting changes to the mind require changes inthe brain. Most important, a pill is not needed to accomplish this goal. A re-cent pilot study (Siegel, 2006) with attention-deficit hyperactivity disorder(ADHD) patients confirmed this hypothesis, demonstrating that individualscan be taught how to alter the ingrained tendencies of their mind to be easilydistracted. More than sixty subjects with ADHD were taught to eliminateand inhibit their impulses by utilizing mindfulness techniques practicedduring meditation. When Siegel first showed the results from his study tohis colleagues, the first question was “What was the dosage of the medica-tion you used?”


Siegel (2006) explained how experience can actually activate genes tostimulate synaptic growth. Neural stem cells, which are uncommitted blobsof neuroplasma in our brains, divide spontaneously every twenty-four hoursor so. When they divide, one remains with the stem cell line, and the otherwaits for a novel experience to be inspired to grow into an integrated neuronin the brain—no novel experience, no neuronal growth. However, providethat experience repeatedly and interesting things start to happen. It takesabout a month for the neuron to get inspired and another two or threemonths to get established. After 90 to 120 days, massive changes will occurin the integrative functions of the brain related to new stem cell division anddifferentiation.

The implications from these findings are profound. As Siegel suggests,scientific evidence now exists confirming every psychotherapist’s dream.Psychotherapy does not just change one’s mind; it alters the brain. One es-pecially important parallel from this research for addiction treatment is therecognition that changing one’s behavior and mind, as well as one’s brain,requires a certain commitment of time. AA’s intuitive recognition and rec-ommendation of “ninety meetings in ninety days” takes on added authoritywhen the implication of Siegel’s work is carefully examined. AA got itright: To produce the desired change toward sobriety, an alcoholic’s brainwill require at least ninety days before it can make the massive changes instem cell differentiation and division Siegel describes. The neurosciencesare confirming that effective therapy requires three essential components:

1. A novel experience2. An optimal amount of emotional arousal to prime the brain for

neuronplasticity:• new synaptic connections• modification of old synaptic connections• stimulate stem cells to differentiate into fully integrated neurons

3. Support

THE NEUROPHYSIOLOGY OF ATTACHMENT

As data from the neurosciences accumulated, researchers searched for atheoretical framework to help translate their discoveries into an explanationthat would have both clinical relevance and practical application for treat-ment. The emergence of this accumulative information from diverse per-spectives required a comprehensive cohesive theory to integrate and explainthis shared phenomenon. Attachment theory provided this needed para-digm. In effect, attachment theory can be viewed as an attempt to update


psychoanalytic theory in light of the newer discoveries in developmentalneurobiology and the neurosciences (Diamond & Marrone, 2003). Further-more, attachment theory has evolved into a body of knowledge that pro-vides a translation of findings from numerous domains of study into a com-mon language and conceptual framework that includes psychoanalysis,genetics, memory, evolutionary psychology, child development, and inter-personal neurobiology. This integration enables researchers and scientistsfrom a wide range of traditionally independent fields of research to coalesceinto a unified perspective. Another refreshing feature of attachment theoryand its associated influence in the interdisciplinary sciences is how much itnaturally inspires, informs, and confirms child development studies, theneurosciences, treatment outcome studies, animal studies, and modernpsychodynamic theory.

Siegel (1999), for instance, provides convincing evidence that attach-ment not only influences a child’s developing neurophysiology, but can alsostimulate neurogenesis in an adult. Cox (2006) supports this view when hepoints out that an attachment experience causes neurons to fire, neuronalactivity causes gene expression to change, and the resulting stimulation ofnew proteins promotes new brain structure. In the following outline Siegeldescribes the way the attachment system works to alter brain activity (1999,p. 67). His description has been expanded so parallels can be drawn be-tween a child’s developing mind and an addict’s addicted brain.

1. Attachment is an inborn system in the brain that evolves in ways thatinfluence and organize motivational, emotional, and memory pro-cesses with respect to significant caregiving figures, whether thosecaregivers are parents, sponsors, or group members.

2. The attachment system motivates infants (and adults) to seek proxim-ity to parents (and other primary caregivers such as friends, spouses,therapists, and fellow members of AA for instance), increasing thepotential for meaningful communication with them.

3. At the most basic evolutionary level, this behavioral system improvesour chances for survival. As Bowlby implies, just as we are morelikely to survive on the plains of the Serengeti in Africa if we have acompanion, our chances for survival increase if we have a companionwhen we are battling a serious case of cancer or even taking a walkdown a dark alley. Recovering from an addiction is more likely to besuccessful if someone is not trying to do it alone.

4. At the level of the mind, attachment establishes an interpersonal rela-tionship (an alliance) that helps the immature brain (or the addicted


brain) use the mature functions of the parent’s (or group leader’s)brain to organize its own processes.

5. The emotional transactions of secure attachment involve a parent’s (orgroup’s) responses to the child’s (or addict’s) verbal and nonverbalsignals, which can serve to amplify the child’s (or addict’s) positiveemotional states and to modulate negative states.

6. In particular, the aid parents (or group members) can give in reducinguncomfortable emotions such as fear, anxiety, or sadness enables chil-dren (or other group members) to be soothed and gives them a havenof safety when they are upset.

7. Repeated experiences become encoded in implicit memory as expec-tations and then as mental models or schemata of attachment whichserve to help the child (or addict) feel an internal sense of SecureBase.

INTERDISCIPLINARY RESEARCH AND ATTACHMENTTHEORY: A SOURCE FOR INFORMING

ADDICTION TREATMENT

The contributions that attachment theory (Bowlby, 1988) has to offer onaddiction and treatment have not been appreciated or recognized for theirfar-reaching implications. Until the sheer magnitude of accumulated evi-dence from developmental neurobiology (Siegel, 1999), the neurosciences(Schore, 2003a; Sroufe, 1996), and developmental psychoanalysis (Stern,1985) forced the psychoanalytic community to embrace Bowlby’s work, at-tachment theory had been exiled to the fringes of psychoanalytical theoryand judged to only have relevance for social psychology and child develop-ment. Diamond and Marrone (2003) and Cortina and Marrone (2003), uti-lizing Kuhn’s (1962) concept of the difficulty of all sciences accepting para-digm shifts, suggests that the resistance to attachment theory within thepsychoanalytic community is because Bowlby’s theories were not just amatter of offering a slight revision of psychoanalysis, but in actuality, “at-tachment theory proposes a completely new framework from which tounderstand clinical and developmental phenomena” (Cortina & Marrone,2003, p. 14).

The potential impact of attachment theory’s contributions to treatment isnot limited to just addiction. Bowlby’s original ideas (1958, 1973) haveevolved into a body of knowledge that furnishes a translation of findingsfrom numerous domains of study, providing a common language and con-ceptual framework. This integration enables researchers and scientists froma wide range of traditionally independent fields of research to coalesce into


a unified perspective. Another refreshing feature of attachment theory andits associated influence in the interdisciplinary sciences is how much it nat-urally inspires, informs, and confirms child developmental studies, theneurosciences, treatment outcome studies, animal studies, and modernpsychodynamic theory. (These sentences are repeats of sentences a fewparagraphs prior to this paragraph.) Each of these different streams of re-search will be briefly covered to help illustrate attachment theory’s rele-vance to group treatment and addiction.

Addiction As a Brain Disease

This section aims to integrate knowledge gathered from several disci-plines about interpersonal experiences, mental processes, child develop-ment, attachment, stress, and substance use to help provide a conceptualframework for describing an interpersonal neurobiology of treatment. It isalso recommended that group psychotherapy can be an especially effectivemedium for the delivery of this crucial element of therapy if the proper para-digm for guiding treatment application is adapted. Recent evidence from adiverse number of scientific disciplines (i.e., neurosciences, animal studies,neurobiology, child development, etc.) now indicates that attachment the-ory (Bowlby, 1988) furnishes an especially effective and all-encompassingtheoretical formula for informing the way group therapy should be appliedif the full potential of these research findings are to be realized and thegreater potential for successful treatment is to be maximized.

CONTRIBUTIONS FROM CHILD DEVELOPMENT STUDIES

Attachment theory, more than any other theoretical perspective, placesparticular emphasis on early attachment experiences as crucial for deter-mining an infant’s neurobiological development. All infants start with a ge-netic substrate. As their brain develops, an early and huge sprouting of syn-apses and neurons occurs. An experience that the child’s brain expects andis waiting for must be provided if the structure of the brain is to develop. De-pending on whether that experience “happens,” the structure of the brain,for better or for worse, is established and set for life. The absence or pres-ence of crucial early experiences either strengthens or weakens certainneuronal substrates of the brain. There are critical developmental stageswhen certain experiences must be provided or the opportunity for that expe-rience will be forever lost. The absence of critical experiences will shapethe structure of the brain for the rest of the child’s life and in many casesleaves the vulnerable individual with unalterable consequences.


For example, the infant’s brain is waiting for the experience of binocularvision. If that experience is not provided by the age of four months, thebrain will never be able to acquire depth perception. The learning of a sec-ond language is another good illustration. Those cultures that provide amultilingual experience for the child’s developing brain during the first fiveyears of life are able to take advantage of the brain’s receptivity to this op-portunity. Second languages can be learned later in life, but as we all know,this is a much more difficult and arduous accomplishment. In a very similarway, the quality of the early attachment relationship in the first year of lifehas a very powerful effect on the development of the emotional relationalcore of a person. The structure of a child’s developing brain is more recep-tive and more likely to be profoundly shaped by the quality of the attach-ment experience. As illustrated later in the chapter, once these identifiablepatterns or attachment styles are established in the brain, they persistthrough adulthood. Although other experiences such as trauma and other at-tachment relationships can have an impact on this relational core, alter-ations in attachment styles are difficult to extinguish and unlearn.

The Developing Brain

All neural development starts with a genetic substrate. The newborn in-fant’s brain exhibits a high initial sprouting of neural synapses. As the childdevelops, its brain is waiting for an experience. Depending on whether thatexperience is provided or not, two potential outcomes will occur. One is fre-quently referred to as blooming and the other is called pruning.

Blooming: As the newborn infant’s brain develops, there is an ini-tial sprouting of neural synapses. Due to the infant’s limited psy-chomotor capabilities, the brain at this stage is a passive recipient,waiting for an experience. As experiences and environmental stimula-tion are provided, these occurrences shape the structure of the brain.

Pruning: If these experiences and age-appropriate environmentalstimulation are not provided, pruning occurs. Pruning is actual neuro-nal death, resulting in the weakening of synaptic potentials and theweakening of neuronal pathways.

To the degree that a particular experience is provided, the developingbrain responds with neuronal growth. If these experiences are not provided,the child goes from a potentially large neural substrate to one shaped bypruning and lack of stimulation, which alters the structure of the brain forlife. Synaptic connections that are reinforced by an infant’s exposure to lan-


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guage, sounds, facial expressions, and even lessons in cause and effect (i.e.,the infant smiles, mother smiles back) become permanent parts (blooming)of the brain’s structure. Tentative connections that are not reinforced byearly experience are eliminated (pruning). Examples include binocular vi-sion, the development of language, musical competence, and the capacityfor attachment. Developing kittens deprived of visual stimulation for thefirst four months of their life lose the capacity forever to have binocular vi-sion (depth perception). As any parent knows, children exposed to foreignlanguages and music in the first few years of their life demonstrate a muchgreater capacity for the enrichment of these skills than those who attempt tolearn later in life. If critical periods of stimulation are not provided, the de-veloping brain moves on. The remaining neural structure is difficult to alter.A more chilling example of the potentially detrimental impact of failure toprovide proper needed responses to a developing brain is seen in theisolated, affectionless sociopath whose capacity for human warmth andattachment is forever lost.

Circuits in the different regions of the brain mature at different times. Asa result, different circuits are more sensitive to life’s experience at differentages. Consider the typical critical developmental periods of a child’s brain:

• Birth to one year: Motor development, emotional control, vision, at-tachment, implicit memory, and vocabulary.

• One to two years: Second language, math, logic, and rudimentarysigns of explicit memory (i.e., may grasp meaning of “soon” and “af-ter dinner,” but has limited knowledge of days and time).

• Two to three years: Music, separation and individuation, object con-stancy, relationships between objects.

The brain is an open system that interacts with and is easily influencedby its environment. The relationship between a child’s brain and the envi-ronment is reciprocal: brain development affect’s a child’s response to ex-periences, and a child’s experiences influence brain development. Further-more, interpersonal relations or attachment are necessary for normal braindevelopment. Research has demonstrated that attachment and interpersonalinteractions not only influence brain activity but also are crucial for braindevelopment.

For instance, the kind of emotional attunement provided by secure at-tachment actually increases blood flow to the prefrontal areas of the child’sbrain, resulting in growth of neural tissue in the emotional and attentioncenters of the brain. Without the emotional resonance provided by attune-ment from an attachment figure, the child’s excitement and prefrontal arousal


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areas of the brain are dampened, and growth in regions of the brain that en-courage inhibition are accelerated.

Although abundant of research demonstrates that secure attachmentstimulates growth in important areas of the brain, the reverse is also true.The absence of stimulation at crucial stages of brain development can in-hibit neural growth. In addition, stress can have a significant impact on thedeveloping brain through the mechanism of neurochemical activity. Neuro-chemical stress not only impacts the mature brain, it also adversely impactsthe immature or developing brain. Studies have shown that the brains of ne-glected children are strikingly different from brains of children who werenot neglected. Neglect produces children whose head circumferences aremeasurably smaller, and whose brains on magnetic resonance scanning evi-dence shrinkage from the loss of billions of cells. Similar anatomicalchanges, related to the parts of the brain that mediate emotions and attach-ment, were also discovered in children raised by depressed mothers. In allthese cases research has convincingly demonstrated, nurture not only affectsnature; it often determines nature.

Secure Attachment Creates Neurophysiological Homeostasis

The absence of attachment is not limited to physiological disruptions ofthe brain. Not only do nurturance, social communion, play, and communi-cation have their home in the limbic territory, but other aspects of the bodyare severely affected when attachment is disrupted. Abandoned individualsexperience multiple disruptions to their entire homeostasis. Lewis et al.(2000) give a disturbing account of all that can go wrong when children andadults are forced to deal with loss.

Prolonged separation affects more than feelings. A number of somaticparameters go haywire in despair. Because separation deranges thebody, losing relationships can cause physical illness. Growth hor-mone levels plunge in despair—the reason why children deprived oflove stop growing, lose weight no matter what their caloric intake, anddwindle away. . . . Children aren’t the only ones whose bodies respondto the intricacies of loss: cardiovascular function, hormone levels,and, immune processes are disturbed in adults subjected to prolongedseparation. . . . In his fascinating book Love and Survival, DeanOrnish surveyed the literature on the relationship between isolationand human mortality. His conclusion: dozens of studies demonstratethat solitary people have a vastly increased rate of premature death


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from all causes—they are three to five times likelier to die early thanpeople “with ties to a caring spouse, family, or community.” (pp. 79-80)

During critical times of development, if children experience poor attach-ment, their brain shows less opiate receptor density. Consequently, it ismore difficult for the individuals to regulate affect and self-soothe. De-prived of an adequate supply of their own body’s natural painkillers, indi-viduals are more vulnerable to painful affect states. When isolated monkeysare given high doses of opiates, it inhibits their separation cry. When givenopiate antagonists, their separation cry returns and their separation stress re-sponse is enhanced. The situation is very similar with human heroin addictswho do not react to separation or loss. When they are high, they simply treatpeople as if they do not matter. The heroin in their veins protects themagainst separation anxiety and the panic of attachment loss.

Accumulating evidence on the impact of loss suggests overwhelminglythat attachment figures (relationships) are powerful regulators of normalphysiology. How individuals handle separation and loss is determined bythe length and quality of their earliest attachment relationships. The qualityof this early relationship is encoded in the memory and limbic system. Be-fore understanding the full impact that attachment and separation can haveon a person, it will be important to explore the biology and neuroanatomy ofmemory.

To summarize, three important points must be remembered about at-tachment:

1. Secure attachment creates stable neurophysiological homeostasis.2. With a secure attachment experience, the individual is more able to

regulate self.3. With the absence of a stable attachment experience, the individual is

more vulnerable to disruption.

The Biology of Attachment and Emotion

Recent advances in the study of the biology of emotions have resulted ina new model of emotion that is highly compatible with attachment theory.This new model of emotion is not only more theoretically useful, it is alsomore closely aligned with actual clinical application. Emotions, from thisperspective, cannot be separated from one’s physiological makeup. Notonly is this true for humans, but it is the case for most social mammals. PaulEkman’s (1992) classic work is the most recent example of evidence sug-


gesting that animals and humans share a common physiological link be-tween facial expressions and emotions.

Emotional life starts with universal innate functions that are criticallyshaped by early experiences and continue on to become a major and uncon-scious organizing force for all mental activity. Attachment is a specializedexample of this. It starts with the natural capacity of the child to send andreceive emotional signals with his or her primary caregiver. The nature ofthe child’s capacity to accurately read emotional signals in self and others iscrucially shaped by the mother-infant bond and becomes an unconsciousfoundation for all subsequent interpersonal relationships.

The work of Ekman and others (i.e., Izard, 1971) have also confirmed acentral proposition of the survival importance of emotions first put forth byDarwin, who proposed that facial expressions are identical all over theglobe, in every culture, and with every human being. These findings suggestthat emotions are universal, closely tied to our physiology, and central to allhuman experience and relatedness. Emotions also serve a communicationfunction, starting first with the mother and infant. The demonstration of af-fect helps maintain attachment (the separation cry, for instance) and is theearliest and most primitive form of communication. It mediates attachmentand serves a basic survival function.

With the mounting evidence that emotions are innate, not learned, andthat attachment shapes the structure of the brain and affect our memory, at-tachment theorists have concluded that all other previous models of psycho-dynamic theory are lacking in an accurate representation of the correctinterplay between the brain, emotion, and attachment. One primary reasonfor the inadequacies and inaccuracies in other previous theoretical modelsis that they are hampered by a polarization between psychology and biol-ogy, that is, the result of medicine’s heritage of the mind-body dualism leftover from the influence of René Descartes. This polarization is totally in-compatible with the position of attachment theory. Emotions, from an at-tachment perspective, are basic brain functions and not an epiphenomenonof psychodynamic conflicts.

Darwin was actually one of the first to propose a theory that was devoidof this polarization. He believed that emotions were behaviors that aroseand persisted because of their ability to advance survival and the repro-duction of the species. Because of evidence such as Ekman’s, which sug-gests that emotions are hardwired and closely linked to facial expressions,emotions must be considered part of our phylogenetic past—a past that wegenetically share with other mammals. Attachment theory, with its integra-tion of biology and psychology of emotions, assumes the capacity for emo-tion is innate and not learned. This capacity for emotion becomes part of a


broader function of the brain, which reads the environment and readies thebody for an appropriate response (flight-fight). Our emotional responsesalso affect our memory of these experiences and because of this, emotion islooked upon as an important organizer of mental activity that shapes ourpriorities, beliefs, and our convictions in life. Thus, the connections be-tween our emotions have important, far-reaching implications in determin-ing and defining us as human beings.

Emotions also play a significant role in our socialization. The emotionalsystem is particularly aimed toward the social part of our environment,reading the emotional signals from others and displaying our own appropri-ate emotional states (i.e., smiling when our loved one enters the room) forothers to read. Infants especially are born with an innate emotional fluencythat provides an immediate language between mother and infant.

Anatomy of Attachment

Because of recent advances in the science of neurobiology and theneuroanatomy of emotion and memory, attachment theory pays particularattention to the parts of the brain that mediates these components. Attach-ment theorists see the limbic system as the crucial apparatus of the brain be-cause it is the seat of both emotions and memory. Not only is the limbic sys-tem a powerful mediator of attachment, the intricate interplay betweenemotion and memory in this system lays a foundation for understanding theimpact that separation and loss has on a person’s physiological and psycho-logical state. The limbic system is at an advantage to accomplish its orga-nizing tasks because it is located at a neuroanatomical crossroads that isessential for organizing complex brain functions. All learning and condi-tioning takes place at the limbic level. Information is encoded and storedhere forming a motivational map indicating the location of emotionally sig-nificant objects like food, predators, and sexual partners. This informationis so highly processed at this point that the individual can scan his environ-ment and immediately sense secure versus dangerous areas. The rapid fir-ing of neurons at the limbic level will allow a person to tell you there isdanger, but leave that person unable to tell you why, like the patient who hasa gut feeling, but cannot explain it.

Because of our society’s preoccupation with facts and psychology’sobligatory heritage with the “talking cure,” science shares the same culturalbias that we all have about the hierarchical structure of the brain. Commonteaching implies that the lower areas of the brain—which contain the limbicsystem—must obviously serve lower brain functions. Since the neocotex isconsidered the latest developmental achievement of human evolution, our


neocortex is assumed to obviously serve a higher and thus more importantbrain function. Attachment theorists consider this to be a mistake and sug-gest that this popular hierarchy may actually be misleading and even a hin-drance to the correct understanding of brain functioning. The limbic systemactually provides an important organizing component to our brain thatactually determines how we live and run out lives.

Attachment theory contends that the neocortex actually serves the so-called lower parts of the brain and that it is actually at the limbic level thatthe most crucial levels of communication occur. Consider how words spo-ken without emotion have little power to persuade. Also consider researchthat demonstrates the powerful exchange of wordless communication thatgoes on between a mother and her infant. Lewis et al. (2000) write about thesubtleties of this type of communication reminding us that what is obscureis not always without significance.

Emotionality is the social sense organ of limbic creatures. While vi-sion lets us experience the reflected wavelengths of electromagneticradiation, and hearing gives information about the pressure waves inthe surrounding air, emotionality enables a mammal to sense the innerstates and the motives of the mammals around him. (pp. 62-63)

Implicit versus Explicit Memory

A close link exists between memory and emotions because this associa-tion helped humans survive as a species. Since all emotional learning takesplace at the limbic level, and the limbic system is anatomically intercon-nected with memory, information that is available for recall has a profoundinfluence on attachment, psychopathology, and learning. Emotionally chargedinformation is stored and encoded here, functioning as a “motivationalmap.” This “map” serves an important task, indicating emotionally signifi-cant objects such as food, predators, and sexual partners. Primitive mancould immediately scan his environment and sense (i.e., gut feeling, intu-ition, etc.) secure versus dangerous situations. This information is finelyprocessed and stored so a person could immediately sense danger and reactwithout having to stop and think or explain why.

Knowledge That Cannot Be Explained

Many ingenious and creative studies have been designed to show that itis possible for people to acquire knowledge and improve their performanceon a task without their understanding why they solved the problem as they


did. Subjects in these studies exhibit the acquisition of knowledge by dem-onstrating an improvement in their performance on a new task. When askedhow they solved the problem, they were unable to explain the strategiesthey applied in their solution. Similar results were discovered with brain-damaged individuals who had lost their hippocampus, the area of the brainrequired for the storage and recall of explicit memory. Even though individ-uals without a hippocampus could learn new tasks and demonstrate thisability by completing an assigned task, they were unable to rememberlearning it. They were also unable to explain how they accomplished orsolved the problem.

Knowledge without awareness is a scientifically demonstrated phenom-enon. Although this capacity to experience comprehension divorced frommemory is similar to what psychodynamic theory calls the unconscious, at-tachment theory prefers making the distinction between explicit and im-plicit memory because they believe these terms are more anatomically cor-rect and more in line with what actually occurs in the brain.

1. Explicit Memory: This type of memory is really a small percentage ofmemory. It is information that is accessible for recall and is more re-lated to the storage and retrieval of facts.

2. Implicit Memory: Knowledge that cannot be explained. It is memorydivorced from the power of comprehension and thought. The greatestpercentage of our knowledge is implicitly stored and more difficult toretrieve. Implicit memory also represents stuff we have learned (i.e.,muscle memory like riding a bike or hitting a ball, etc.), but can’t ex-plain how to do it, but still can do. Although there is some similarity tothe unconscious, it is not just repression, active censorship, or dissoci-ation. The information is there and can often be demonstrated by aperson’s action, but cannot be explained. Implicit memory is distin-guished from explicit memory by three important features.• Relational: This type of memory is more emotionally loaded be-

cause it serves survival purposes. It is anatomically driven by pow-erful affect states like fear, anger, hunger, and sex. Its activation isinstantaneous, not requiring the loss of time it might take to processinformation (i.e., Is that a bear about to jump on me? Am I in dan-ger? What should I do?).

• Earliest Memory: This is the kind of memory working most inchildhood before the development of language. It is when the childwas most vulnerable and under the influence of powerful affectstates.


• Emotional: Implicit memory is “hardwired” to emotions and thelimbic system. It mediates attachment and is closely aligned withBowlby’s concept of the internal working model.

CONTRIBUTIONS FROM THE NEUROSCIENCES

Although an abundance of research evidence suggests that inadequateattachment can have a profound influence on a child’s developing brain, ac-cumulated evidence also suggests that a number of environmental factorscontribute to the brain’s increased susceptibility to addictive diseases. Re-search on the possible relationship between certain genetic anomalies andalcoholism has led to the discovery of a statistically significant incident of agenetic variant (called an allele, which is an alternate form of a gene occu-pying the same position on matching chromosomes) that is related to anumber of behavioral syndromes.

• Addictive disorders• Smoking• Compulsive overeating• Obesity• Attention-deficit disorder• Pathological gambling• Tourette’s syndrome

These disorders are linked by a common biological substrate (a “hard-wired” system consisting of cells and signaling molecules) that leads toeither an inborn or induced imbalance in the limbic-diencephalic area of thebrain (commonly referred to as the pleasure center of the brain) that leaves aperson with feelings of deficits in safety, warmth, and a full stomach. Ifthese requirements are not responded to, the limbic system signals threat,anxiety, and discomfort. Craving will be triggered that motivates the indi-vidual to take action to eliminate negative emotions. This condition isreferred to as the reward deficiency syndrome (Blum, Cull, Braverman, &Comings, 1996).

REWARD DEFICIENCY SYNDROME

Reward deficiency syndrome (RDS) involves a form of sensory depriva-tion of brain pleasure mechanisms. The syndrome is believed to be a conse-quence of an individual’s biochemical/neurological inability to derive re-


ward from ordinary everyday activities. It is hypothesized that depletion indopamine and serotonin levels contributes to this condition. In a “normalperson,” neurotransmitters work together in a cascade of excitement or inhi-bition—between complex stimuli and complex responses—leading to astate of well-being. In the cascade theory of reward, genetic anomalies, pro-longed stress, or long-term abuse can lead to a self-sustaining pattern ofabnormal cravings in both animals and human beings. Disruption can beinduced by all of the following:

• Prolonged stress• Genetic anomalies• Prolonged substance abuse

Each of these three factors is briefly examined to see what research find-ings have contributed to the understanding of the addicted brain.

Prolonged Stress and Addiction

There are a number of irrefutable and undeniable facts about stress.Place someone under enough stress too frequently or for too long, and theperson’s chances for developing a major disease or dying will be greatly in-creased (Sapolsky, 2004). The ability of major stressors to suppress immu-nity below baseline has been substantiated by hundreds of human and ani-mal studies. Essentially all of these studies show a link between increasedor decreased stress and disease or mortality outcomes. Psychoneuroim-munologists have demonstrated that this link is established through thefollowing steps:

1. The individuals in question have been stressed.2. Stress causes them to turn on the stress response (the secretion of

glucocorticoids, epinephrine, etc).3. The duration and magnitude of the stress response in these individuals

is great enough to suppress immune function.4. Suppressed immune function increases the odds of these individuals

developing a disease, and impairs their ability to defend against thatdisease once they have it.

Unfortunately, the relationship between stress and disease—especiallythe addictions—is not always this straightforward. The interplay betweengenetic potential and individual response styles (some people are highstress reactors while others are low stress responders), interacting with at-


tachment history (secure versus insecure attachment styles), and the indi-vidual psychodynamics operating within the individual (some people aredrawn to chaotic relationships and stressful lifestyles) will determine whowill be at risk to develop an addiction or a substance abuse disorder. How-ever a number of stressful circumstances have been identified that will in-crease the risk that someone will be more vulnerable to develop an addic-tion disorder. Each will be briefly reviewed.

A Mother’s Stress and the Developing Embryo

Both prenatal and postnatal stresses increase the risk of vulnerability todisease. The relationship between fetal nutritional events and lifelong risksof metabolic disease was first described by David Baker of SouthamptonHospital in England. The emerging discipline of fetal origins of adult dis-ease (FOAD) is now accumulating vast amounts of data demonstrating theconnection between parental stress, hunger, malnutrition, and death. Sapol-sky sums up this research as follows:

Expose a fetus to lots of glucocortocoids and you are increasing itsrisks for obesity, hypertension, cardiovascular disease, insulin-resis-tant diabetes, maybe reproductive impairments, maybe anxiety, andimpaired brain development. And maybe even setting up that fetus’seventual offspring for the same. (2004, p. 100)

Preliminary research indicates that maternal environment—the hormonal-laced bath that envelops a developing embryo—may contribute to later de-velopment of psychopathology. This suggests that maternal stress begetsfetal stress. Early effects, at least during the first or second trimester, affectthe children most because that is when the developing brain is in its mostcritical stages. Anything affecting brain development will have long-lastingeffects. For instance, Avishai-Eliner, Brunson, Sandman, & Baram (2002)found that women who reported high levels of anxiety during pregnancywere twice as likely as nonstressed mothers to have children with behav-ioral problems, depression, and anxiety when these children were assessedat four and seven years of age. All of this suggests that diseases blamed onlifestyles may start from birth. Evidence exists that if the mother was un-healthy or overly stressed during pregnancy, chances are that certain dis-eases can be “programmed” by unfavorable conditions in utero. Animalstudies reported similar results. For instance, Hofer (1984) reported thatmice and primates born to highly stressed mothers demonstrated height-ened emotionality and timidity as they avoided open arms of mazes and def-


ecated excessively. Hofer suggested that stress during pregnancy promoteddecreased sensitivity in the hippocampus in these yet unborn infants, ac-counting for their difficulties regulating stress responses.

Secure Attachment and Development

Both mother and newborn can contribute to the level of stress in the rela-tionship. Although evidence exists that an infant’s temperament will play asignificant part in determining secure attachment, research has demon-strated that a number of factors can contribute to overcoming negativetemperaments. Mothers who have what Fonagy, Gergely, Jurist, & Target(2002) call “high reflective function” (empathy and insight as a result oftheir own secure attachment) and have increased sensitivity are likely toproduce more securely attached children, especially if these children havenegative temperaments. Experimentally increasing maternal sensitivity formothers of infants with negative temperaments yielded an exceptionallylarge effect in terms of increasing attachment security from 28 percent to 68percent.

A number of other studies demonstrated that early loss, trauma, and ne-glect impact a child’s development resulting in elevated glucocortocoids lev-els, and decreased size and activity in the most highly evolved part of thebrain, the frontal cortex. Another obvious stressor is post-traumatic stresssyndrome (PTSD) as a result of childhood sexual and physical abuse. Trau-matologists teach us that trauma, especially repeated trauma in childhood,has profound effects on a child’s developing brain, leaving the child vulnera-ble to addiction. See Chapter 10 on co-occurring disorders for a more exten-sive discussion of the relationship between trauma and addiction.

Secure Attachment and Adaptation to Stress

Secure attachment can be viewed as a protection against psychopatho-logy. Attachment security is associated with a wide range of healthier per-sonality variables such as lower anxiety, less hostility, ego resilience, lessdepression, increased affect regulation, and addiction. Conversely, insecureattachment is strongly associated with the presence of family risk factorssuch as maltreatment, major depression, bipolar disorder, alcoholism, andsubstance abuse. A child’s relational context imprints into the developingbrain either resilience against or a vulnerability to later formation of psychi-atric disorders.

An overall look at the studies on this subject identifies the importance ofadult attachment style as a key factor in determining success or failure in ad-


aptation to stress. Bowlby’s (1980) theoretical formulation has clear implica-tions for a wide range of life events, involving issues related to life and death,physical and emotional threats, normative and nonnormative developmentaltasks, and personal and interpersonal losses. In all of these life domains, at-tachment working models seem to shape the way people appraise and copewith stressors and to moderate their emotional reactions to these events.

Bowlby’s theory (1980) also implies that insecure attachment can beviewed as a risk factor that may detract from the individual’s resilience intimes of stress. The early attachment experience of insecure persons (bothanxious-ambivalent and avoidant) is characterized by unstable and in-adequate regulation of distress by the caretaker and a sense of personal inef-ficacy in relieving discomfort (Bowlby, 1973; Shaver & Hazan, 1992).These experiences may obstruct the development of the inner resourcesnecessary for successful coping with and adaptation to life stressors.

Adult personality is seen as a product of an individual’s interactions withkey figures during all years of immaturity, especially interactions with attach-ment figures. Thus an individual who has been fortunate to grow up in an or-dinarily good home with ordinarily affectionate parents has always knownpeople from whom he or she can seek support, comfort, and protection, andwhere they are to be found. So deeply established are the child’s expectationsand so repeatedly have they been confirmed that, as an adult, the person findsit difficult to imagine any other kind of world (Bowlby, 1973).

Others, who have grown up in less secure circumstances, will be muchless fortunate in the way the brain develops. For some the very existence ofcaretaking and supportive figures is unknown; for others the whereaboutsof such figures has been constantly uncertain. For many more the likelihoodthat a caretaking figure would respond in a supportive and protective wayhas been at best hazardous and at worst nil. When such people becomeadults, it is hardly surprising that they have no confidence that a caretakingfigure will ever be truly available and dependable. Through their eyes theworld is seen as comfortless and unpredictable, and they respond either byshrinking from it or by doing battle with it (Bowlby, 1973, pp. 208-209).

High Stress Responders versus Low Stress Respondersand Ambiguous Situations

As Bonanno’s (2004) (see Chapter 10 on trauma and resilience) researchshowed, not everyone will respond with a similar intensity to the samestressful situation. One important determinant is the person’s history of se-cure versus insecure attachment. Sapolsky’s (2004) research with primateson the Serengeti sheds some light on how this difference can be played out


with human beings. Sapolsky established a research paradigm in which ba-boons were placed in an ambiguous threatening situation. He then recordedtheir responses and measured their glucocorticoid levels, an indicator of thedegree of their stress response. In the first scenario, he placed securely andinsecurely attached (separated at birth from their mothers) baboons in obvi-ously threatening situations with rival baboons demonstrating aggressivebehavior. In the second scenario, he had rival baboons placed safely off inthe distance in nonagressive positions, a situation that was clearly ambigu-ous since the threat was not immediate. The insecurely attached baboonscould not discern the difference between these situations while the securelyattached baboons could. The securely attached baboons could

tell that one situation is bad news, the other is meaningless. But somemales get agitated even when their rival is taking a nap across thefield—the sort of situation that happens five times a day. If a male ba-boon can’t tell the difference between the two situations, on the aver-age, his resting glucocorticoid levels are twice as high as those of theguy who can tell the difference. If a rival napping across the fieldthrows a male into turmoil, the latter’s going to be in a constant stateof stress. (Sapolsky, 2004, pp. 313-314)

As we have learned, those individuals who respond to every social provoca-tion with an overreaction are at much greater risk to either develop a diseaseor turn to substances to help manage their internal turmoil.

Poverty, Socioeconomic Status, and Stress

One of the best examples for chronic stress is poverty. Being poor in-volves many physical stressors such as manual labor and work-related acci-dents. Psychological stressors include the increased lack of control and lackof predictability that one has in one’s life. Health care access, poor diets,fewer financial resources, more dangerous working situations, exposure toriskier toxic environments, infant mortality, and crime are just a few of thecontributing factors to stress. Consequently, poverty is associated with in-creased risks for every major disease. Not surprisingly, it also places thepoor at greater risk for developing substance abuse disorders. Animal re-search helps substantiate the relationship between stress and substance use.Stress a rat before a session of drug exposure and the rat is more likely toself-administer to the point of addiction. Unpredictable stress drives a rat toaddiction more effectively than predictable stress. Stress a pregnant rat andher offspring will have an increased propensity for drug self-administration.


Addicted humans, rats, and primates are all more likely to relapse whenplaced under stress. Experimentally manipulating the environment of a ratin “recovery” (substituting a saline solution for a drug that has been self-administered by pressing a lever will extinguish the lever pressing by therat) by infusing the rat with a bit of the drug during a stressful situation willresult in an increase in the self-administration of the drug. A review ofcountless studies similar to these led Sapolsky to conclude,

In these instances, the stressor during development can’t be workingmerely by causing a transient rise in dopamine release. Somethinglong term has to be occurring. Perinatal experiences causing life-long “programming” of the brain and body. It’s not clear how thisworks in terms of addictive substances, other than that there obviouslyhas to be a permanent change in the sensitivity of the reward path-ways. (2004, p. 348)

Animal Studies

Evidence gathered from animal research on the relationship between in-secure attachment and stress validates many of the findings in child devel-opment studies. For instance, one study that has been repeated numeroustimes called The Resident Intruder Paradigm examines “socially defeatedrats” who are placed under laboratory-induced stressful situations. An in-truder rat is placed in a dominant rat’s territory. The resident dominant ratwill usually initiate a “mock attack” on the intruder. When this occurs, theintruder rat typically rolls over and exposes his underbelly. After a few min-utes, the animal will be removed from the dominant rat’s territory. Soon af-terward, the intruder rat will typically go into a week-long bout of depres-sion (loses weight, stops grooming, stress hormones become elevated, sleepis disturbed, and weight loss is recorded). This is a normal response to feel-ing defeated. However, when the experiment is controlled for secure versusinsecure attachment, different response patterns are noted for insecurelyand securely attached rats. Securely attached rats recover much morequickly while rats that have been separated at birth (insecure attachment) donot recover and often die unless given treatment. As with their human coun-terparts who feel socially defeated, treatment involves antidepressants orplacing the intruder rat in a secure environment with a “therapist rat” thatprovides support and contact. Without treatment, these insecurely attached,socially defeated rats never spontaneously recover. They refuse to eat, de-velop secondary infections, lose weight, and in some cases, die.


Another popular research paradigm examines parental consistency andthe way predictability can contribute to reducing stress, even during diffi-cult times. Rhesus monkeys were placed under three different conditions inwhich availability of food was experimentally manipulated. The threeconditions included the following:

1. Low foraging demands2. High foraging demands3. Switching from high foraging demands to low foraging demands

every two weeks.

When foraging was stable—either high or low—monkeys behaved nor-mally. Infant monkeys fared well when the mother was subjected to stableforaging conditions, whether these conditions were high or low. Conditionscould last either two or ten hours, but remained predictable. However, un-predictability led to clinginess and mother forcing separation on her infant.Major changes within the monkey colony produced more tension, less mu-tual grooming, and more dominance behavior. More clinging behavior wasobserved with the young as mothers separated from their infants while theinfants struggled to maintain contact.

Genetic Anomalies

Nature versus Nurture

The nature versus nurture debate that has dominated the biological andsocial sciences in the past century is a false dichotomy built on an outdatedand false distinction. Recent advances in the neurosciences have recentlytaught us that they are not mutually exclusive categories. The interplay be-tween genetic potential and environmental circumstances either enhancesor inhibits gene expression. Attachment theory is joining a number of otherdisciplines in the neurosciences in leading the way from genetic determin-ism or what Perry (2002) calls the “tyranny of the genes.” Perry providestwo excellent historical examples about the nature and nurture interplay.

One thousand years ago, less than 1 percent of the population of West-ern Europe could read. Essentially all of the population had this ge-netic potential to learn to read yet this potential remained untappeduntil the advent of universal public education.

In 1211, Fredrick II, Emperor of Germany, in an attempt to discoverthe natural “language of God,” raised dozens of children in silence.


God’s preferred language never emerged; the children never spokeany language and all died in childhood (van Cleve, 1972). (Perry,2002, p. 79)

Research evidence also shows that complex neural patterns are charac-terized by extensive plasticity. During the critical period of neural develop-ment, new synaptic pathways are laid down so that the brain is literallyshaped by experience. But existing pathways can be strengthened or weak-ened all through adult life. The capacity for plasticity of the CNS is an evo-lutionary adaptation that enables organisms to interact more effectivelywith a changing environment. Perry (2002) outlines in detail the eight dif-ferent processes of neurodevelopment that captures the opportunity andvulnerability inherent in the genetic potential of each individual.

1. Neurogenesis2. Migration3. Differentiation4. Apoptosis5. Arborization6. Synaptogenesis7. Synaptic Sculpting8. Myelination

The “Use It or Lose It” Consequence

The effects of childhood environment, favorable or unfavorable, interactwith all processes of neurodevelopment. The many functions of the humanbrain result from a complex interplay between genetic potential and appro-priately timed experiences. The neural systems responsible for mediatingcognitive, emotional, social, and physiological functioning develop in child-hood and, therefore, childhood experiences play a major role in shaping thefunctional capacity of these systems. When necessary experiences are notprovided at optimal times, these neural systems do not develop in optimalways. Abuse studies, evidence of children reared in orphanages that lackemotional contact, and animal deprivations studies all point to the need forchildren to have stable emotional attachments with touch from primarycaregivers, and spontaneous interactions with peers.

The expression of genetic potential requires optimal environmental con-ditions. Our neural systems do not develop without necessary experiences.Our neural systems are created, organized, and altered in response to expe-rience throughout the life cycle. The time in life when the brain is most sen-sitive to experience—and therefore most easily influenced in positive and


negative ways—is in infancy and childhood. During this time experiencewill shape neural systems in ways that influence functioning for a lifetime.This is a time for great opportunity—and great vulnerability—for express-ing the genetic potential in a child.

Natural Selection and the Neurophysiology of Survival

The brain contains mechanisms for selective enhancement or inhibitionof patterns of behavior that are mediated by social context and attachment.Hence, behavior of animals interacting with other animals of their species isnot a one-way street from genes to social groups; the dynamics of socialgroups also have a strong influence on the very biochemistry of gene ex-pression. The primary strategy that natural selection furnished us in order tomeet these objectives is the creation of relationships. It is not as independ-ent and solitary individuals that we have succeeded as a species; it isthrough our interdependent relationships—families, clans, communities,tribes, and societies—that we survive and thrive. We need one another.Consequently, some of the most powerful and complex neural systems arededicated to affiliation, communication, and attachment.

At a very basic level, survival is related to being able to avoid beingeaten. The chances for survival are greatly enhanced if one has a compan-ion, whether one is on the plains of the Serengeti, a dark alley in New YorkCity, or the suburbs of Atlanta. Survival skills must be mastered early if thehelpless infant is to survive. Behaviors that bond the newborn to the care-giver are essential. The separation cry is the most obvious example of sur-vival. The capacity to perceive the mood and intention of others to inspirepredictable nurturing behavior is another example. These skills combinedwith genetic endowment produce the repertoire of behaviors that character-ize us as human. Any imbalances or deficiencies related to this capacity arethe basis for all psychopathology and all the addictions.

Self-Care and Support

It is important to understand how stress and caring behavior fit into thebiological makeup of humans and other social mammals. Natural selectionnot only favors the survival of the fittest (erroneously assumed to mean themost aggressive), but included those species that were genetically hard-wired to care, bond, love, and become attached. Consequently, the brain hasthe capacity for the gene expression for caring. Whether it gets expressed ornot depends on whether the social environment inhibits or promotes its ex-pression. Neuroimaging studies are showing us that altruism, caring, and


love (attachment) are hardwired into the brain because these behaviors helpus survive as a species. Even Darwin raised the point that survival of the fit-test and natural selection did not just mean strength and aggression.

It has often been assumed that animals were in the first place renderedsocial, and that they feel as a consequence uncomfortable when sepa-rated from each other, and comfortable whilst together; but it is a moreprobable view that these sensations were first developed, in order thatthose animals which would profit by living in society, should be in-duced to live together, . . . for with those animals which were bene-fited by living in close association, the individuals which took thegreatest pleasure in society would best escape various dangers; whilstthose that cared least for their comrades and lived solitary would per-ish in greater numbers. (Darwin, 1871)

Researchers (i.e., Eisler & Levine, 2002) following Darwin’s lead haveidentified the existence of biochemical markers for three major patterns ofresponse to stressful, complex situations and that all three are explicable asevolutionary adaptations. In other words, the brain contains mechanismsfor enhancement or inhibition of conflicting behavioral patterns that can beexplained as adaptations to stressful evolutionary pressures. Three primarypatterns have been identified as follows:

1. Fight or flight2. Dissociative3. Tend and befriend

The pattern the brain “chooses” depends upon and is mediated in part bythe context and dynamics of social groups, support systems (or the lack ofthem), and relationships. Experimental evidence exists showing that envi-ronments can be created that either enhance or suppress competition (fightor flight), isolation (dissociation), and (tend and befriend) cooperation.Even if fight or flight responses are more prevalent in some groups of peo-ple than the caring responses, the caring responses remain available. Theevidence is stronger that the “tend-and-befriend response” (tending of off-spring and social bonding) is stronger in females; however, analogousmechanisms exist in males, but most social systems inhibit the full develop-ment of the genetic expression for caring in males. Furthermore, a vastamount of evidence suggests that “persistent stress tends to bias the brain’spathways in the direction of hyperarousal or dissociative responses, andcaring relationships tend to bias the brain’s pathways in the direction oftend-and-befriend responses” (Eisler & Levine, 2002, p. 46).


However, caring behavior is tied to biological motivations other thanmere survival or reproduction. Caring behavior produces pleasure in all butthe most seriously damaged individuals. Research evidence points to theimportance of intrinsic motivations in most mammals for pleasure and posi-tive affect (i.e., caring, cooperation, love, and bonding.). When careseekingbehavior (empathy and attunement) is met by the caregiver, a sense of reliefand satisfaction is experienced by both parties. This satisfaction reflects theneed that all developmentally mature adults have—the need to give andreceive in relationships.

Caring, Dopamine, and Oxytocin

Caring does good things to the brain, whether the person is receiving it orproviding it. As far as the central nervous system is concerned, caring andfeeling stress are incompatible. One or the other is dominant, but it is diffi-cult for both to be operating equally or simultaneously. Either the sympa-thetic nervous system (stress response) or the parasympathic nervous sys-tem (caring response) is prevailing over the other. Eisler and Levine (2002,p. 25) write, “Persistent positive social bonding or attachment experiencescan increase levels of oxytocin and the parasympathetic nervous systempathways that this hormone enhances, which tend to counterbalance activi-ties of the sympathetic stress system.”

In all mammals a system of neurotransmitters and peptide hormones (e.g.,dopamine, oxytocin) appears for affect regulation and mediation of bonding.Persistent stress decreases the activity level of the oxytocin system itself—and therefore the ability to bond with anybody. Whereas dopamine is in-volved in a wide range of positive emotions, oxytocin is specifically impor-tant for positive emotions relating to social and family connections. Sincesupportive social attachments tend to increase oxytocin levels and decreaselevels of stress hormones such as cortisol, there is every reason to suspectthe same biochemical effects can occur if the level of interpersonal supportis increased by creating an environment such as AA or group therapy thatpromotes rather than inhibits caring. Eisler and Levine (2002, p. 15) write,

There are a variety of results that oxytocin inhibits both fight-or-flightresponses and another type of common response . . . called dissociation.Dissociative responses are characterized by freezing and withdrawalfrom social interactions, and like fight-or-flight responses are commonin chronically stressed people such as abused children. By contrast,oxytocin promotes responding to stress by seeking positive social inter-


actions and nonanxious sensory stimulation (i.e., music). A subclass ofthese responses is what Taylor et al. (2000) termed tend-and-befriend.

Because evidence suggests that the experimental administration of oxy-tocin can inhibit the development of drug tolerance and withdrawal (Eisler& Levine, 2002), and since caring for and being cared for by others stimu-lates the release of endogenous oxytocin, a case can be made for the impor-tance of the type of bonding and attachment that occurs in AA and grouptherapy. This suggests that if caring produces the release of oxytocin, thecraving for more drugs should be reduced. The neurophysiology of caringfurnishes the addiction treatment field with an alternative explanation forwhy group therapy and AA are so effective in the treatment of addiction.Any treatment that promotes caring for and caring from others has a biolog-ical advantage over treatments that do not allow or promote this process.Comparing brain activity of people looking at pictures of loved ones or atpictures of nonromantic friends found that patterns of activity in the cortexwas markedly different depending on which type of face the subject was ex-posed to. Functional imagery brain scans of brains processing a romanticgaze bear a striking resemblance to the brain activity of new mothers listen-ing to infants’ cries, and people under the influence of cocaine. Since thepleasure derived from caring and being cared for leads to an increase of lev-els of oxytocin, and high levels of oxytocin decrease the need for moredrugs, this suggests that attachment to people is inversely related to the needfor more drugs.

In summary, adult attachment styles are valid predictors of the ways inwhich people cope with stressful events. Securely attached persons aremore tolerant of stressful events and have more accessibility of unpleasantemotions, without being overwhelmed by the resulting distress. The attach-ment literature describes secure attachment as dealing with distress by ac-knowledging it, enacting self-care strategies, and turning to others for emo-tional support. In a vast number of studies, the working models of securepeople, in which significant others are available when needed to bring reliefand comfort, are manifested in the tendency to seek support when copingwith stressful experiences. Insecurely attached avoidant individuals inhibitemotional display, deny negative affect and memories, and devalue eventsthat may cause painful feelings (Hazan & Shaver, 1987).

Animal Studies and Environment Effects on Gene Expression

Once again animal research lends supporting evidence of the importanceof nurturing and secure attachment to a child’s development and how nur-


turing environments can overcome “risky genes.” Infant rats raised by high-grooming mother rats showed less evidence of disturbance as adults. Incontrast, infant rats raised by low-grooming mother rats tend to becomelow-grooming mothers as adults. When pups born to a low-grooming strainof rats were “adopted” and raised by high-grooming rats, the offspring ofthe low-grooming rats demonstrated high-grooming behavior. Further-more, the low-grooming rats that were adopted and raised by high-groom-ing mothers were more likely to give birth to high-grooming pups whowould grow up to become high-grooming mothers as adults. When pupsborn to a low-grooming rat strain are adopted and raised by high-groomingrats, the offspring of the low-grooming rat pups demonstrate high-groom-ing behavior. Apparently, nurturing environments and caring parents canovercome genetic potential for negative temperaments. Steve Suomi, com-mission member of the National Institute of Child Health and Human De-velopment, has done extensive research with rhesus monkeys showing hownurturing and genes interact (2004). He has found that strong mothering notonly eliminates the negative impact of risky genes, it even appears certain ofthose genes may be turned into an advantage.

Prolonged Substance Abuse and Other CompulsiveAddictive Behavior

No matter how great the genetic potential or how much stress dominatesone’s life, the potential for becoming addicted would never develop if thatperson did not introduce substances into the central nervous system. Thesimple fact is that substance use itself is the greatest cause of addiction be-cause the toxicity of substance use is the greatest contributor to the alter-ation of an individual’s neurobiology. Emerging neurological research andbrain imagery studies confirm this simple fact, suggesting that addiction ismore than just a bad habit. No less than the director of National Institute onDrug Abuse (Alan Leshner, 1997b) and the director of National Institute ofMental Health (Steve Heyman, 1995) contend that once an individualcrosses over a yet undefined line, an alteration of neurophysiology occursthat cannot be reversed. They contend that prolonged use of substances canalter neural synapses and the endogenous production of certain neuro-transmitters that eventually results in permanent alterations of brain func-tioning. These alterations in turn affect the reward centers of the brain,which are hypothesized to be around the medial forebrain bundle (MFB),resulting in certain behavioral priorities. Consequently, under optimallyvulnerable conditions, prolonged use of substances interplaying with stressand the toxic effects of chemicals can produce alterations in the neuro-


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pathways and biochemistry of the brain, leaving vulnerable individuals tosuffer an increased occurrence for certain disorders (i.e., reward deficiencysyndrome) of which addiction is one common result.

Not all substances will impact the brain equally. Some drugs are so toxicthat they literally assault the biological underpinnings of our neurobiology.Consequently, because of the sheer magnitude of their potency, they aremuch more capable of altering a user’s neurophysiology and neuroanatomy.Crack cocaine and meth crystal are the prime examples of this phenome-non. Although it is not rare to find a casual drinker or even an occasionalmarijuana user, it is rare, if not impossible, to find a casual meth or crack co-caine user. These drugs are just too chemically potent for the brain to han-dle. Their toxicity is too extreme and their assault on the neurobiologicalunderpinnings of the structure of the brain too damaging. Drugs such asheroin also do their damage because they directly tap into the brain chemis-try that regulates the bonds of love and attachment. When people becomeaddicted to drugs, one of the most common reactions expressed by friendsand loved ones is a sense of bewilderment at the addict’s ability to turn hisor her back on family and friendships. This also explains why it is impossi-ble to do psychotherapy with practicing addicts or alcoholics; they are inca-pable of forming a therapeutic alliance, thus preventing their therapistsfrom having any influence in their lives.

The reward deficiency syndrome supports many of the new researchfindings from the emerging neurobiology of addiction. Prolonged use ofsubstances alters synapses and the endogenous production of certain neuro-transmitters. At some point, the addicted brain becomes qualitatively differ-ent from the nonaddicted brain. Alan Leshner (1996), the former director ofNIDA, argues that prolonged use can produce alterations in the neuro-physiology of the brain that cannot be reversed. When this “switch” in thebrain occurs, the substance user changes forever from an abuser to an addictor an alcoholic. The addicted brain becomes qualitatively different in itsneurobiology from the nonaddicted brain. This position explains why alco-holics and addicts can never return to “controlled drinking” or casual sub-stance use. Their brain is forever irreversibly altered. Another interestingaspect of this perspective is that the neurosciences are now furnishingevidence to a fact that Alcoholics Anonymous has always intuitively knownabout alcohol consumption, the brain, and addiction. Using AA’s ownunique vernacular, AA members have been reminding one another for de-cades that, “it is impossible to tell when a cucumber becomes a pickle, butonce a pickle, a pickle can never become a cucumber again.”

Alan Leshner (1997a) explains the significance of recognizing the fun-damental discontinuity between chemical use and addiction.


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What matters is that while addiction may be the result of a lot of druguse, it is not the same as using drugs a lot. Drug use and drug addictiondo not reside together along a continuum of say, drug use, drug abuse,a whole lot of drug abuse, and then addiction. And the user cannotvoluntarily move back and forth along such a continuum at will. Ad-diction is a qualitatively different state because the addicted brain is,in fact, different in its neurobiology from the nonaddicted brain.(1997a, p. 2)

Heyman (1995), writing from a neuroscience perspective, says that ad-aptations in brain functioning that result from excessive chemical use pro-duce somatic and psychological dependence, which in turn induces long-term changes in brain functioning that underlie drug craving in response toconditioned cues. An essential component of this adaptation and change inbrain functioning is the “commandeering of motivational systems of thebrain” by the drug, and this results in denial or the loss of the capacity forawareness that this has happened. Heyman cautions treatment personnelnot to confuse denial with lying and that denial does not mean that the alco-holic or addict is not telling the truth. Rather, it is the result of motivationalsystems of the brain becoming controlled by the reward circuitry of thebrain. Brain adaptations, as the result of repeated drug use, are hypothe-sized to be absolutely central to the production of addictive behavior andbehavioral priorities. Implications for treatment are profound. Much of ad-dicts’ or alcoholics’ behavior is not under their volitional control or choice.Interventions that take into careful consideration the lack of motivation andthe degree of denial on the part of the addicted individual are more likely tobe effective than those approaches that assume the person has the emotionaland mental capacity to choose and behave as someone who is in control ofhis or her brain functioning.

Neuropsychological Impairment

Surprisingly, one of the most important and often ignored variables inthe diagnosis and treatment of addiction is the effect that drugs and alcoholhave on the brain. This has important implications for a number of reasons.Most simply put, all forms of psychotherapy (individual, group, family, cog-nitive, psychodynamic, etc.) rest on the assumption that people will be ra-tional enough to make decisions based on accurate insight and understand-ing of themselves and their situation. It is impossible to conduct traditionalforms of therapy with addicted patients who are actively using substancesor are in the very early stages of recovery. Although most therapists would


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agree with such a position, few fail to understand the significance of sub-stance abuser’s cognitive impairment three, six, or even nine months intotheir recovery because these symptoms are often very subtle and specific.Because most alcoholics and addicts do not demonstrate significant diffi-culties in their verbal intelligence, they often “sound better” than they reallyare. An awareness and understanding of these cognitive deficits is neces-sary so adaptations can be made in treatment that matches the needs and ca-pabilities of the addicted patient. These factors will be explored at length inChapter 8, which deals with early treatment strategies and group psycho-therapy.

On neuropsychological tests sensitive to abstract reasoning, flexiblethinking, fluid intelligence, and new learning, alcoholics and addicts con-sistently score in the brain-impaired range. Yet their verbal intelligence andold learning remains pretty much intact. Consequently, they will often ap-pear unimpaired to the unsuspecting observer. Their level of impairment isusually not permanent and does not involve cortical structural damage.Rather, their brain dysfunction is of a diffuse nature, usually the result of analcohol-induced encephalopathy exacerbated by nutritional and vitamindeficiencies. Most alcoholics and addicts experience “spontaneous recov-ery” from the loss of cortical functioning if they remain alcohol and drugfree and improve their vitamin and nutritional intake. This recovery of cog-nitive functioning is gradual and steady. The greatest improvement is usu-ally experienced in the first months with total recovery achieved after one totwo years of abstinence.

Heyman goes on to emphasize that it must be remembered that addictionis a disease of the brain. “At the core of a disease model of addiction basedon modern neurosciences is the concept that in a vulnerable individual, ade-quate drug use produces long-lived adaptations in brain functioning” (Ver-bal communication, 1995). Based on years of accumulated data derivedfrom the neurosciences, he views addiction as a disease uniquely tied intoneural underpinnings of motivation and emotion, the pathophysiology ofwhich involves drug-induced, long-lived molecular changes in the brains ofvulnerable individuals. This results in a perversion of the normal volitionalcontrol of behavior. Heyman believes this ingrained behavioral pattern can-not be altered as long as chemicals are being used and “like all patients witha serious chronic disease, the addicted individual can be asked to complywith treatment and to avoid behavior that put him at high risk of relapse.”

Looking at addiction from this perspective helps explain why this disor-der can take on many forms and manifest itself across myriad patterns.Schaffer (1995) has acknowledged that he has gradually come to hold theposition that addiction is best understood as an altered state of conscious-


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ness, which involves components of biochemical and physiological alter-ations of brain operations that are tied into adaptation in brain rewardcircuitry that results in long-term changes in brain functioning. These phys-iological adaptations of brain functioning underlie compulsive behavior inresponse to conditioned cues. Consequently, addiction has more to do withlearned behavior (conditioned responses due to powerful, emotional rewardexperiences) and deficits in cognitive and emotional functioning than ithas to do with dependence on a drug or withdrawal symptoms related toabstinence. Once an addictive style or obsessive-compulsive pattern of re-sponding and thinking is established in the brain because of a substance’sbiochemical impact, the person is conditioned or prone to substitute onemanifestation, compulsion, or object of addictive preoccupation for another.

Conclusion

After reviewing the way that the interplay between stress, genetics, andsubstance abuse can influence or induce the reward deficiency syndrome,what can we conclude from all this? Even if someone is genetically loadedto develop alcoholism or some other related addiction, it is unlikely that thiswill occur if that person has the good fortune to be born to parents who pro-vide a secure base or secure attachment, do not live in poverty, and are se-curely attached themselves. These conditions will not only minimize thelevel of stress in the developing child’s brain and life, but will also providethe child as an adult with more inner resources or resiliency if trauma or ad-versity should befall him or her. This inner resource (as the neurosciencesare teaching us) reflects a peak level of neurophysiological and neuro-biological development that has primed the individual’s genetic potential inthe most advantageous way, thus optimizing the person’s capacity for stressmanagement and interpersonal closeness.

Even if a child has the misfortune to be born to two alcoholic parents, theevidence from child development and the neurosciences suggests the childwould be at little risk to develop an addiction if these optimal circum-stances were still provided. However, it is highly unlikely and improbablethat two alcoholic parents could provide an ideal optimal environmentfor the child’s developing brain. Consequently the entire question aboutcausation is confounded by the nature-nurture interaction. As part of thisnew developing perspective, attachment theory is challenging the old mind-body dualistic model that has plagued medical care since the time of Des-cartes. Alcoholics Anonymous sidesteps this entire debate by keeping itsimple: Just don’t drink. No matter how great a risk someone might be be-cause of environmental and genetic circumstances in his or her life, the ab-


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sence of substances in the body makes all this debate about causation mootand purely academic.

ATTACHMENT AND ANIMAL RESEARCH

The consequences of a mammal’s failure to attach have been widelydemonstrated by animal research. Research with monkeys has been particu-larly useful because of the many important parallels discovered betweenisolated monkeys and addictive behaviors found with addicts and alcohol-ics. Monkeys raised in isolation from other monkeys in their colonies anddeprived of secure attachment have extreme difficulties surviving or fittingin their monkey society. They are frequently loners and have difficulty get-ting along with other monkeys because they cannot read or express appro-priate emotional and signals. Isolated monkeys get into fights more fre-quently, are often self-injurious, aggressive, and demonstrate inappropriatesexual behavior. They also have food and water binges as well as a demon-strated difficulty in unlearning dysfunctional patterns of behavior.

The “isolation syndrome” of Kraemer (1985) has special relevance foraddiction. Witness the similarity between isolated monkeys and the practic-ing alcoholic and addict. The implications for diagnosis and treatment areprofound. Isolated monkeys, like addicts and alcoholics, are more likely todemonstrate the following:

1. Food and water binges2. A propensity to prefer and consume more alcohol than “normal mon-

keys”3. Difficulty extinguishing learned patterns of behavior or altering re-

sponse sets4. Unstable, aggressive relationships5. Self-defeating behavior6. Poor sexual relationships7. Difficulty providing parenting8. A tendency to isolate (“loners”)

Peer Monkeys

Research has also shown that when these loner monkeys are placed withpeer “therapist monkeys” who have had a healthy attachment relationship,the sick isolated monkeys start to look “normal.” Their behavior changesand they began to fit in with the other monkeys in the colony. Howeverwhen they are taken away from their “therapist monkeys,” their improve-


ment does not hold up. They quickly deteriorate and do not function as wellbecause they still do not demonstrate the capacity to learn and respond toappropriate emotional signals and cues.

Peer monkeys and the attachment to “therapist monkeys” can offset poorparental attachment experiences. Parallels have been drawn to children whohave been raised by absent or alcoholic parents. Sometimes the siblings inthe family can compensate for the parental failings.

When “therapist monkeys” are returned to the society after spendingprolonged periods of time with the sick monkeys, they show more signs ofdepression and anxiety. One could make a case for a syndrome commonlyseen in therapist “burnout.”

Isolated or sick monkeys also demonstrate other signs of impairment intheir neurochemistry. Some of the common findings include the following:

1. Norepinephrine levels are depleted. If levels get too low, despair re-sponse is worse.

2. Disregulation of the dopamine system occurs, resulting in a tendencyto be more easily overwhelmed by sensory input.

3. Serotonin levels are adversely impacted. Low levels lead to depres-sion and high levels lead to high dominance ranking in the colony.

4. The body’s natural opiate system is adversely affected.

CONTRIBUTIONS OF THE RELATIONALPERSPECTIVE TO GROUP PSYCHOTHERAPY

Attachment theory, as part of the development of the newer relationalmodels within psychodynamic theory, represents a conceptual revolutionthat has emerged over the past few years, which not only synthesizes thebest ideas of psychoanalysis, cognitive sciences, and neurobiology, but alsoprovides a credible and practical way to understand and treat addiction. Therelational perspectives also provide inherently valid alternative explana-tions for why twelve-step programs work as they do and how the curativeforces in these programs have a direct relation to the strategies that need tobe emphasized when treating patients with substance abuse disorders. At-tachment theory (Bowlby, 1980) also provides the first compelling theorythat offers a practical alternative rationale for the addiction cycle that is notonly compatible with the disease concept, but expands it by providing amore complete and intellectually satisfying theoretical explanation whyAlcoholic Anonymous (AA) works as it does. With its rich heritage andsolid grounding in psychodynamic theory, attachment theory provides a re-


spected theoretical perspective that helps legitimize the recommendationsof the abstinence-based treatment approach.

The integration of the neurosciences and attachment theory also repre-sents a comprehensive meta-theory of addiction that not only integrates di-verse mental health models with the disease concept, but also furnishesguidelines for clinical practice that are compatible with existing addictiontreatment strategies. Most addiction specialists who deliver treatment on aregular basis adhere to an abstinence-based treatment approach closelyaligned with twelve-step treatment philosophy. Any theory is doomed to beignored if it contradicts direct clinical experience of those who work withthis population on a consistent, daily basis. Any proposed theory—no mat-ter how comprehensive or intellectually satisfying it is—will not maintaincredibility if its basic premises fly in the face of applied practical experi-ence and the fundamental realities of successful clinical applications.

Addiction treatment, for the most part, has historically been dominatedby the twelve-step abstinence-based treatment approach. Consequently, in-depth psychodynamic-oriented psychotherapy has often been dismissed asirrelevant to addiction treatment. Attachment theory has helped shift psy-choanalytic thinking from classical drive or instinct theory to a relationalapproach with its greater emphasis on adaptation, developmental arrest-ment, and deficits in self-structure. The evolution of the relational modelshas shifted the focus away from intra-psychic struggles to an exploration ofthe interpersonal or relational difficulties that contribute to a person’s ad-dictive behavior. Most important, the relational perspective has ushered ininnovative ways for understanding addiction and the difficulties that thetypical addict and alcoholic brings to treatment.

The Neuroscience of Group Psychotherapy

Interpersonal neurobiology offers a framework for group therapists toharness the powerful insights of neuroscience in an effort to guide treatmentapplications. The brain is profoundly interpersonal, and emotions organizethe brain. Narrative and attachment are fundamental to changing behaviorand mediate changes in the brain and mind. Group therapists can add an-other dimension to their perspectives by considering people’s neurobio-logical profile that will make itself known through their attachment style.Nowhere is the potential for interactive repair more visible than in grouppsychotherapy. Early developmental experiences of neglect, abuse, andprolonged stress with its ensuing release of toxic stress hormones in con-junction with chemical bombardments to the brain induced by excessivesubstance use eventually become imprinted in a person’s neuron circuitry.


Group treatment, if guided by the principles of attachment theory, providesan excellent opportunity to alter and modify these imprinted pathwaysthrough neurogenesis promoted by the corrective interpersonal responsive-ness available in the group. Consequently, the substance abuser is eventu-ally able to modify dysfunctional neuropathways and essentially over timehave his or her brain “rewired.”

Roth (2004) shares the opinion that addiction is fundamentally a diseaseof isolation. This statement describes the heart and soul of addiction andwhy group psychotherapy is such an effective modality for the treatment ofaddiction. This book strives to help readers understand why this is so. Thenotion that addiction is both a solution to and a consequence of an impairedability to establish and maintain relationships is implied throughout thisbook. If abstinence and recovery are to be achieved and maintained, theaddicted individual must develop the capacity to establish healthy emotion-ally regulatory relationships. Group therapy is the ideal vehicle for accom-plishing this end. Roth’s (2004) suggestion that individuals do not recover,groups recover, helps explain why addiction treatment cannot be success-fully accomplished unless the addicted individual makes the commitmentto be in a relationship with someone or something other than his or her drugof choice. As long as addicted individuals remain attached to a drug, theywill not be able to attach to anyone else or to a culture of recovery. Withoutthat commitment, any hope of treatment and recovery is impossible. Rothcaptures this principle when he deftly writes that addiction is a disease thatwas designed to interfere with attachment. When the addict or alcoholiceven considers attaching to something other than the drug of his or herchoice, this in itself is a powerful step in the direction of recovery. Groupscomposed of individuals struggling with similar difficulties with detach-ment and attachment are better able to accomplish this task because groupsreduce the sense of isolation and shame that accompanies every addictiveprocess.

This book aims to provide a more comprehensive and satisfying para-digm that better explains and incorporates these diverse new discoveries ofthe neurosciences. Attachment theory provides such a paradigm as it natu-rally informs and organizes these discoveries. Not only does attachmenttheory furnish an all-encompassing theoretical formula for understandinghow interpersonal relationships shape and sculpt the brain, it also provides amodel for correcting ingrained irregularities of brain functioning. Most im-portant, attachment theory does not introduce another new model of therapyinto an already huge and confusing armament of existing therapeuticapproaches, each professing their advantages over the others. Instead, at-tachment theory offers a transtheoretical formula that identifies and sub-


stantiates what all effective therapeutic models and treatments already do.For those of us in the addiction treatment and group therapy field, attach-ment theory validates the importance of an interpersonal approach thatpromotes the establishment of strong emotional bonds conducted within anenvironment of mutual support and emotional arousal. All of this is ex-plored thoroughly in the next chapter.


Groups and neurobio of addiction

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