Since May is Mental Health Month, I thought I would utilize Sigmund Freud to discuss substance abuse. Freud certainly is a name that looms large in the fields of psychology and psychiatry. His structural model defining one's psyche is made up of three distinct hypothesized constructs - namely, the id (which we are born with and can be thought of as that part of our personality crying out for "I want what I want when I want it" or immediate gratification); the ego (the "executive" of our personality, which develops and helps us to see things from a realistic perspective); and the superego (which develops as well and can be broken down into the ego ideal and the conscience - think of these parts of our personality as helping us to distinguish right from wrong).

This personality paradigm, if you will, finds the ego balancing between our need for immediate gratification, and at the same time not "offending our superego" such that we lie awake at night plagued by guilt. While I have spoken of these complex structures in rather elementary terms, the description will serve my purpose in making an important point.

Individuals with addiction issues are constantly struggling with their need for immediate gratification. If they don't like the way they feel, they take a drink or a drug that seems to deliver a change in mood - the problem is that when we go beyond their id and get into the realm of their superego, there are consequences. While their ego attempts to counterbalance between the id and the superego, it utilizes three primary defense mechanisms: denial (I don't have any problem with alcohol or drugs); projection (I am not the problem you are the one with the problem); and rationalization (the reason I have a problem is A, B, and C - so I don't bear any responsibility).

These defense mechanisms that are used in the service of the ego to preserve one's self-esteem, often serve as a roadblock in helping the addicted individual see reality. Some clinicians try to strongly confront these defenses - but this often leads to the person becoming even more defensive - how ironic! Instead, this author advocates a "carefrontational" approach - one that treats the individual with respect and dignity - never shamming or blaming, but does indeed hold them responsible for their personal recovery.

Of course, there are many knowledgeable professionals who are more than willing to help people with their struggle to develop a better sense of self-esteem and not have to resort to changing how they feel in the immediacy of the moment - a temporary and at times deadly solution.

Lastly, for those of you who are budding neuropsychologists and psychiatrists, please note that research has begun to make great strides in correlating brain structures with Freud's theoretical constructs. This clinician believes that when we embrace "scientific totality" in search of empirical evidence we will certainly come up with evidenced-based practices that lead to first-rate treatment for the disease of addiction - indeed, we have already made great strides!

About the Author

Harris Stratyner, Ph.D., CASAC

Harris Stratyner, Ph.D., CASAC, is a Clinical Associate Professor at the Mount Sinai School of Medicine; he is also with Caron Treatment Centers.

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