Dying For It
A brief look at "addiction to near death"
Posted Jul 25, 2014
Some of you reading this may be surprised to learn that there is a small literature on the idea of people being “addicted” to "near death experiences" (NDEs). Arguably, most people’s perceptions of "near death addiction" are probably based on the 1990 US film Flatliners. In that film, a group of five medical students (played by Keifer Sutherland, Kevin Bacon, Julia Roberts, Oliver Platt and William Baldwin) attempt to examine whether there is anything beyond death by carrying out experiments into NDEs. Keifer Sutherland’s character (Nelson) is continually made to experience clinical death (i.e., flatlining with no heartbeat) before being brought back to life by his classmates.
This Hollywood portrayal of possible "near death addiction" bears little resemblance to the academic literature – most of which has been written from a psychodynamic perspective – and relates more to continual self-destructive experiences (usually by adolescents or young adults). The concept of "addiction to near death" (ATND) originates from the writings of Dr. Betty Joseph, a distinguished psychoanalytic clinician often lauded as “the psychoanalysts’ psychoanalyst” and known for her work with highly resistant "difficult to treat" patients.
Dr. Joseph first wrote about the "addiction to near death" concept in a 1982 issue of the International Journal of Psychoanalysis. This form of masochistic pathology was a concept that she found useful when working with psychologically dysfunctional adolescents. As Dr. Janet Shaw noted in a more recent 2012 paper on ATND in the Journal of Child Psychotherapy:
“At [the adolescent] stage of development, there is a tendency for adolescents who are troubled to turn to destructive or self-destructive behaviour, suicidal ideation, self-harm, self-starvation and inappropriate sexual behaviour. This is often profoundly shocking and alarming to others, especially if the young person finds the impact on others pleasurable. [Betty] Joseph described a patient addicted to near death as being caught up in a wish to gain pleasure by destroying both himself and the analytic relationship…[She] described masochistic destruction of the self taking place with libidinal satisfaction, despite much concomitant pain. The masochistic position is deeply addictive and this way of using pain for the purposes of pleasure becomes habitual. She summed this up as, ‘the sheer unequalled sexual delight of the grim masochism’ and described the awful pleasure that is achieved in this way."
However, as Dr. Shaw rightly points out, not all types of destructive and self-destructive behaviour fall into such a category. In her 1982 paper, Dr. Joseph outlined case studies she had treated psychoanalytically from her private practice. Here, she described the masochistic dynamics of her patients, and how hard it was for them to alter these dynamics and get better. She noted that one of the key aspects of the dynamics she described was that her patients derived immense libidinal satisfaction from engaging in destructive near-death behaviours. More specifically, she wrote:
“There is a very malignant type of self-destructiveness, which we see in a small group of our patients, and which is, I think, in the nature of an addiction – an addiction to near-death. It dominates these patients' lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so-called thinking, and the way they communicate with themselves. It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this. The picture that these patients present is, I am sure, a familiar one – in their external lives these patients get more and more absorbed into hopelessness and involved in activities that seem destined to destroy them physically as well as mentally, for example, considerable over-working, almost no sleep, avoiding eating properly or secretly over-eating if the need is to lose weight."
In a 2006 issue of Psychanalytic Psychology, Dr. William Gottdeiner also noted that the ATND is such a strong motive that successful treatment of such individuals is unusually difficult. However, Dr. Gottdeiner asserted that one of the severe weaknesses of Joseph’s writings is that she failed to provide in-depth clinical examples of anyone who had engaged in potentially deadly activities. This, Gottdeiner contended, threatened the validity of the ATND construct. Despite such inherent weaknesses, Gottdeiner still believed the ATND construct had strong face validity (i.e., “there are people who seem to repeatedly engage in potentially lethal behavior, making the ATND construct plausible”). Consequently, Gottdeiner tested the construct validity of ATND on females with substance use disorders (SUDs). His argument was that:
“If individuals who are diagnosed with an SUD are successfully treated and they continue to engage in potentially deleterious behavior, then that finding would support the notion that the individual has an addiction to near-death experiences, and that the individual’s substance abuse was a comorbid disorder.”
Gottdeiner’s paper attempted to validate the ATND construct via secondary analysis “of data from a treatment outcome study of individuals who were in residential therapeutic community treatment for SUDs and who received simultaneous safe-sex education during treatment." His study findings showed that despite safe-sex education and sexual activity in the therapeutic communities being prohibited, that some of the participants still engaged in risky sexual behaviour (irrespective of whether their sexual partners were HIV-positive or not). Gottdeiner argued that these findings tentatively supported the ATND construct. However, Gottdeiner was the first to admit that his study had inherent weaknesses. As he noted:
“The limitations were: data were from retrospective self-reports [and] contained no baseline measures of sexual activity, safe-sex knowledge, condom use, HIV status; it had no male participants, no specific questions about near-death behavior, nor whether alternative safe-sex activities were practice…The limitations of [the] study are considerable, and some might even argue that the connection between the ATND construct and the data presented herein is too much of a stretch to be scientifically useful…Obviously, stronger data would lead to stronger conclusions. Despite the limitations of this study, the findings should motivate clinicians to more seriously consider the existence of an addiction to near-death in their clients."
More recently, Dr. Janet Shaw examined the ATND construct through the description and evaluation of an in-depth case study account of an adolescent female ("Susan"). Her paper explored “the way in which pleasure, which is sadistic and masochistic in nature, is associated with cruelty towards the self or others in adolescence.” Dr. Shaw wrote that it felt as if Susan’s main aim was to torment her. As Shaw reported:
“In addition to suicide threats, similar to those she made in the assessment, she made constant reference to systematically starving herself. She was painfully thin, although not actually anorexic and she was poisoning herself by repeatedly taking paracetamol. Susan’s threats to self-harm had a deeply disturbing quality and she clearly enjoyed making them. There was a wish to punish me, as well as herself, through her phantasised attacks…The case material is an example of an adolescent girl with ‘an addiction to near death’ constituting a dominant way of relating to others. Her relentless and manipulative references to self-harm, suicide and dangerous behaviour at various stages of the work were designed to shock and alarm…Susan’s self-destructive behaviour was also continuing in relation to her self- starvation. She said she took laxatives in an attempt to lose more weight. She was becoming dangerously thin and three years into her psychotherapy an appointment with the referring psychiatrist resulted in a diagnosis of anorexia nervosa.”
This quote doesn’t do justice to the very detailed account that Dr. Shaw provided in her lengthy paper. However, her written account is heartfelt and brutally honest. Shaw concludes that the compelling power of addiction overviewed in Susan’s case mustn’t be underestimated. As she notes:
“The narcissistic idealisation of sadistic and masochistic behaviour offers some protection from fear and terror for the patient, but the consequence is to severely limit capacity for thought and imagination, and to restrict awareness. ‘Addition to near death’ forms a small but significant component of the clinical casework of a child and adolescent psychotherapist: it is hoped that Susan’s case material serves to illuminate the phenomenon further and its technical challenges.”
Whether the clinical case of Susan provides any more evidence for validation for Joseph’s ATND construct than the more empirical work of Gottdeiner is debatable. However, this is certainly a fascinating – if somewhat harrowing – area of clinical and academic work that certainly warrants further empirical examination.
References and further reading
Gottdiener, W.H. (2006). A preliminary test of the Addiction-to-Near-Death construct. Psychoanalytic Psychology, 23, 661-666.
Joseph, B. (1982). Addiction to near death. International Journal of Psychoanalysis, 449-456.
Joseph, B. (1988). Addiction to near death. In Bott Spillius, E. (Ed.) Melanie Klein Today (pp.311-323). London and New York: Routledge.
Ryle, A. (1993). Addiction to the death instinct? A critical review of Joseph’s paper ‘Addiction to near death’. British Journal of Psychotherapy, 10, 88–92.
Shaw, J. (2012). Addiction to near death in adolescence. Journal of Child Psychotherapy, 38, 111-129.