Of all of the clinical issues I’ve explored throughout my career, there is one which has baffled me because I have found no psychodynamic treatment which has proven to be successful. I have, however, developed my own hypothesis regarding the cause of these difficulties and can speculate regarding why it might be unreasonable to attempt to treat this through psychotherapy alone. 

I have categorized seven compulsions into what I call “the Oralities” (taken from the word “oral”) which refers to taking substances into ones mouth or body in an attempt to reduce anxiety. This anxiety is based on an overwhelming feeling of emptiness and isolation. These issues would include compulsive eating, smoking, alcoholism and drug abuse. Three other issues are sublimations for direct oral satisfaction: compulsive buying, compulsive gambling and compulsive sex. 

I believe that the origin of these symptoms can be found in the earliest days of life. 

An infant will cry for one of three reasons: It is in pain. It is hungry. It needs to be held. 

A cry of pain is very obvious. The infant will suddenly scream. Parents generally recognize this howl and immediately attend to the child. 

The baby’s responses to hunger or the need to be held, however, are almost identical and, therefore, are hard to differentiate. The distress might start as a whimper, graduate to a cry and culminate as a howl. The parent, not knowing what the child needs, understandably assumes the child is hungry. They feel that the introduction of a nipple offering either breast milk or formula will stop the crying. That will suffice for the hungry child. If, on the other hand, the child is not hungry but wants to be held, it expresses it by rejecting the nipple. This is the infant’s way of letting the parents know that it wants to be held. If the parent recognizes the baby’s need and meets it, the infant will receive the comfort it is seeking and stop crying. 

If, however, the parent rejects the child’s message that it needs to be held and continues to insist that he accept the nipple, the infant will begin to associate food not only with hunger but as a substitute for closeness, warmth and security. Rather than feeling a physical connection or intimacy with the parent, the infant ends up feeling alone, disconnected and unable to have its needs met. 

Eventually, these feelings will be compensated for with food. Taking something into ones mouth becomes a double determinant. It satisfies not only the need for food but it fills the emptiness created by the absence of the comforting parent. Over time, especially for the child whose only experience of being held occurs during feedings, there develops an identification of the association of fullness with being held. 

The food-as-comfort later extends out to cigarettes, alcohol and drugs which, like food, are taken directly into the body. This creates a change in brain chemistry that leads to a change in mood. Compulsive spending, gambling and sex eventually become sublimations for the early oral needs and they, too, create a change in mood. 

The child, and later the adult, will overeat not because it is hungry but because it feels empty, alone or anxious. Many patients say they will eat or drink at night when everyone is asleep and they feel very alone. It is also fairly common for patients to shop compulsively when they are feeling alone or depressed. They are attempting to fill the emptiness. (It occurs to me that this may account for the popularity of the late night shopping programs on television.) 

When I realized how early in life these deprivations occur, I began to understand why psychotherapy, as we know it, can not succeed without another essential element. An infant‘s need to be held can occur at any time of the day or night. Similarly, the adult who feels an intense need to connect can experience that need at any time of the day or night. As a therapist, I can be available when someone is in crisis, but I cannot possibly always be there when someone is feeling the need to connect. If I were to try to do that, I would not be able to have a private life. Clearly, this is why 12 step programs with their institutionalized use of a hotline, support system and sponsors can achieve some success. Through Alcoholics Anonymous and other similar programs, there is the promise that someone will be there to simply reassure you that you are not alone. Someone is always available. A former patient expressed his dependency when he told me that when he can’t count on people he can always count on the bottle in his cabinet. With AA, this does not have to be the case. 

The story of the establishment of AA is fairly well known. Bill Wilson and Bob Smith promised each other that they would be there for each other when they wanted to drink. Both of them had been through the worst. Their marriages had failed. They had ruined their careers. They had spent time sleeping it off in drunk tanks, jail cells and hospitals. Nothing worked for either of them until they met and promised to be there for each other 24 hours a day. Eventually, they sought out other problem drinkers and formed the first group of Alcoholics Anonymous. Other groups later followed and sought to provide support for people with other addictions. 

AA provides an atmosphere that helps people deal with the feelings of isolation, despair and aloneness which have driven them to attempt to seek relief in substances. They can relate to and identify with the pain described by others and realize that they are not alone in their misery. They are in an atmosphere that is safe and protected because there is no judgment or criticism. When they reach a point where they feel comfortable enough and develop a level of trust, they can begin to talk about their own pain. 

For many, this is the first place where they can actually express their feelings because as children they closed off when they received the message that many of their thoughts, feelings and needs were wrong, bad or sinful. Children who get these messages internalize their feelings and begin to feel guilty and alone. At the AA meetings, as the adult begins to discover that he is not crazy, sick, weird or wrong, the doubts, guilts, and feelings of loneliness begin to dissipate. He learns to forgive himself for both his thoughts and actions and can begin to make peace with himself. 

Hopefully, the ability to trust and be open will extend out to others and decrease the isolation which contributed to his developing the addiction in the first place. 

As I learned more about the groups dealing with orality issues, I started to understand why they succeeded with some people and not with others. AA claims a 38% success rate. At first look this seems to be a low number, but it is the only group that has met with any success. Those who are committed and follow the 12 Step Program have a reasonably good chance of learning to live their lives free of their particular form of addiction. I believe that this happens when the person can develop with others in the group the real connections that were absent in their infancy. 

As I explored the success of the program, I also began to understand more about the 62% who were not successful. The first step in the 12 Step Program requires surrender. It admits a powerlessness to control ones addiction and the need to surrender to a higher power. Traditionally, people attributed the term “higher power” to a concept of God. They speak of “letting go and letting God.” For those who don’t have faith or a belief in God, the higher power can be redefined as something outside oneself. 

But, the idea of giving up or losing control is threatening to many people. Despite the fact that their lives are driven by their addiction, they continue to struggle on their own. For many, the struggle is related to the concept of the disease model of alcoholism. The thought that they have a disease for which there is no cure is abhorrent to them. In addition, the very idea that they will need to stay in a program for the rest of their lives is completely unacceptable. 

My belief is that orality based addictions are not incurable diseases. I feel that, when an addict is able to learn to trust and, eventually, to truly connect with others, the pain of aloneness and isolation will lift. There may be the temptation to return to old coping mechanisms whenever the person experiences feelings of emptiness, but, over time, the temptation will decrease in both frequency and intensity. 

Dependency in infancy is a natural developmental stage. In order to be truly independent, the child must have had the original connection to the parent. If that connection was not made, a void occurs which makes it impossible for movement through the next developmental stages to occur. The child continues to seek comfort from substances and is not able to develop the ability to seek comfort from within himself. 

In order for a child to become truly independent, he must develop confidence in his ability to take care of himself. Rather than continue to feel emotionally isolated, once he discovers that he can trust others and himself, he can go on to handle the normal stresses of life without using substances. 

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