1. Group Psychotherapy
with Addicted Populations
An Integration of Twelve-Step
and Psychodynamic Theory
Third Edition
Philip J. Flores, PhD
The Haworth Press®
New York
3. CONTENTS
Foreword xv
Jeffrey D. Roth
PART I: THEORETICAL MODELS
Chapter 1. Interpersonal Neurobiology and Addiction:
An Attachment Theory Perspective 3
Interpersonal Neurobiology 4
The Neurophysiology of Attachment 7
Interdisciplinary Research and Attachment Theory:
A Source for Informing Addiction Treatment 9
Contributions from Child Development Studies 10
Contributions from the Neurosciences 19
Reward Deficiency Syndrome 19
Attachment and Animal Research 37
Contributions of the Relational Perspective to Group
Psychotherapy 38
Chapter 2. Attachment Theory As a Theoretical Basis
for Understanding Addiction 43
Attachment Theory and Self-Psychology 45
Attachment Styles and Secure Attachment 46
Ainsworth and the Strange Situations 47
Implications for Treatment 48
Implications for Addiction Treatment 60
Summary of Treating Addiction As an Attachment
Disorder 62
Chapter 3. The Disease Concept and Group
Psychotherapy 65
Abstinence: Is it Necessary? 66
Paradigm Shift 74
Specific Implications of Group Therapy and the Disease
Concept 81
Addiction, Abstinence, and the Disease Concept 84
4. Chapter 4. Psychodynamic Theory and the Relational
Models 97
Character Pathology and Addiction 99
Contributions of Object-Relations Theory
and Self-Psychology 101
Margaret Mahler’s Theory of Normal Development 106
Ego Psychology and Object-Relations Theory 107
Mahler’s Stages of Normal Development 112
Beyond the Ego: Kohut’s Self-Psychology 126
Definition of Terms 134
The Self-Medication Hypothesis and Affect Regulation 138
Application for Therapy: Corrective Emotional Expression 143
Addiction As an Attempt at Self-Repair 152
Self-Esteem Vulnerabilities 154
The Reparative Approach 160
Chapter 5. Alcoholics Anonymous and Twelve-Step
Programs 163
Misconceptions About Alcoholics Anonymous 164
Values, Science, and AA 167
Philosophy of Science and the Limits of Rationality 173
The Self-Help Movement 177
Alcoholics Anonymous: Its Historical Roots 178
AA—Why and How It Works: An Interpretation of AA 182
Pragmatism: Its Influence on AA 185
Existential View of AA 188
AA—How it Works: A Phenomenological Perspective 196
The Self-Attribution of Alcoholism 201
Honesty, Denial, and the Need for Others 204
AA: A Self-Psychology Perspective 207
AA: A Treatment for Shame and Narcissism 209
Higher Power As an Attachment Object 214
PART II: ADDICTION TREATMENT
IN THE GROUP
Chapter 6. Different Models of Group Psychotherapy 221
Some Models of Group Psychotherapy 222
Psychological Levels of Intervention 223
Specific Applications for Addictions Treatment 250
5. Chapter 7. Preparing the Chemically Dependent Person
for Group Therapy 257
Selection and Composition 259
Implications of Research Findings 261
Therapeutic Alliance and Cohesion in Group 262
Pre-Group Preparation: Increasing Treatment Retention
and Reducing Dropouts 267
Recommendations for Entry into a Therapy Group 269
Present and Gain Acceptance of the Contract 282
Chapter 8. Interactional Group Psychotherapy 287
Yalom’s Basic Tasks 288
The Model-Setting Participant 291
Interpersonal Honesty and Spontaneity 295
Establishment of the Group Norms 298
The Norm of Self-Disclosure 299
Procedural Norms and Antitherapeutic Norms 302
Importance of Group 303
The Here-and-Now Activation and Process Illumination 305
Interpersonal Theory of Behavior 316
Sullivan’s Interpersonal Theory of Psychiatry 317
Examples of Yalom’s Here-and-Now Focus 324
Integration of Modern Analytic Approach 332
Conclusion 348
Chapter 9. Modifications of Yalom’s Interactional Model 351
Treatment Considerations and Group Therapy 353
Recommendations for Group Psychotherapy 356
Protocol 356
Early and Later Stage Treatment 361
Therapist Attributes and Special Considerations
for Affect Attunement 364
Careseeking, Affect Attunement, and Psychotherapy 368
Group Therapy and ACOA 370
Addiction and the Family 371
Common Identified Characteristics of ACOA 372
ACOA and Shame 375
Alcoholics Anonymous and Group Psychotherapy 376
6. Chapter 10. Co-Occurring Disorders and Group
Psychotherapy: An Attachment Theory
Perspective 379
Addiction—The Cart or Horse of Mental Illness? 380
Cross-Addiction 381
The Relationship Between Mental Health and Addiction 384
Axis I Disorders 386
Axis II: Character Pathology and Addiction 386
Borderline Personality Organization and Pathological
Narcissism 388
Kernberg’s Borderline Pathology 390
Kernberg’s Description of Supportive Psychotherapy 391
Narcissistic Personality Disorder 395
Dynamics of Multiple Addictions 404
Integration of Divergent Treatment Philosophies 407
The Relational Models: An Integration 410
Chapter 11. The Leader in Group Therapy 413
Values of the Group Leader 414
The Therapist As a Person 417
Qualities of the Group Leader 417
Guidelines and Priorities for the Group Leader 431
Roles of the Group Leader 431
Focus of the Group Leader 434
Characteristics of the Group Leader 438
The Therapeutic Process: Therapists’ and Patients’
Contributions 443
The Alliance and Addiction: Special Considerations 452
Group Leadership Functions 454
The Implications for Conducting a Successful Therapy
Group 456
Alcoholism Treatment Outcome Studies 458
Patient Characteristics Related to Types of Therapy 460
Specific Group Strategies and Requirements 463
Recommendations 466
Convergence of Therapist and Patient Characteristics 467
7. PART III: CLINICAL APPLICATIONS
Chapter 12. Diagnosis and Addiction Treatment 473
Avoidant Society: Cultural Roots of Impaired Attachment 475
Criterion Definitions of Addiction 478
Drug Groups 480
Drug Dependence and the Drug Groups 481
Neuropsychological Impairment 483
Stages of Change Model 490
Relapse Prevention 492
Interpersonal Neurobiology, Motivation, and Stages
of Change Model and Brain Impairment 493
Chapter 13. Early Stage Group Treatment:
Confrontation, Intervention, and Relapse 495
Special Problems of the Addicted Patient 496
The Use of Therapeutic Leverage 498
Confrontation 501
Intervention 512
Relapse and Recovery 525
Early Stage versus Later Stage Relapse 528
Therapist versus Patient’s Contributions to Relapse 530
Later Stage Relapses 532
Relapse Prevention 534
Chapter 14. Inpatient Groups and Middle Stage
Treatment 535
Yalom’s Recommendations for Inpatient Groups 544
Composition of the Inpatient Groups 547
Yalom’s Strategies and Techniques of Leadership 549
Agenda Rounds 552
Difficulties with Agenda Rounds 557
The Special Circumstances of Inpatient Therapy Groups
Within the Hospital 558
Leader’s Transparency About Alcohol and Drug Use 559
The Group Contract 560
Simultaneous Membership in Other Groups 562
The Special Problems of Confidentiality on an Inpatient
Unit 564
Active Outreach 567
8. Group Members Who Relapse and Come to Group 568
Attending Group Under the Influence 569
Summary Recommendations for Inpatient Group Therapy 572
Chapter 15. Late Stage Group Treatment:
Conflict, Repair, and Reunion 575
Paradigm Shift 577
The Concurrent Treatment of Addiction and Character
Pathology 580
Later Stage Treatment Strategies 583
Yalom’s Model and Self-Psychology 584
Treatment of Internal Structural Deficits 587
Treatment of Introjections 589
Later Stage Treatment: Conflict, Repair, and Reunion 593
Attachment, Addiction, and the Working Alliance 597
Research and the Therapeutic Alliance 601
The Alliance: What Is it and Why Is it Important? 603
Attachment, the Therapeutic Alliance, and Negative
Process 608
Chapter 16. Transference in Groups 613
Definition of Transference 614
Transference Possibilities in Group 618
Modification of Transference Distortions in Groups 621
Types of Transference in Groups 623
Common Types of Acting Out Transference 625
Abuse of Transference 631
Countertransference 631
Projective Identification 636
Pathways for Psychological Change 640
Addiction and Countertransference 641
Chapter 17. Resistance in Group 647
Resistance: A Definition 648
Group Resistance and the Work of Wilfred Bion 651
The Leader’s Influence on the Basic Assumptions 654
Resistance to Intimacy in Groups 658
Resistance to Immediacy 663
9. Resistance to Feelings in Group 665
Special Considerations of Resistance to Addiction 669
The Group Leader’s Effect on Group Resistance 672
Chapter 18. The Curative Process in Group Therapy 677
Yalom’s Curative Factors 679
Curative Factors in Group 679
Existential Factors 682
Curative Factors in AA 687
Curative Factors Operating in Different Types
of Therapy Groups 689
Mechanisms of Change and Cure in Group Therapy 689
The Curative Process 694
Working Through with the Addicted Patient 698
Stages of Cure in a Therapy Group 699
Addiction and Goals of Termination 704
Conclusion 707
References 711
Index 737
11. 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 provide
the person with an ongoing opportunity for novel experiences and optimal
emotional arousal within the context of a safe, supportive, interpersonal re-
lationship and affective bond. In short, if you want to change someone’s
mind, become emotionally attuned with the individual and talk with him or
her in a meaningful, caring manner. State-of-the-art neuroimaging tech-
niques have confirmed this to be so. Schore’s (2003a) review of hundreds of
neuroimaging studies demonstrated the importance of the implicit, body-
based, nonverbal affective communication that occurs within the critical
component of the intersubjective field of the therapeutic alliance. This criti-
cal process accounts for the greatest structural changes in the brain during
effective therapy. The neurosciences have led the way to an understanding
of human behavior that is moving beyond the limits of the mind-body dual-
ism, which has dominated medical science for the past 300 years. This
emerging evidence has prompted Lewis, Amini, & Lannon (2000) to write,
“Dividing the mind into ‘biological’ and ‘psychological’ is as fallacious as
classifying light as a particle or a wave” (p. 167).
Brain-mapping studies (Braun et al., 2000), in vivo neurochemistry, and
studies of brain receptors (Insel & Quirion, 2005), and state-of-the-art
neuroimaging 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 operant
shaping, and brain neuronal reorganization reflect mounting evidence that
the 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 to
change its structure and function in particular by expanding or strengthen-
ing circuits that are used and by shrinking or weakening those that are rarely
engaged. [Although] the science of neuroplasticity has mostly documented
brain changes that reflect physical experience and input from the outside
world” (2004, p. 1), more recent research in the area of meditation has
shown that altering the structure of the brain is not limited to only external
physical rehearsal. The brain can also change in response to purely internal
4 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
12. mental signals, similar to those practiced in meditation. Furthermore, those
individuals who have the most practice at it are the ones who demonstrate
the most alteration in brain circuitry. “This opens the tantalizing possibility
that the brain, like the rest of the body, can be altered intentionally. Just as
aerobics sculpt the muscles, so mental training sculpts the gray matter in
ways 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 also
how 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 the
other 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 had
returned to normal. The untreated patient stayed the same. Preliminary
studies also showed that functional magnetic resonance imaging (fMRI)
can predict with high accuracy whether an individual will relapse following
treatment 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 treatments
for addiction, but actually validates many current methods already being
utilized. 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 a
strong emotional bond—will alter neural pathways and synaptic strength.
All forms of psychotherapy, from psychoanalysis to cognitive behavioral
therapy (CBT), are successful to the degree to which they accomplish this
and enhance growth in relevant neuron circuitry. The use of communicative
language and emotional attunement provides the best medium for neuronal
growth and integration.
The false separation that exists between biology and psychology is grad-
ually diminishing thanks to the contributions of attachment theory and the
neurosciences. Research has revealed a number of erroneous conclusions
about 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
13. 5. Speaking in a meaningful way, paying attention, and attachment alters
brain biochemistry and changes in synaptic transmission, strength, and
numbers.
6. Attachment can alter gene expression.
As Siegel (2006) points out, we are at an exciting moment in the history
of psychotherapy as neuroscience has shown us the way to integrate the
clinical field of psychotherapy with the independent field of neuroscience.
No longer is the simple “single-skull” view of the mind appropriate since
recent research findings from the neurosciences have now altered com-
pletely how we define the mind. The old reductionistic perspective that the
mind 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 mind
was to give the person a pill or alter synaptic connections in some way. The
mind is much more than just the activity of the brain. The mind uses the
brain to cultivate itself or as Siegel (2006) says, “The brain is the plaything
of the mind.” No longer is the mind viewed as a singular encapsulated organ
enclosed within an individual. The new perspective reconciles this miscon-
ception when it defines the mind as the flow of energy and information
within the brain as well as the flow of energy and information between
brains. The interpersonal neurobiological perspective enables group thera-
pists to embrace the findings of the neurosciences and use these findings to
understand how the mind is altered through group psychotherapy, primarily
through the experience of being with others.
The mind develops as the genetically programmed maturation of the
brain is shaped by ongoing experience, and the experience that sculpts the
brain the most is not drugs, but relationships. As Siegel reminds us, one of
the most powerful relationships is a properly conducted and managed ther-
apy relationship (2006). No form of psychotherapy is effective unless it
changes the brain, and long-lasting changes to the mind require changes in
the 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 individuals
can be taught how to alter the ingrained tendencies of their mind to be easily
distracted. More than sixty subjects with ADHD were taught to eliminate
and inhibit their impulses by utilizing mindfulness techniques practiced
during meditation. When Siegel first showed the results from his study to
his colleagues, the first question was “What was the dosage of the medica-
tion you used?”
6 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
14. Siegel (2006) explained how experience can actually activate genes to
stimulate synaptic growth. Neural stem cells, which are uncommitted blobs
of neuroplasma in our brains, divide spontaneously every twenty-four hours
or so. When they divide, one remains with the stem cell line, and the other
waits for a novel experience to be inspired to grow into an integrated neuron
in the brain—no novel experience, no neuronal growth. However, provide
that experience repeatedly and interesting things start to happen. It takes
about a month for the neuron to get inspired and another two or three
months to get established. After 90 to 120 days, massive changes will occur
in the integrative functions of the brain related to new stem cell division and
differentiation.
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 the
recognition 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 authority
when the implication of Siegel’s work is carefully examined. AA got it
right: To produce the desired change toward sobriety, an alcoholic’s brain
will require at least ninety days before it can make the massive changes in
stem cell differentiation and division Siegel describes. The neurosciences
are confirming that effective therapy requires three essential components:
1. A novel experience
2. 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 a
theoretical framework to help translate their discoveries into an explanation
that 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 explain
this shared phenomenon. Attachment theory provided this needed para-
digm. In effect, attachment theory can be viewed as an attempt to update
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 7
15. psychoanalytic theory in light of the newer discoveries in developmental
neurobiology 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 scientists
from a wide range of traditionally independent fields of research to coalesce
into a unified perspective. Another refreshing feature of attachment theory
and its associated influence in the interdisciplinary sciences is how much it
naturally inspires, informs, and confirms child development studies, the
neurosciences, treatment outcome studies, animal studies, and modern
psychodynamic theory.
Siegel (1999), for instance, provides convincing evidence that attach-
ment not only influences a child’s developing neurophysiology, but can also
stimulate neurogenesis in an adult. Cox (2006) supports this view when he
points out that an attachment experience causes neurons to fire, neuronal
activity causes gene expression to change, and the resulting stimulation of
new proteins promotes new brain structure. In the following outline Siegel
describes 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 that
influence and organize motivational, emotional, and memory pro-
cesses with respect to significant caregiving figures, whether those
caregivers 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 the
potential for meaningful communication with them.
3. At the most basic evolutionary level, this behavioral system improves
our chances for survival. As Bowlby implies, just as we are more
likely to survive on the plains of the Serengeti in Africa if we have a
companion, our chances for survival increase if we have a companion
when we are battling a serious case of cancer or even taking a walk
down a dark alley. Recovering from an addiction is more likely to be
successful 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
8 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
16. 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 (or
group’s) responses to the child’s (or addict’s) verbal and nonverbal
signals, which can serve to amplify the child’s (or addict’s) positive
emotional states and to modulate negative states.
6. In particular, the aid parents (or group members) can give in reducing
uncomfortable emotions such as fear, anxiety, or sadness enables chil-
dren (or other group members) to be soothed and gives them a haven
of 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 which
serve to help the child (or addict) feel an internal sense of Secure
Base.
INTERDISCIPLINARY RESEARCH AND ATTACHMENT
THEORY: A SOURCE FOR INFORMING
ADDICTION TREATMENT
The contributions that attachment theory (Bowlby, 1988) has to offer on
addiction and treatment have not been appreciated or recognized for their
far-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 theory
and 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 the
psychoanalytic community is because Bowlby’s theories were not just a
matter of offering a slight revision of psychoanalysis, but in actuality, “at-
tachment theory proposes a completely new framework from which to
understand clinical and developmental phenomena” (Cortina & Marrone,
2003, p. 14).
The potential impact of attachment theory’s contributions to treatment is
not limited to just addiction. Bowlby’s original ideas (1958, 1973) have
evolved into a body of knowledge that furnishes a translation of findings
from numerous domains of study, providing a common language and con-
ceptual framework. This integration enables researchers and scientists from
a wide range of traditionally independent fields of research to coalesce into
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 9
17. a unified perspective. Another refreshing feature of attachment theory and
its associated influence in the interdisciplinary sciences is how much it nat-
urally inspires, informs, and confirms child developmental studies, the
neurosciences, treatment outcome studies, animal studies, and modern
psychodynamic theory. (These sentences are repeats of sentences a few
paragraphs 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 conceptual
framework for describing an interpersonal neurobiology of treatment. It is
also recommended that group psychotherapy can be an especially effective
medium for the delivery of this crucial element of therapy if the proper para-
digm for guiding treatment application is adapted. Recent evidence from a
diverse 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-encompassing
theoretical formula for informing the way group therapy should be applied
if the full potential of these research findings are to be realized and the
greater potential for successful treatment is to be maximized.
CONTRIBUTIONS FROM CHILD DEVELOPMENT STUDIES
Attachment theory, more than any other theoretical perspective, places
particular 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 and
is 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 certain
neuronal substrates of the brain. There are critical developmental stages
when certain experiences must be provided or the opportunity for that expe-
rience will be forever lost. The absence of critical experiences will shape
the structure of the brain for the rest of the child’s life and in many cases
leaves the vulnerable individual with unalterable consequences.
10 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
18. For example, the infant’s brain is waiting for the experience of binocular
vision. If that experience is not provided by the age of four months, the
brain will never be able to acquire depth perception. The learning of a sec-
ond language is another good illustration. Those cultures that provide a
multilingual experience for the child’s developing brain during the first five
years 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 similar
way, the quality of the early attachment relationship in the first year of life
has a very powerful effect on the development of the emotional relational
core 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 identifiable
patterns or attachment styles are established in the brain, they persist
through 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 child
develops, its brain is waiting for an experience. Depending on whether that
experience 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 environmental
stimulation are not provided, pruning occurs. Pruning is actual neuro-
nal death, resulting in the weakening of synaptic potentials and the
weakening of neuronal pathways.
To the degree that a particular experience is provided, the developing
brain responds with neuronal growth. If these experiences are not provided,
the child goes from a potentially large neural substrate to one shaped by
pruning and lack of stimulation, which alters the structure of the brain for
life. Synaptic connections that are reinforced by an infant’s exposure to lan-
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 11
19. 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 by
early experience are eliminated (pruning). Examples include binocular vi-
sion, the development of language, musical competence, and the capacity
for attachment. Developing kittens deprived of visual stimulation for the
first four months of their life lose the capacity forever to have binocular vi-
sion (depth perception). As any parent knows, children exposed to foreign
languages and music in the first few years of their life demonstrate a much
greater capacity for the enrichment of these skills than those who attempt to
learn 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 to
provide proper needed responses to a developing brain is seen in the
isolated, affectionless sociopath whose capacity for human warmth and
attachment is forever lost.
Circuits in the different regions of the brain mature at different times. As
a result, different circuits are more sensitive to life’s experience at different
ages. 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 rudimentary
signs 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 influenced
by 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 brain
development. Research has demonstrated that attachment and interpersonal
interactions not only influence brain activity but also are crucial for brain
development.
For instance, the kind of emotional attunement provided by secure at-
tachment actually increases blood flow to the prefrontal areas of the child’s
brain, resulting in growth of neural tissue in the emotional and attention
centers of the brain. Without the emotional resonance provided by attune-
ment from an attachment figure, the child’s excitement and prefrontal arousal
12 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
20. 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 attachment
stimulates 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 the
developing brain through the mechanism of neurochemical activity. Neuro-
chemical stress not only impacts the mature brain, it also adversely impacts
the immature or developing brain. Studies have shown that the brains of ne-
glected children are strikingly different from brains of children who were
not neglected. Neglect produces children whose head circumferences are
measurably smaller, and whose brains on magnetic resonance scanning evi-
dence shrinkage from the loss of billions of cells. Similar anatomical
changes, related to the parts of the brain that mediate emotions and attach-
ment, were also discovered in children raised by depressed mothers. In all
these cases research has convincingly demonstrated, nurture not only affects
nature; it often determines nature.
Secure Attachment Creates Neurophysiological Homeostasis
The absence of attachment is not limited to physiological disruptions of
the brain. Not only do nurturance, social communion, play, and communi-
cation have their home in the limbic territory, but other aspects of the body
are severely affected when attachment is disrupted. Abandoned individuals
experience multiple disruptions to their entire homeostasis. Lewis et al.
(2000) give a disturbing account of all that can go wrong when children and
adults are forced to deal with loss.
Prolonged separation affects more than feelings. A number of somatic
parameters go haywire in despair. Because separation deranges the
body, losing relationships can cause physical illness. Growth hor-
mone levels plunge in despair—the reason why children deprived of
love stop growing, lose weight no matter what their caloric intake, and
dwindle away. . . . Children aren’t the only ones whose bodies respond
to the intricacies of loss: cardiovascular function, hormone levels,
and, immune processes are disturbed in adults subjected to prolonged
separation. . . . In his fascinating book Love and Survival, Dean
Ornish surveyed the literature on the relationship between isolation
and human mortality. His conclusion: dozens of studies demonstrate
that solitary people have a vastly increased rate of premature death
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 13
21. from all causes—they are three to five times likelier to die early than
people “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 is
more 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 monkeys
are given high doses of opiates, it inhibits their separation cry. When given
opiate antagonists, their separation cry returns and their separation stress re-
sponse is enhanced. The situation is very similar with human heroin addicts
who do not react to separation or loss. When they are high, they simply treat
people as if they do not matter. The heroin in their veins protects them
against separation anxiety and the panic of attachment loss.
Accumulating evidence on the impact of loss suggests overwhelmingly
that attachment figures (relationships) are powerful regulators of normal
physiology. How individuals handle separation and loss is determined by
the length and quality of their earliest attachment relationships. The quality
of this early relationship is encoded in the memory and limbic system. Be-
fore understanding the full impact that attachment and separation can have
on a person, it will be important to explore the biology and neuroanatomy of
memory.
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 in
a new model of emotion that is highly compatible with attachment theory.
This new model of emotion is not only more theoretically useful, it is also
more closely aligned with actual clinical application. Emotions, from this
perspective, cannot be separated from one’s physiological makeup. Not
only is this true for humans, but it is the case for most social mammals. Paul
Ekman’s (1992) classic work is the most recent example of evidence sug-
14 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
22. 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 critically
shaped by early experiences and continue on to become a major and uncon-
scious organizing force for all mental activity. Attachment is a specialized
example of this. It starts with the natural capacity of the child to send and
receive emotional signals with his or her primary caregiver. The nature of
the child’s capacity to accurately read emotional signals in self and others is
crucially shaped by the mother-infant bond and becomes an unconscious
foundation for all subsequent interpersonal relationships.
The work of Ekman and others (i.e., Izard, 1971) have also confirmed a
central proposition of the survival importance of emotions first put forth by
Darwin, who proposed that facial expressions are identical all over the
globe, in every culture, and with every human being. These findings suggest
that emotions are universal, closely tied to our physiology, and central to all
human experience and relatedness. Emotions also serve a communication
function, starting first with the mother and infant. The demonstration of af-
fect helps maintain attachment (the separation cry, for instance) and is the
earliest and most primitive form of communication. It mediates attachment
and serves a basic survival function.
With the mounting evidence that emotions are innate, not learned, and
that 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 correct
interplay between the brain, emotion, and attachment. One primary reason
for the inadequacies and inaccuracies in other previous theoretical models
is 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 left
over 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 epiphenomenon
of psychodynamic conflicts.
Darwin was actually one of the first to propose a theory that was devoid
of this polarization. He believed that emotions were behaviors that arose
and 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 we
genetically 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
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 15
23. broader function of the brain, which reads the environment and readies the
body for an appropriate response (flight-fight). Our emotional responses
also affect our memory of these experiences and because of this, emotion is
looked upon as an important organizer of mental activity that shapes our
priorities, 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 emotional
system 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) for
others to read. Infants especially are born with an innate emotional fluency
that provides an immediate language between mother and infant.
Anatomy of Attachment
Because of recent advances in the science of neurobiology and the
neuroanatomy of emotion and memory, attachment theory pays particular
attention 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 between
emotion and memory in this system lays a foundation for understanding the
impact 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 is
essential for organizing complex brain functions. All learning and condi-
tioning takes place at the limbic level. Information is encoded and stored
here forming a motivational map indicating the location of emotionally sig-
nificant objects like food, predators, and sexual partners. This information
is 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 is
danger, but leave that person unable to tell you why, like the patient who has
a gut feeling, but cannot explain it.
Because of our society’s preoccupation with facts and psychology’s
obligatory heritage with the “talking cure,” science shares the same cultural
bias that we all have about the hierarchical structure of the brain. Common
teaching implies that the lower areas of the brain—which contain the limbic
system—must obviously serve lower brain functions. Since the neocotex is
considered the latest developmental achievement of human evolution, our
16 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
24. neocortex is assumed to obviously serve a higher and thus more important
brain 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 system
actually provides an important organizing component to our brain that
actually 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 that
the most crucial levels of communication occur. Consider how words spo-
ken without emotion have little power to persuade. Also consider research
that demonstrates the powerful exchange of wordless communication that
goes on between a mother and her infant. Lewis et al. (2000) write about the
subtleties of this type of communication reminding us that what is obscure
is not always without significance.
Emotionality is the social sense organ of limbic creatures. While vi-
sion lets us experience the reflected wavelengths of electromagnetic
radiation, and hearing gives information about the pressure waves in
the surrounding air, emotionality enables a mammal to sense the inner
states 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 takes
place at the limbic level, and the limbic system is anatomically intercon-
nected with memory, information that is available for recall has a profound
influence on attachment, psychopathology, and learning. Emotionally charged
information is stored and encoded here, functioning as a “motivational
map.” This “map” serves an important task, indicating emotionally signifi-
cant objects such as food, predators, and sexual partners. Primitive man
could immediately scan his environment and sense (i.e., gut feeling, intu-
ition, etc.) secure versus dangerous situations. This information is finely
processed and stored so a person could immediately sense danger and react
without having to stop and think or explain why.
Knowledge That Cannot Be Explained
Many ingenious and creative studies have been designed to show that it
is possible for people to acquire knowledge and improve their performance
on a task without their understanding why they solved the problem as they
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 17
25. did. Subjects in these studies exhibit the acquisition of knowledge by dem-
onstrating an improvement in their performance on a new task. When asked
how they solved the problem, they were unable to explain the strategies
they applied in their solution. Similar results were discovered with brain-
damaged individuals who had lost their hippocampus, the area of the brain
required for the storage and recall of explicit memory. Even though individ-
uals without a hippocampus could learn new tasks and demonstrate this
ability by completing an assigned task, they were unable to remember
learning it. They were also unable to explain how they accomplished or
solved the problem.
Knowledge without awareness is a scientifically demonstrated phenom-
enon. Although this capacity to experience comprehension divorced from
memory 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 of
memory. 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 memory
divorced from the power of comprehension and thought. The greatest
percentage of our knowledge is implicitly stored and more difficult to
retrieve. 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 to
the unconscious, it is not just repression, active censorship, or dissoci-
ation. The information is there and can often be demonstrated by a
person’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 is
instantaneous, not requiring the loss of time it might take to process
information (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 in
childhood before the development of language. It is when the child
was most vulnerable and under the influence of powerful affect
states.
18 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
26. • Emotional: Implicit memory is “hardwired” to emotions and the
limbic system. It mediates attachment and is closely aligned with
Bowlby’s concept of the internal working model.
CONTRIBUTIONS FROM THE NEUROSCIENCES
Although an abundance of research evidence suggests that inadequate
attachment can have a profound influence on a child’s developing brain, ac-
cumulated evidence also suggests that a number of environmental factors
contribute to the brain’s increased susceptibility to addictive diseases. Re-
search on the possible relationship between certain genetic anomalies and
alcoholism has led to the discovery of a statistically significant incident of a
genetic variant (called an allele, which is an alternate form of a gene occu-
pying the same position on matching chromosomes) that is related to a
number 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 to
either an inborn or induced imbalance in the limbic-diencephalic area of the
brain (commonly referred to as the pleasure center of the brain) that leaves a
person with feelings of deficits in safety, warmth, and a full stomach. If
these 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 is
referred 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-
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 19
27. ward from ordinary everyday activities. It is hypothesized that depletion in
dopamine and serotonin levels contributes to this condition. In a “normal
person,” neurotransmitters work together in a cascade of excitement or inhi-
bition—between complex stimuli and complex responses—leading to a
state 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 of
abnormal cravings in both animals and human beings. Disruption can be
induced 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 the
person’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 increased
or decreased stress and disease or mortality outcomes. Psychoneuroim-
munologists have demonstrated that this link is established through the
following 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 that
disease once they have it.
Unfortunately, the relationship between stress and disease—especially
the addictions—is not always this straightforward. The interplay between
genetic potential and individual response styles (some people are high
stress reactors while others are low stress responders), interacting with at-
20 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
28. tachment history (secure versus insecure attachment styles), and the indi-
vidual psychodynamics operating within the individual (some people are
drawn to chaotic relationships and stressful lifestyles) will determine who
will 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 to
disease. The relationship between fetal nutritional events and lifelong risks
of metabolic disease was first described by David Baker of Southampton
Hospital in England. The emerging discipline of fetal origins of adult dis-
ease (FOAD) is now accumulating vast amounts of data demonstrating the
connection 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 its
risks for obesity, hypertension, cardiovascular disease, insulin-resis-
tant diabetes, maybe reproductive impairments, maybe anxiety, and
impaired brain development. And maybe even setting up that fetus’s
eventual 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 begets
fetal stress. Early effects, at least during the first or second trimester, affect
the children most because that is when the developing brain is in its most
critical stages. Anything affecting brain development will have long-lasting
effects. For instance, Avishai-Eliner, Brunson, Sandman, & Baram (2002)
found that women who reported high levels of anxiety during pregnancy
were twice as likely as nonstressed mothers to have children with behav-
ioral problems, depression, and anxiety when these children were assessed
at four and seven years of age. All of this suggests that diseases blamed on
lifestyles 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. Animal
studies reported similar results. For instance, Hofer (1984) reported that
mice and primates born to highly stressed mothers demonstrated height-
ened emotionality and timidity as they avoided open arms of mazes and def-
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 21
29. ecated excessively. Hofer suggested that stress during pregnancy promoted
decreased 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 a
significant part in determining secure attachment, research has demon-
strated that a number of factors can contribute to overcoming negative
temperaments. Mothers who have what Fonagy, Gergely, Jurist, & Target
(2002) call “high reflective function” (empathy and insight as a result of
their own secure attachment) and have increased sensitivity are likely to
produce more securely attached children, especially if these children have
negative temperaments. Experimentally increasing maternal sensitivity for
mothers of infants with negative temperaments yielded an exceptionally
large effect in terms of increasing attachment security from 28 percent to 68
percent.
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 the
brain, the frontal cortex. Another obvious stressor is post-traumatic stress
syndrome (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, less
depression, increased affect regulation, and addiction. Conversely, insecure
attachment is strongly associated with the presence of family risk factors
such as maltreatment, major depression, bipolar disorder, alcoholism, and
substance abuse. A child’s relational context imprints into the developing
brain 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 of
adult attachment style as a key factor in determining success or failure in ad-
22 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
30. 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 developmental
tasks, and personal and interpersonal losses. In all of these life domains, at-
tachment working models seem to shape the way people appraise and cope
with stressors and to moderate their emotional reactions to these events.
Bowlby’s theory (1980) also implies that insecure attachment can be
viewed as a risk factor that may detract from the individual’s resilience in
times of stress. The early attachment experience of insecure persons (both
anxious-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 resources
necessary for successful coping with and adaptation to life stressors.
Adult personality is seen as a product of an individual’s interactions with
key 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 known
people from whom he or she can seek support, comfort, and protection, and
where they are to be found. So deeply established are the child’s expectations
and so repeatedly have they been confirmed that, as an adult, the person finds
it difficult to imagine any other kind of world (Bowlby, 1973).
Others, who have grown up in less secure circumstances, will be much
less fortunate in the way the brain develops. For some the very existence of
caretaking and supportive figures is unknown; for others the whereabouts
of such figures has been constantly uncertain. For many more the likelihood
that a caretaking figure would respond in a supportive and protective way
has been at best hazardous and at worst nil. When such people become
adults, it is hardly surprising that they have no confidence that a caretaking
figure will ever be truly available and dependable. Through their eyes the
world is seen as comfortless and unpredictable, and they respond either by
shrinking from it or by doing battle with it (Bowlby, 1973, pp. 208-209).
High Stress Responders versus Low Stress Responders
and Ambiguous Situations
As Bonanno’s (2004) (see Chapter 10 on trauma and resilience) research
showed, not everyone will respond with a similar intensity to the same
stressful situation. One important determinant is the person’s history of se-
cure versus insecure attachment. Sapolsky’s (2004) research with primates
on the Serengeti sheds some light on how this difference can be played out
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 23
31. with human beings. Sapolsky established a research paradigm in which ba-
boons were placed in an ambiguous threatening situation. He then recorded
their responses and measured their glucocorticoid levels, an indicator of the
degree of their stress response. In the first scenario, he placed securely and
insecurely attached (separated at birth from their mothers) baboons in obvi-
ously threatening situations with rival baboons demonstrating aggressive
behavior. In the second scenario, he had rival baboons placed safely off in
the distance in nonagressive positions, a situation that was clearly ambigu-
ous since the threat was not immediate. The insecurely attached baboons
could not discern the difference between these situations while the securely
attached baboons could. The securely attached baboons could
tell that one situation is bad news, the other is meaningless. But some
males get agitated even when their rival is taking a nap across the
field—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 the
guy who can tell the difference. If a rival napping across the field
throws a male into turmoil, the latter’s going to be in a constant state
of 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 disease
or 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 lack
of predictability that one has in one’s life. Health care access, poor diets,
fewer financial resources, more dangerous working situations, exposure to
riskier toxic environments, infant mortality, and crime are just a few of the
contributing factors to stress. Consequently, poverty is associated with in-
creased risks for every major disease. Not surprisingly, it also places the
poor 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 to
self-administer to the point of addiction. Unpredictable stress drives a rat to
addiction more effectively than predictable stress. Stress a pregnant rat and
her offspring will have an increased propensity for drug self-administration.
24 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
32. Addicted humans, rats, and primates are all more likely to relapse when
placed under stress. Experimentally manipulating the environment of a rat
in “recovery” (substituting a saline solution for a drug that has been self-
administered by pressing a lever will extinguish the lever pressing by the
rat) by infusing the rat with a bit of the drug during a stressful situation will
result in an increase in the self-administration of the drug. A review of
countless studies similar to these led Sapolsky to conclude,
In these instances, the stressor during development can’t be working
merely by causing a transient rise in dopamine release. Something
long term has to be occurring. Perinatal experiences causing life-
long “programming” of the brain and body. It’s not clear how this
works in terms of addictive substances, other than that there obviously
has 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 numerous
times called The Resident Intruder Paradigm examines “socially defeated
rats” who are placed under laboratory-induced stressful situations. An in-
truder rat is placed in a dominant rat’s territory. The resident dominant rat
will usually initiate a “mock attack” on the intruder. When this occurs, the
intruder 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, sleep
is disturbed, and weight loss is recorded). This is a normal response to feel-
ing defeated. However, when the experiment is controlled for secure versus
insecure attachment, different response patterns are noted for insecurely
and securely attached rats. Securely attached rats recover much more
quickly while rats that have been separated at birth (insecure attachment) do
not recover and often die unless given treatment. As with their human coun-
terparts who feel socially defeated, treatment involves antidepressants or
placing the intruder rat in a secure environment with a “therapist rat” that
provides 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.
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 25
33. Another popular research paradigm examines parental consistency and
the way predictability can contribute to reducing stress, even during diffi-
cult times. Rhesus monkeys were placed under three different conditions in
which availability of food was experimentally manipulated. The three
conditions included the following:
1. Low foraging demands
2. High foraging demands
3. 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 stable
foraging conditions, whether these conditions were high or low. Conditions
could 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 was
observed with the young as mothers separated from their infants while the
infants struggled to maintain contact.
Genetic Anomalies
Nature versus Nurture
The nature versus nurture debate that has dominated the biological and
social sciences in the past century is a false dichotomy built on an outdated
and false distinction. Recent advances in the neurosciences have recently
taught us that they are not mutually exclusive categories. The interplay be-
tween genetic potential and environmental circumstances either enhances
or inhibits gene expression. Attachment theory is joining a number of other
disciplines in the neurosciences in leading the way from genetic determin-
ism or what Perry (2002) calls the “tyranny of the genes.” Perry provides
two 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 untapped
until the advent of universal public education.
In 1211, Fredrick II, Emperor of Germany, in an attempt to discover
the natural “language of God,” raised dozens of children in silence.
26 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
34. God’s preferred language never emerged; the children never spoke
any 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 literally
shaped 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 effectively
with a changing environment. Perry (2002) outlines in detail the eight dif-
ferent processes of neurodevelopment that captures the opportunity and
vulnerability inherent in the genetic potential of each individual.
1. Neurogenesis
2. Migration
3. Differentiation
4. Apoptosis
5. Arborization
6. Synaptogenesis
7. Synaptic Sculpting
8. Myelination
The “Use It or Lose It” Consequence
The effects of childhood environment, favorable or unfavorable, interact
with all processes of neurodevelopment. The many functions of the human
brain result from a complex interplay between genetic potential and appro-
priately timed experiences. The neural systems responsible for mediating
cognitive, emotional, social, and physiological functioning develop in child-
hood and, therefore, childhood experiences play a major role in shaping the
functional capacity of these systems. When necessary experiences are not
provided at optimal times, these neural systems do not develop in optimal
ways. Abuse studies, evidence of children reared in orphanages that lack
emotional contact, and animal deprivations studies all point to the need for
children to have stable emotional attachments with touch from primary
caregivers, 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
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 27
35. negative ways—is in infancy and childhood. During this time experience
will 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 inhibition
of patterns of behavior that are mediated by social context and attachment.
Hence, behavior of animals interacting with other animals of their species is
not a one-way street from genes to social groups; the dynamics of social
groups also have a strong influence on the very biochemistry of gene ex-
pression. The primary strategy that natural selection furnished us in order to
meet these objectives is the creation of relationships. It is not as independ-
ent and solitary individuals that we have succeeded as a species; it is
through 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 are
dedicated to affiliation, communication, and attachment.
At a very basic level, survival is related to being able to avoid being
eaten. 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 York
City, or the suburbs of Atlanta. Survival skills must be mastered early if the
helpless 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 inspire
predictable nurturing behavior is another example. These skills combined
with genetic endowment produce the repertoire of behaviors that character-
ize us as human. Any imbalances or deficiencies related to this capacity are
the basis for all psychopathology and all the addictions.
Self-Care and Support
It is important to understand how stress and caring behavior fit into the
biological makeup of humans and other social mammals. Natural selection
not only favors the survival of the fittest (erroneously assumed to mean the
most aggressive), but included those species that were genetically hard-
wired to care, bond, love, and become attached. Consequently, the brain has
the capacity for the gene expression for caring. Whether it gets expressed or
not depends on whether the social environment inhibits or promotes its ex-
pression. Neuroimaging studies are showing us that altruism, caring, and
28 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
36. love (attachment) are hardwired into the brain because these behaviors help
us 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 rendered
social, and that they feel as a consequence uncomfortable when sepa-
rated from each other, and comfortable whilst together; but it is a more
probable view that these sensations were first developed, in order that
those 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 the
greatest pleasure in society would best escape various dangers; whilst
those 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 have
identified the existence of biochemical markers for three major patterns of
response to stressful, complex situations and that all three are explicable as
evolutionary adaptations. In other words, the brain contains mechanisms
for enhancement or inhibition of conflicting behavioral patterns that can be
explained as adaptations to stressful evolutionary pressures. Three primary
patterns have been identified as follows:
1. Fight or flight
2. Dissociative
3. Tend and befriend
The pattern the brain “chooses” depends upon and is mediated in part by
the context and dynamics of social groups, support systems (or the lack of
them), and relationships. Experimental evidence exists showing that envi-
ronments can be created that either enhance or suppress competition (fight
or 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. The
evidence is stronger that the “tend-and-befriend response” (tending of off-
spring and social bonding) is stronger in females; however, analogous
mechanisms exist in males, but most social systems inhibit the full develop-
ment of the genetic expression for caring in males. Furthermore, a vast
amount of evidence suggests that “persistent stress tends to bias the brain’s
pathways in the direction of hyperarousal or dissociative responses, and
caring relationships tend to bias the brain’s pathways in the direction of
tend-and-befriend responses” (Eisler & Levine, 2002, p. 46).
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 29
37. However, caring behavior is tied to biological motivations other than
mere survival or reproduction. Caring behavior produces pleasure in all but
the most seriously damaged individuals. Research evidence points to the
importance of intrinsic motivations in most mammals for pleasure and posi-
tive affect (i.e., caring, cooperation, love, and bonding.). When careseeking
behavior (empathy and attunement) is met by the caregiver, a sense of relief
and satisfaction is experienced by both parties. This satisfaction reflects the
need that all developmentally mature adults have—the need to give and
receive in relationships.
Caring, Dopamine, and Oxytocin
Caring does good things to the brain, whether the person is receiving it or
providing it. As far as the central nervous system is concerned, caring and
feeling 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 experiences
can increase levels of oxytocin and the parasympathetic nervous system
pathways 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. Since
supportive social attachments tend to increase oxytocin levels and decrease
levels of stress hormones such as cortisol, there is every reason to suspect
the same biochemical effects can occur if the level of interpersonal support
is increased by creating an environment such as AA or group therapy that
promotes rather than inhibits caring. Eisler and Levine (2002, p. 15) write,
There are a variety of results that oxytocin inhibits both fight-or-flight
responses and another type of common response . . . called dissociation.
Dissociative responses are characterized by freezing and withdrawal
from social interactions, and like fight-or-flight responses are common
in chronically stressed people such as abused children. By contrast,
oxytocin promotes responding to stress by seeking positive social inter-
30 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
38. actions and nonanxious sensory stimulation (i.e., music). A subclass of
these 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 group
therapy. This suggests that if caring produces the release of oxytocin, the
craving for more drugs should be reduced. The neurophysiology of caring
furnishes the addiction treatment field with an alternative explanation for
why 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 at
pictures of nonromantic friends found that patterns of activity in the cortex
was markedly different depending on which type of face the subject was ex-
posed to. Functional imagery brain scans of brains processing a romantic
gaze bear a striking resemblance to the brain activity of new mothers listen-
ing to infants’ cries, and people under the influence of cocaine. Since the
pleasure 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 more
drugs, this suggests that attachment to people is inversely related to the need
for more drugs.
In summary, adult attachment styles are valid predictors of the ways in
which people cope with stressful events. Securely attached persons are
more tolerant of stressful events and have more accessibility of unpleasant
emotions, 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 secure
people, in which significant others are available when needed to bring relief
and comfort, are manifested in the tendency to seek support when coping
with stressful experiences. Insecurely attached avoidant individuals inhibit
emotional display, deny negative affect and memories, and devalue events
that may cause painful feelings (Hazan & Shaver, 1987).
Animal Studies and Environment Effects on Gene Expression
Once again animal research lends supporting evidence of the importance
of nurturing and secure attachment to a child’s development and how nur-
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 31
39. turing environments can overcome “risky genes.” Infant rats raised by high-
grooming mother rats showed less evidence of disturbance as adults. In
contrast, infant rats raised by low-grooming mother rats tend to become
low-grooming mothers as adults. When pups born to a low-grooming strain
of rats were “adopted” and raised by high-grooming rats, the offspring of
the 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 who
would grow up to become high-grooming mothers as adults. When pups
born to a low-grooming rat strain are adopted and raised by high-grooming
rats, the offspring of the low-grooming rat pups demonstrate high-groom-
ing behavior. Apparently, nurturing environments and caring parents can
overcome 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 how
nurturing and genes interact (2004). He has found that strong mothering not
only eliminates the negative impact of risky genes, it even appears certain of
those genes may be turned into an advantage.
Prolonged Substance Abuse and Other Compulsive
Addictive Behavior
No matter how great the genetic potential or how much stress dominates
one’s life, the potential for becoming addicted would never develop if that
person did not introduce substances into the central nervous system. The
simple 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 and
brain imagery studies confirm this simple fact, suggesting that addiction is
more than just a bad habit. No less than the director of National Institute on
Drug Abuse (Alan Leshner, 1997b) and the director of National Institute of
Mental Health (Steve Heyman, 1995) contend that once an individual
crosses over a yet undefined line, an alteration of neurophysiology occurs
that cannot be reversed. They contend that prolonged use of substances can
alter 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 optimally
vulnerable conditions, prolonged use of substances interplaying with stress
and the toxic effects of chemicals can produce alterations in the neuro-
32 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
40. pathways and biochemistry of the brain, leaving vulnerable individuals to
suffer an increased occurrence for certain disorders (i.e., reward deficiency
syndrome) of which addiction is one common result.
Not all substances will impact the brain equally. Some drugs are so toxic
that they literally assault the biological underpinnings of our neurobiology.
Consequently, because of the sheer magnitude of their potency, they are
much 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 occasional
marijuana 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 neurobiological
underpinnings of the structure of the brain too damaging. Drugs such as
heroin also do their damage because they directly tap into the brain chemis-
try that regulates the bonds of love and attachment. When people become
addicted to drugs, one of the most common reactions expressed by friends
and loved ones is a sense of bewilderment at the addict’s ability to turn his
or 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 therapists
from having any influence in their lives.
The reward deficiency syndrome supports many of the new research
findings from the emerging neurobiology of addiction. Prolonged use of
substances 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 of
NIDA, argues that prolonged use can produce alterations in the neuro-
physiology of the brain that cannot be reversed. When this “switch” in the
brain occurs, the substance user changes forever from an abuser to an addict
or an alcoholic. The addicted brain becomes qualitatively different in its
neurobiology 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 interesting
aspect of this perspective is that the neurosciences are now furnishing
evidence to a fact that Alcoholics Anonymous has always intuitively known
about alcohol consumption, the brain, and addiction. Using AA’s own
unique vernacular, AA members have been reminding one another for de-
cades that, “it is impossible to tell when a cucumber becomes a pickle, but
once 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.
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 33
41. What matters is that while addiction may be the result of a lot of drug
use, it is not the same as using drugs a lot. Drug use and drug addiction
do not reside together along a continuum of say, drug use, drug abuse,
a whole lot of drug abuse, and then addiction. And the user cannot
voluntarily 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 to
conditioned cues. An essential component of this adaptation and change in
brain functioning is the “commandeering of motivational systems of the
brain” by the drug, and this results in denial or the loss of the capacity for
awareness that this has happened. Heyman cautions treatment personnel
not 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 motivational
systems of the brain becoming controlled by the reward circuitry of the
brain. Brain adaptations, as the result of repeated drug use, are hypothe-
sized to be absolutely central to the production of addictive behavior and
behavioral 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 and
the degree of denial on the part of the addicted individual are more likely to
be effective than those approaches that assume the person has the emotional
and mental capacity to choose and behave as someone who is in control of
his or her brain functioning.
Neuropsychological Impairment
Surprisingly, one of the most important and often ignored variables in
the diagnosis and treatment of addiction is the effect that drugs and alcohol
have 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 traditional
forms of therapy with addicted patients who are actively using substances
or are in the very early stages of recovery. Although most therapists would
34 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS
42. agree with such a position, few fail to understand the significance of sub-
stance abuser’s cognitive impairment three, six, or even nine months into
their 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 really
are. 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 in
Chapter 8, which deals with early treatment strategies and group psycho-
therapy.
On neuropsychological tests sensitive to abstract reasoning, flexible
thinking, fluid intelligence, and new learning, alcoholics and addicts con-
sistently score in the brain-impaired range. Yet their verbal intelligence and
old learning remains pretty much intact. Consequently, they will often ap-
pear unimpaired to the unsuspecting observer. Their level of impairment is
usually not permanent and does not involve cortical structural damage.
Rather, their brain dysfunction is of a diffuse nature, usually the result of an
alcohol-induced encephalopathy exacerbated by nutritional and vitamin
deficiencies. Most alcoholics and addicts experience “spontaneous recov-
ery” from the loss of cortical functioning if they remain alcohol and drug
free 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 to
two years of abstinence.
Heyman goes on to emphasize that it must be remembered that addiction
is a disease of the brain. “At the core of a disease model of addiction based
on 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 derived
from the neurosciences, he views addiction as a disease uniquely tied into
neural underpinnings of motivation and emotion, the pathophysiology of
which involves drug-induced, long-lived molecular changes in the brains of
vulnerable individuals. This results in a perversion of the normal volitional
control of behavior. Heyman believes this ingrained behavioral pattern can-
not be altered as long as chemicals are being used and “like all patients with
a serious chronic disease, the addicted individual can be asked to comply
with 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 the
position that addiction is best understood as an altered state of conscious-
Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 35
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Special thanks to Jason Aronson Press for their generous willingness to grant permission to use material
from a previous publication. Earlier but somewhat different formulations of some of the ideas in this new
edition have appeared in the following publication:
Chapters 1, 2, and 4, incorporate some material from “Addiction as an attachment disorder” by Philip
Flores, which appeared in Flores, P. J. (2004). Addiction as an attachment disorder. (2004). Jason
Aronson 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 have
appeared in the following publication:
Chapter 13 incorporates some material from Conflict and Repair in Addiction Treatment: An Attachment
Disorder 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 Perseus
Books 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 2007
616.86'0651—dc22
2007031809](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)