PSYCHOTHERAPY AS ADDICTION
These days psychotherapy is quite popular. It was not always so – certainly not in Britain. When I was first training in psychotherapy, in the 1970s, the entire notion of counselling, psychotherapy, and psychoanalysis was viewed as strange and exotic – something that Americans, such as Woody Allen, might engage in. There were hardly any psychotherapists anywhere in Britain outside of the Hampstead enclave in north London. Clinical psychologists in training were taught to be highly distrustful of this American fashion, and to view anything associated with Freud as completely beyond the scope of respectable science. The influential psychologist Hans Eysenck declared that British clinical psychology should have nothing to do with psychotherapy. We were trained in behaviour therapy, in the paradigms of either Pavlovian classical conditioning or reward-based operant conditioning. These were attempts to control and predict behaviour by means of schedules of reward. Visionary behaviourists, such as B.F. Skinner, proposed that entire societies of the future could be run on scientific principles of operant conditioning. The very notion of ‘mind’ was viewed as scientifically flawed since, unlike the brain or behaviour, the mind was not observable and measurable – and certainly not something to be explored.
Times change. Now everyone seems to go to a psychotherapist or counsellor at some point in their life. In some ways this is obviously a good thing. Emotional distress and confusion can be talked about and examined. There is, in general, a vastly greater degree of psychological mindedness amongst the population. Much less shame is attached to having mental health difficulties. Might there be negative or shadow aspects of this cultural and societal shift?
I would like to suggest that although contemporary psychotherapy is not explicitly based on classical and operant conditioning, these processes of reward do occur covertly – and possibly at times harmfully. They are mediated by some of the same neurobiological pathways of reward that are activated by heroin. It is only through the relatively recent understanding of interpersonal neurobiology and psychosomatics, expressed in the work of clinician-scientists such as Allan Schore (1994; 2019), Stephen Porges (2011), Dan Siegel (1999) and many others, that it has become possible to appreciate the neurochemical addictive aspects of psychotherapy. Prior to this, when psychotherapy was thought of only in terms of the mind, this psycho-neuro-biological addiction potential could not be formulated.
The original paradigm for psychotherapy was psychoanalysis as developed by Sigmund Freud in the 19th century – based on a format of 5 (or more) sessions per week with the patient lying on a couch. Those who practise in this way consider that this framework of intensive work, with a psychoanalytic session structured into 5 days of the patient’s week, provides the optimum opportunity for the details of the patient’s neurosis to emerge and be examined as it unfolds in the transference to the analyst. I have no doubt that some may benefit from such work. However, it is my view that this daily experience of psychoanalysis can be addictive – and, like all addictions, can have harmful effects and give rise to withdrawal symptoms.
These thoughts were prompted by a recent dream in which people I was associated with (unspecified) turned out to be, in a hidden way, dealing in drugs. I was shown wads of money and slabs of some kind of addictive substance that looked a bit like chocolate (i.e., sweet and soothing). As an outcome of this dream, I have written this article.
Why might intensive psychotherapy be addictive? This is actually not hard to understand once we consider the process from the framework of addiction and reward. The experience of having someone pay deep attention to us, listening intently to what we say, thinking about it, and (at least some of the time) responding with empathy, is most unusual. It is not a common feature of human interaction! However, it can of course be extremely gratifying. It feels good – and triggers a cascade of neurobiological processes mediating pleasure. There is an inherent soothing quality to it – even if we may sometimes not like what is said. Ventral vagus nerve activation brings feelings of safety. The attention feeds our narcissism, encouraging a belief that the contents and products of our minds are intensely interesting.
Most of us will probably have felt we did not receive enough empathic attention as children. The great psychoanalyst Heinz Kohut considered that empathy is an essential psychological nutrient – one that is often in short supply during formative years. Even the most well-intentioned parents will be mis-attuned at times, or busy, or tired, or preoccupied. Siblings and other rivals steal these parental resources from us! How wonderful it can feel then, when as adults we can experience this empathic and attuned attention – and from a parental type of figure who can seem much more understanding than the original parent! Moreover, this attentive parental figure, along with the posture of lying on a couch in a quiet and softly lit room, invites regression and the expression of childhood needs and feelings that we otherwise may have been expected to grow out of. The illusion is evoked and sustained that infantile desires can be fulfilled. However, as with all addictive experiences, this has to be paid for – and it is expensive. Like those addicted to a chemical drug, the psychoanalytic addict’s life and finances become structured around funding and obtaining the substance that is craved – which, in this instance, is the neurobiological reward chemistry associated with attention.
An obvious objection to this account would be that often psychoanalytic sessions involve anxiety and are far from pleasurable – expressed in Bion’s famous quip that when confronting the unknown of the unconscious, there should be two rather frightened people in the room, the analyst and the patient. Moreover, analysts are not always attuned or empathic. Sometimes, perhaps often, the patient may feel misunderstood or criticised – but at least now and again he or she will feel the analyst understands and is attuned. This provides the reward. It is known that the most effective operant conditioning schedules are those in which the reward appears only sometimes – the pigeon in the ‘Skinner box’ will keep pecking the lever frantically in search of the pellet of food that emerges occasionally, much more so than if the pellet is provided regularly and predictably. I know from personal experience with a particular analyst whose empathy was markedly fluctuating (over 50 years ago when I was in my early 20s) how compelling and utterly preoccupying that state of mind can be, of searching anxiously for the rare moment of feeling understood – and how rewarding and calming it felt when found.
Attuned attention from another person activates circuits involving dopamine, oxytocin, acetylcholine, and endogenous opioids – all of which are linked with reward, pleasure, social bonding, and feelings of safety. Both psychotherapy’s attuned attention and heroin activate the mesolimbic dopamine system, producing feelings of pleasure and reinforcement. Attuned attention engages the endogenous opioid system—our brain’s natural opioids (endorphins, enkephalins) contribute to feelings of warmth, safety, and trust, in ways very similar to the effects of heroin. Of course, there are differences in the effects of heroin and attuned attention. Heroin floods and hijacks the reward systems, whilst attuned attention engages a more natural process. However, we must bear in mind that intensive psychotherapy, particularly 5 times a week, is not a natural process. There is no other normal human context in which we experience the attuned attention of another person for 50 minutes every day, without any requirement of reciprocity. Psychotherapy on such an intensive basis takes the natural components of pleasures of social attunement, and their accompanying brain biochemistry, and condenses these into a concentrated daily dose.
In conventional psychoanalysis, much attention is given to the patient’s reaction to the weekend break and holiday disruptions. Typically, these are viewed in terms of reactivations of infantile responses to separation, loss, or experiences of abandonment – childhood states when the experience of attunement was lost. Whilst this perspective no doubt has at times some validity, it is also possible to see the patient’s reactions as essentially withdrawal symptoms from the psychoanalytic drug – closely analogous to those associated with addictive drugs. The neurobiology is very similar in the two cases.
Those of us who work in the psychoanalytic field will be aware of instances where patients are in therapy for very many years. Often this is regarded as positive, an indication that a thorough analysis is taking place. In general, the psychoanalytic culture approves of long analyses, and these are seen as necessary for those who train to be psychoanalysts – and thus receive approval from that particular peer group. The drawbacks, in terms of the expenditure of money, time, and relational resources, are seldom talked about.
We must also note, of course, that there can be a mutual attunement between analyst and patient which is also gratifying for the analyst. Whilst the roles are not reciprocal or symmetrical, the analyst also has the daily experience of analysands listening attentively (at least some of the time). The regularity of the daily session activates a sense of safety and predictability that is reassuring to both – and the analyst additionally benefits from the soothing regularity of income. For both, the sense of the passage of time is partially suspended, each immersed in the timelessness of the unconscious. This very unusual set-up, that most people might otherwise regard as very odd indeed (as I have found whenever I attempted to explain it to a person completely unfamiliar with psychoanalysis) is given validity and approval by the existence of the relevant psychoanalytic or psychotherapeutic organisations and their associated culture. Outside of that subculture, psychoanalysis on a five times a week basis for many years would continue to appear an exotic and unrealistic pursuit.
Sometimes we encounter patients who have been in long term therapy with a therapist who has retired or died – and the patient is seeking another practitioner in order to resume the process. When asked what problem or goal they wish to address, the person is often rather vague, perhaps simply expressing a need for “support”. There may be some people, perhaps those with forms of neurodiversity, for whom long term psychotherapeutic assistance in managing their mind and regulating their emotions, is a genuine need, rather similar to the way some people need long term medicine for a medical condition. However, in other instances the picture often looks very much like addiction.
The attunement experience in psychotherapy can be used positively – enabling the client to achieve the feelings of safety and trust that allow difficult or complex emotions and patterns in the mind to be explored and provide the motivation to work towards change. This tends to occur when the psychotherapy has a goal or focus – something the client explicitly wishes to change or achieve – and when the sessions are less frequent. Psychotherapy that combines being very frequent, unfocused, and open-ended, would seem to carry more danger of creating an unhelpful addiction. Whilst the attunement experience is valuable in enabling psychotherapeutic change, it should not be an end in itself.
The insights and discoveries of psychoanalysis concerning the dynamics of the mind, the nature of the unconscious and transference, and the significance of early experience, are all profoundly important. Most of this knowledge was established by Freud in the late 19th and early 20th centuries. The modern application of psychoanalytic knowledge requires integration with neuroscience and, crucially, needs to be goal oriented (as it was originally for Freud). The goal might be resolution of a psychological or psychosomatic problem, improved functioning or performance, or increase in self-knowledge and self-awareness – but without a goal the work may drift into a malign comfort that is essentially an addiction. Regular reviews of progress are advisable.
There is no inherent reason why psychoanalytic knowledge must be confined to the traditional 5 times a week and on the couch format, with a focus on how a patient’s neurosis emerges in the transference relationship with the analyst. In addition to applications in brief and focused formats, it can enrich modalities that include somatic and non-verbal modalities such as EMDR and energy psychotherapy (working with acupoints and other subtle energy centres). These carry much less risk of addiction to the process because the work is focused, goal oriented, and is not driven fundamentally by therapist-patient attunement.
Summary and implications
The psychological and neurobiological effects of attentional attunement from one human being to another constitute a powerful vector of reward, which can function as a lever for positive growth and change. The ventral vagus nerve activation within the interpersonal neurobiology of the therapeutic dyad, along with the release of oxytocin, dopamine, and endogenous opioids create the feelings of safety and trust that are, as Carl Rogers claimed many decades ago, fundamental requirements for therapeutic progress. On the other hand, if used intensively and for prolonged periods, as with any other brain-altering agent that lessens pain and increases pleasure, attentional attunement carries the potential for addiction. Psychotherapy should have a purpose and a goal – and it should have an end.
The views expressed here concerning the potential hazards and danger of psychotherapy are of course merely my own sincere opinions – and may be incorrect or misguided.
Some relevant references:
Cantor, C. (2009) When Therapy Becomes an Addiction. Psychology Today, posted December 6.
Diamond, S. A. (2009). Can Therapy Be Addictive? The Power and Terror of Termination. Psychology Today, posted December 11.
Gallese V, Eagle MN, Migone P. Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations. J Am Psychoanal Assoc. 2007 Winter;55(1):131-76. doi: 10.1177/00030651070550010601. PMID: 17432495.
Kohut, H. (1971). The Analysis of the Self. New York. International University Press.
Mollon, P. (2001). Releasing the Self. The Healing Legacy of Heinz Kohut. London. Whurr/Wiley.
Porges SW (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W. W. Norton & Company.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103.
Schore, A.N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. Erlbaum.
Schore, A.N. (2019). Right Brain Psychotherapy, New York: W.W. Norton.
Schultz, F. (2023). Reward, Pleasure and Motivation. Cambridge Textbook of Neuroscience for Psychiatrists, Cambridge University Press, pp. 199 – 207 DOI: https://doi.org/10.1017/9781911623137.032
Siegel, D. J. (1999). The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York: Guilford Press.