In Terms of Ego Defense Mechanisms

This study (1) looked at the use of ego defense mechanisms in alcoholics and in addicts and found that alcoholics tend to use immature ego defense mechanism rather than the a mixture of immature and mature ego defense mechanisms addicts attempt to deploy, however unsuccessfully.

The main point arising from this study is to differentiate, in terms of specialized and individualized treatment, between clients in relation to the varying emotion regulation difficulties they have and, as a result, the ego defense mechanisms they employ in response to these emotion regulation difficulties.

It may be that a “one fits all!” treatment plan does not reflect differences in emotion regulation difficulties and the ego defense mechanisms these difficulties elicit.

We have long found this area of ego defense mechanisms fascinating from a psycho-analytic perspective but now this enhanced awareness of the function of these defense mechanisms from a psychologically based theory of emotion regulation dysregulation helps us so much in understanding this very prevalent psycho-behavioural response in addicts and alcoholics.

It obviously, in terms of our greater theory on addictive behaviour as emotion dysfunction, also adds to the idea that addictive behaviour is driven by emotion dysfunction and these are manifest in the various ego defense mechanisms we have all witnessed in ourselves and countless other addicted individuals.

“Defined as “a problematic pattern of drug use, leading to clinically significant impairment or distress” (APA 2013; p. 481), substance use disorder (SUD) is one of the most prevalent and costly of psychiatric disorders (SAMHSA 2014).

Theorists and researchers have suggested that emotion regulation may be involved both in development and maintenance of SUDs. Although it has been studied for a long time, the association between emotion regulation and SUDs is complex…As stated by Kober (2014), the scientific literature on SUDs suggests that emotion regulation is one of the main motivations for substance use, but also that emotion dysregulation might be at the same time the casual factor of the substance use and its consequence.

With regard to the emotion regulation function, SUD patient’s reports often suggest that drugs are not the problem but the solution because they are used to look for relief from negative emotional states (Jones, Corbin and Fromme 2001, Le Moal 2009).

…a large amount of studies showed that negative affective states trigger drug craving, drug use and relapse (Shiffman et al. 1996, Sinha and Li 2007). These findings are in line with the “self-medication hypothesis” by Khantzian (1985) which postulates that negative affective states propel to drug use and that the choice of drug is consistent with its effect on negative affective states which individuals are experiencing. In this sense, the self-medication theory suggests that drug consumption and SUDs are ways to cope with negative affective states which individuals are not able to alleviate otherwise.

Additionally, emotion dysregulation seems to be involved in the etiology and maintenance of SUDs (Kober 2014). Longitudinal studies found that poor self-control abilities in childhood, including frustration tolerance and impulsivity, predict the onset of drug use and SUDs in adulthood (August et al. 2006, Ivanov et al. 2011, Moffitt et al. 2011). However, initiation of drug use often takes place during adolescence, when emotion regulation abilities generally decrease (Silvers et al. 2012).

Finally, emotion regulation deficits have been found in SUD patients. In particular, low levels of emotion regulation abilities and inadequate emotion regulation strategies are associated both with the presence of SUDs and the frequency of drug consumption (Fox et al. 2008, Fucito et al. 2010, Berking et al. 2011). Although studies identified two main dimensions of emotion regulation that are associated with SUDs, awareness of emotions and distress tolerance (Kun and Demetrovics 2010), the majority of studies were conducted on alcoholics or cigarette smokers (Riley and Schutte 2003, Verdejo et al. 2008, de Sousa Uva et al. 2010, Marshall-Berenz et al. 2011).

Indeed, as found by Sudraba et al. (2012), alcoholics and drug addicts may differ in relation to some emotional intelligence competencies such as emotion regulation skills: drug addicts reported both poorer impulse control and selfactualization abilities than alcoholics. Moreover, some studies showed that opiate addicts have a greater ability to identify their emotions than alcoholics (Kornreich et al. 2003, Foisy et al. 2005).

In this sense, the studies on drug addicts suggest that they are generally able to identify and recognize their affective states but have poor confidence in their abilities to cope with them and to be able to control the impulse to alleviate them resorting to drugs.

A large body of research suggests that emotion regulation and defense mechanisms are related. Defined as unconscious and involuntary mental processes that modify the conscious experience of thought, feeling, and emotion, defense mechanisms allow individuals to preserve themselves from negative emotions or disproportionate anxiety connected to these experiences (Cramer 1991).

According to Vaillant’s original theoretical model (1992) defense mechanisms are generally categorized as immature defenses, which tend to distort reality and that are more commonly associated with less adaptive functioning, and mature defenses that attenuate distressing reality and allow for more adaptive functioning.

Research on the relationship between the emotion regulation and defense mechanisms stressed both similarities and differences between the two constructs. Despite both of them contributing to broader affect regulation abilities, emotion regulation allows the subject to adjust both positive and negative emotional experiences and includes both conscious and unconscious processes; whereas defense mechanisms contribute to help the subject to avoid overwhelming emotional experiences through unconscious mental processes (Calkins and Hill 2007).

In this sense, the association between explicit emotion regulation and defense mechanisms found in many studies (Pellitteri 2002, Alilu et al. 2014) might be due to their specific adaptiveness or maladaptiveness: greater rigidity of emotional regulation strategies generally reflects rigidity of defense mechanisms which lead to maladaptive functioning features (Sala et al. 2015).

Despite the acknowledgment of emotion regulation and defense mechanisms as two components of affect regulation, few studies investigated defense styles among patients with SUDs.

Moreover, research on the association between defense mechanisms and SUDs has shown mixed findings. On the one hand, many studies found that SUD patients were more likely to use immature defense styles than nonclinical controls (Redick et al. 2002, Evren et al. 2012), suggesting that addiction involves the use of maladaptive mechanisms such as denial, projection, suppression and rationalization (Miller 1985, Ward 1991, Benjamin et al. 1996).

On the other hand, some studies reported a more complex relationship between SUDs and defense mechanisms. Studies showed that both immature and mature defense mechanisms are associated with the presence (Redick 2002, Halim and Sabri 2013) and the severity of addiction (Grebot and Dadard 2010, Taskent et al. 2011) among SUD patients.

In particular, beyond the use of immature defenses, these studies highlighted the role of sublimation as a mature defense which enables drug addicts to continuously use drugs as this action is acceptable in the subculture of addicts in order to reduce their unacceptable thoughts or emotions (Halim and Sabri 2013).

Equally,  Evren et al. (2012) did not found any difference neither in mature defense style nor in the use of sublimation between heroin addicts and healthy controls, whereas differences were found only in immature defense mechanisms. Heroin addicts were more likely to use splitting and devaluation than healthy controls.

The aim of the present study is to clarify the nature of the association between difficulties in emotion regulation and SUDs. Specifically, we investigate which dimensions of emotion regulation deficits are specifically associated with SUDs of illicit drugs and whether this association might be explained by the use of defense mechanisms. Based on previous studies on drugs addicts, we hypothesized that the presence of SUDs was associated with deficits in the impulse control ability and less confidence in their ability to regulate negative affective states.

Finally, we hypothesized that difficulties in emotion regulation might lead individuals to use less mature defense mechanisms to cope with negative affect states, increasing the likelihood to use illicit drugs to alleviate them.

Discussion

This study investigated the relationship between SUDs and difficulties in regulating emotions, aiming to examine whether defense mechanisms might be considered as significant mediators. In line with the literature findings the present study suggests that having difficulties in managing negative affects increases risk for SUDs (Kober 2014).

Overall, according to previous studies, substance addicts report poorer awareness of their emotional states (Fox et al. 2008, Kun and Demetrovics 2010) and less ability to cope with negative affect states (Riley and Schutte 2003, Verdejo et al. 2008, Kun and Demetrovics 2010, De Sousa Uva et al. 2010, Marshall-Berenz et al. 2011).

However, although the association between emotion regulation and SUDs has been investigated for a long time, the majority of studies were conducted exclusively on alcoholics or cigarette smokers (Riley and Schutte 2003, Verdejo et al. 2008, Kun and Demetrovics 2010, De Sousa Uva et al. 2010, Marshall-Berenz et al. 2011).

Indeed, as found by recent studies drug addicts do not always show difficulties in recognize their emotions (Kornreich et al. 2003, Foisy et al. 2005) but they generally report poorer self-actualization abilities (Sudraba et al. 2012), compared to alcoholics.

According to recent studies (Fox et al. 2008, Fucito et al. 2010, Berking et al. 2011), our findings showed that, even though poor awareness of emotions can be observed, a specific role in the presence of SUDs is assigned to the individual’s inability to find emotion regulation strategies when they are upset. After all, the poor confidence reported by SUD patients in their abilities to cope with negative affect states seems to support the “self-medication” hypothesis (Khantzian 1985).

According to studies showing that drugs are often used to look for relief from negative emotional states (Jones et al. 2001, Le Moal 2009), our results highlight that SUD inpatients report to feel very depressed every time they experience overwhelming negative affect states showing a lack of confidence with regard to the possibility to modify this condition in a short time. In this sense, the poor confidence in being able to use internal emotional regulation strategies might promote the use of drugs as an external effective replacement.

Moreover, this hypothesis is strengthened by the mediating role played by defense mechanisms. Although literature on the association between SUDs and defense mechanisms has been mainly focused on a greater use of primitive defense mechanisms among drug addicts (Miller 1985, Ward 1991, Benjamin et al. 1996, Khan et al. 2008, Evren et al. 2012, Halim and Sabri 2013), few studies recently suggested that mature defenses are also implicated in the maintenance of SUDs and the intensity of addiction (Redick et al. 2002, Grebot and Dadard 2010).

Furthermore, a new understanding of defense mechanisms as strategies on a continuum from maladaptive to adaptive ones suggests that individuals (both nonclinical and clinical ones) may use a complex mixture of both (Sala et al. 2015).

On this basis, considering both mature and immature defenses, the present study showed that mature rather than immature ones are primarily involved in SUDs. Specifically, the poor confidence in their own abilities to cope with negative affect states lead individuals to a less use of mature defense mechanisms, which increases the probability to have a SUD diagnosis.

As stated above, SUD patients generally report poor confidence in modulating negative emotions through their internal regulation strategies when they feel upset. This might discourage the use of mature defenses such as sublimation or humor, which could weaken the intensity of these affect states and channel unbearable thoughts or emotions into more socially acceptable behaviors (Halim and Sabri 2013). The result is that drug is needed to balance out the emotional arousal which individuals were not able to cope with through adaptive defenses.

In conclusion, the present study helps to clarify the association between SUDs and difficulties in emotion regulation. Indeed, findings from the study showed that drug addicts are characterized by limited access to emotion regulation strategies when they feel upset, and that this association is partially explained by the inability to cope with these feelings through the use of mature defenses. In this sense, the study may have important implications both on research and clinical practice. First, it suggests the need to study the role of mature defense mechanisms on the onset and maintenance of SUDs. Until recent years, empirical studies have considered exclusively the effect of primitive defenses, neglecting mature ones. Finally, results suggest the importance of focusing psychotherapy interventions on SUD patients through strengthening the use of mature defense mechanisms in order to increase their sense of agency and confidence related to their abilities to cope with negative emotions.”

References

1. Di Pierro, R., Benzi, I. M. A., & Madeddu, F. (2015). DIFFICULTIES IN EMOTION REGULATION AMONG INPATIENTS WITH SUBSTANCE USE DISORDERS: THE MEDIATING EFFECT OF MATURE DEFENSES MECHANISMS. Clinical Neuropsychiatry, (4).