In this age of psychotherapeutic accountability, we therapists are forever obsessed with therapeutic outcomes. And for addiction problems, the life or death outcomes become especially poignant because if efforts fail to stop a patient’s harmful use of substances- lives could be on the line. And it is in this effort that I address resistance, transference and countertransference issues even though many in my field see these as useless anachronisms of a bygone psychoanalytic era no longer germane.
But it is to this literature and interventions that I return to again and again because they so often emphasize how difficult it is to develop therapeutic rapport with drug/alcohol addicts or abusers. These encounters with patients are especially painful because they can engender feelings of failure in the psychotherapist when you cannot stop the self-abusive behavior; or control your angry feelings toward the patient when one has been lied to again and again on the slippery slope of patient resistance to stopping or slowing down abuse of substances.
Relationships with a drug is a form of attachment in which the drug user does not have to compromise, negotiate or make concessions. It is a relationship with an object in which the fusion with a drug is superior to available human forms of contact because- it is reliable, always predicable and will produce results that are on a tissue level, immediately gratifying.[i] Thus, through alcohol and drug use patients can be their own ‘Doctors’ using a drug to minimize symptoms of anxiety and depression in the short run. They can use whatever dosage works to reduce feelings of despair and taper doses when their coping is going well. However, patients become unreliable ‘practitioners’ when they attempt to use this coping method over time because, drug tolerance and physiological urgency when he is abstinent becomes a moving target. As time goes on, they need more of the drug to achieve the same effect and then habituate their bodies to crave the drug of choice as they become physically dependent. I have deep sympathy for addicts because they have found the exact answer to their dilemma of finding emotional equilibrium albeit in an illusionary attachment to their drug of choice.
Dealing with abandonment issues is true for premature infants who have been separated from their mothers for any length of time exceeding a month (in incubators, etc.); infants who are separated from mother for medical problems as infants; and those who were in foster care or an orphanage directly after birth. Loneliness, fears of abandonment, issues of resentment for lack of attentiveness all represent a primary narcissism that is deprivation at a very deep level. This is like a post traumatic stress disorder but the anxiety of being alone is more related to separation anxiety and borderline states. The symbiotic phase of union with the mother had been disrupted in these cases and therefore, the symbolic separation from relationships actually causes a re-enactment of an abandonment depression with separation anxiety.
The gestational and birth experience of the child and bipolar dilemma of fusion or separation
I will use the development of the gestational fetus and birth of the child to illustrate the dilemma of alcohol/drug dependency. And how, in many ways, the process of active addiction re-enacts the union experience in the womb with the ‘Great Mother’ and how birth is a separation from this oceanic experience into the cold reality of the world demanding more independence. The trauma of the birth experience makes possible the separation from a state of physical/ psychological dependence on the mother. In this the fetus’s development from womb to birth, the experience is a microcosm which encapsulates the dilemma of the human beings psychological/physiological dependence vs. independence. This archetype is a universal conflict and is symbolized in the creation myths of all cultures. For example, separation from the deity and reunion with God through redemption and forgiveness are from Christian stories; consider also the return of the prodigal son.
I will explain the bipolar nature of attachment/detachment from objects. In the womb a fetus is in symbiotic contact with the mother. In the process of such symbiosis, the fetus is taking in (introjecting) both good and bad sensations, emotions, and thoughts in a rudimentary state. All these are associated with the fetal experience in the womb. Is the experience full of loving assimilation with excellent nutrition, or toxic assimilation based on an illness in the mother? Once contractions begin, the safe womb environment turns into a vessel which breaks apart that symbiotic state of attachment. Passing through the birth canal is a terrifying experience for the fetus and represents a kind of descent into hell where breathing is suppressed, the child is covered with blood and secretions, and has to escape into a world where she has to take a breath for the first time. [ii]
This abrupt detachment from the merger from the mother can be traumatic. This is an oversimplification of the experience of the fetus but it makes the point that in the womb assimilation can be both positive and negative. And birth can be terrifying; It therefore sets the stage for both attraction/ repulsion toward objects of attachment in the human experience based on the unconscious memory of the fetal experience.
All relationships then, have degrees of both symbiosis with the object of attachment and complete detachment/separation as first exemplified in the birthing experience.[iii] Consider new couples who seem to have a dependency with each other that excludes all other relationships. Then after the relationship matures, the couple becomes more distant and are not merged to the same degree. This bipolar dynamic of relationships consists of attraction and repulsion toward the object of attachment whether it be a lover or a family member. Metaphorically, a hit of heroin, a toke on a joint, or to get an alcohol buzz on attracts us to a temporal union of oneness as an undifferentiated being. It is only later with continuous use of drugs that we find disenchantment and want to stop consuming the drug. But with obsessional use for whatever reason, it becomes harder and harder to maintain control of the drug of choice.
So, the physical and psychological ability to deal with the ambivalence of fusion or separation in relationships becomes a recurrent theme in all relationships based on the birth experience. This is true for relations with humans and with drugs (objects). And the intensity on a continuum from fusion with the person or thing to separation with the object intensifies the dramatic nature of all relationships.[iv]
Transference includes patient’s unconscious thoughts and feelings rooted in the past parent figure.[v] Counter feelings are thoughts and feelings which the therapist experiences in direct relationship to the patient’s presentation in which he/she is asked to validate, fulfill and participate in the acting out of the client’s transference projections. [vi] Projections are the attribution of feelings or thoughts of one’s self to another to whom one is in a relationship with usually based on a recapitulation of the feelings a patient had toward male and/or female parent figures. It is an unconscious process and does not go away with either education or self-awareness.[vii]
When the therapist enters into a relationship with an alcohol or drug dependent patient, he/she enters the dramatized emotional state of ambivalence between wanting to be empathic and understanding vs. wanting to maintain an objective therapeutic distance.[viii] The therapeutic goal for the psychotherapist is to help the patient recognize patient’s triggers that occur that predict behavioral acting out with the drug of choice and to reduce the harmful effects of abusing the drug of choice. These goals occur simultaneously. This is a re-enactment short of total union with the patient and the healthy separation that characterizes any nurturing relationship leading to independence from the patient’s presenting problem leading to successful termination. If the transference behavior by the patient is positive; it is characterized by healthy defenses by putting off impulses that are destructive, focusing on identifying vulnerable triggers that consciously or unconsciously trigger relapse, a voluntary dependence on the psychotherapist while in recovery, building up constructive support systems of relationships, and finally wanting to self-rescue or get better (Eros).
Many theorists agree that drinking or drug use may represent an unconscious denial of separateness.[ix] With separateness can come rejection, abandonment and loneliness, if not fears of annihilation. On the other hand, continuing a dependence on one’s drug of choice can ultimately lead to a fear of being devoured or merged with the drug like a puppet on a sting which is reflected in the love addicts have with their drug of choice.[x] Often the defense of denial is so strong that the patient refuses to submit to these positive attitudes toward the psychotherapist. He/she rejects efforts to get better due to inferiority, worrying about symptoms that occur such as anxiety or depression that rebound when he/she stops abusing the drug of choice, and traumatic factors that cause acting out angry behaviors. This then , can induce in the therapist counter-transference behaviors such as helping the patient to avoid negative emotional states for the sake of keeping the relationship going, ignoring the hostility on the part of the patient toward therapist for taking away such a reliable source of gratification, and experiencing guilt over not being able to help the patient.
Guidelines about neutralizing negative transference and negative counter-transference include the therapist reflecting on the induced feelings that result from negative transference; setting boundaries limited to the therapeutic sessions; therapist reducing over-compensatory behaviors such as blaming the patient for the problem; being aware of therapist’s own subtle gestures to rationalize termination (i.e. the patient is not motivated); and involving support of the family to act as ancillary therapists between sessions designed to reduce self-harm as part of a safety plan.[xi]
Therapist counter-transference when acted out can lead to sexual relations with clients; as one survey indicated (Mason 1983) 15% of therapists have sex with their patients.[xii] A therapist acting on angry feelings rejects his patients often resulting in a closed case, transfer or referral. The existence of these incidents is an iatrogenic aspect of psychotherapy and supervision is often warranted to reduce it incidence. What is attempted here is to minimize negative reactions to patients that prevent patient’s needs from being met.
Compensation as a theory of a cause of drug and alcohol abuse:
I have made the point that there are opposite motives for the need for attachment and independence in the human psyche. All human beings have a need to belong, to develop self-esteem and ultimately achieve self- actualization by being their own authority. The process of individualization in western society involves maturing from child- like dependency to more mature independence as the needs to love and to belong co-exist with the needs for self- realization. These needs remain relevant throughout the developmental life cycle. Attachment to drugs and alcohol through addiction is one side of the patient’s problem of physical/psychological ambivalence to merge with the object; addicts are struggling to be independent of their drug of choice. Whether the defensive structure of the patient’s demand a delusion of the undifferentiated state or fear of being killed for being on one’s own; the problem is translated in the therapeutic encounter in ways that threaten the patient’s core of self-preservation.
Jung had illustrated that complexes in the unconscious are contained of opposite contents each with an emotional valence: i.e. submission/dominance; expression/suppression; action/inaction; authority/disqualification; identification/disidentification, etc. What he emphasized was that in dreams, we find compensations at the root for understanding the contra-position of the dream against the patient’s conscious attitude.[xiii] What I find in the conscious attitude of the addicted patient is the unavowed need to remain dependent on an object. However, the compensatory behavior they engage in consciously is quite the opposite bordering on social isolation and attitudes of extreme defiance of dependency on others.
Management clinically of patients who are addicted vacillate from session to session. Positive transference toward the therapist can go on for months, then the patient can quit therapy all together. What is behind this fluctuation is related to the defense mechanism of splitting. “Splitting is the failure in a person’s thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole.”[xiv] At one time he sees the therapist as good for his recovery and then he comes to the conclusion that he is an impediment for his mental health. This is an inability to merge the good and bad traits of a person into their concept of the self and see the other as either all good or all bad. Splitting can bring to a halt a therapeutic process and needs to be discussed with the patient and brought to his/her awareness.
Hitting bottom and Recovery:
When a patient becomes dependent on drugs or alcohol, there are unmistakable symptoms that are used by the therapist to educate both the patient and the family.. They are as follows[xv]:
- Alcohol abstinence syndrome: when not drinking urgency of first drink leading to relapses
- Blackouts- yes; able to function but forgetting the events while intoxicated Emergence of the ‘sincere delusion’ which is not remembering how impaired one is when intoxicated.
- Psychomotor rebound effect- drinks to quell anxiety/ depression and agitation but that does not work
- Medical problems: e.g. belches a lot; esophageal varacies, gastric inflammation, ulcers, eventually hyponatremia, liver disease, etc.
- Legal- citation with public drunkenness, dui, assault, etc.
- Family worried about his drinking and concerned he seek treatment in rehab.
- Abnormal changing tolerance- takes more and more hard stuff or drug to achieve oblivion.
Once these symptoms are apparent the disease process is in full swing. There are psycho-social losses that are compounded. And in this process the patient may still deny the destruction and deterioration of his/her life style. Losses include but are not limited to; legal issues and fines; occupational losses- time needed off work for recovery and poor work performance, losing jobs; loss of relationships- people who are scared or embarrassed by intoxicated patient’s behavior; hospitalization and other medical problems; acute mental health problems; socialization only with peers who get drunk or high; self-care deterioration; suicidal behavior when intoxicated or high; near death experiences or overdose
These kinds of losses lead to a phenomenon of hitting bottom when the patient realizes he cannot go on living with the obsession of drug abuse and seeks treatment. Detoxification is a medical intervention and is recommended to occur in a hospital where one is observed for withdrawal signs and treated.[xvi]
Then comes a period of formal rehabilitation which can last 30, 60, 0r 90 days. In this period, concentration on the following[xvii]:
- Letting the brain recover from addiction requires assessment of medication and psychotherapy needed to lessen symptoms of an underlying mental health issues. Helping the patient cope with his losses and active mourning over the loss of the drug in his/her life and its purpose in maintaining the illusion of safety. Taking care of physical losses incurred through addiction.
- Learning to identify emotional states which the drug /alcohol masked; to express negative and positive emotions and learn to regulate them.
- Dealing with the denial that the drug of choice compelled the patient to avoid the fact that separation from others actually made the problem worse. And that in early recovery, he/she would benefit and sustain sobriety by fellowship.
- Realize that fellowship such as AA or NA is a voluntary dependency and necessary for recovery long term. And it admits that the will of the patient is not enough to sustain recovery. In fact, submission to a higher authority such as Divinity is a necessary component to ensure recovery. Actively working on the 12 steps of recovery and admitting powerlessness over the drug of choice. Going through a ritual initiation forgiving others for the wrongs that they have perpetrated on one, the betrayal, the power moves, etc. and the desire to surrender one’s will to a higher power taking care to humbly recognize one’s dependence on others- getting a sponsor.
- If recovery is to last, one has to recognize triggers that cause relapse and understand that relapse can be an educational event to eliminate from your life those persons, those activities, and those events or places that tempt one to lose focus and abuse the drug of choice again.
- Continue throughout life to learn to grow psychologically and spiritually so that recovery is a continual effort.
- Learning that alcohol/drug addiction is also a social problem in which in a capitalistic society, there are mores, customs and beliefs that sustain the abuse of substances to cope with the pressures of life. Learning that the historical tradition rituals of drinking and getting high is a natural part of cultural life but that the patient cannot participate in that ritual and come to no harm to him/herself. One has to learn to substitute other cultural rituals to create a sense of cultural self-realization.
In summary, I have identified my theory of addiction and relied on traditional methods of recovery including psychoanalytic models and AA/NA for recovery.
[i] Graham, Alan; Glickafus- Hughes, Cheryl “Object relations and addiction: the Role of Transmitting Externalizations”. Journal of Contemporary Psychotherapy, March 1992, Vol. 22, Issue 1, pp. 21-23.
[ii] Grof, Stanislav, Healing Our Deepest Wounds: the Holotropic Paradigm Shift. Stream of Experience Productions, May 2012
[iii] Kernberg, Otto. Object Relations Theory and Clinical Psychoanalysis. Jason Aronson, Inc. NY, NY. 1976
[iv] Searles, H. Countertransference and Related Subjects. International University Press, Ny, NY. 1979
[v] Schwaber, J. A. “introduction in The Transference in Psychotherapy: Clinical Management. International University Press. NY, NY, 1985
[vi] Valenstein, A. F. “A Developmental Approach to Transferences: Diagnostic and Treatment Considerations”, in
The Transference in Psychotherapy: Clinical Management, Ed. Schwaber, E. A. International U. Press. Ny, NY 1981
[vii] DSM 5, American Psychiatric Association. 2013. Arlington, VA. USA
[viii] Arlow, I. A. “Interpretation and Psychoanalytic Psychotherapy: A Clinical Illustration”. In Transference in Psychotherapy: Clinical Management. Ed. By E. A. Schwaber, MD. International University Press, Ny, NY, 1985 p. 107
[ix] Little, M. Transference Neurosis and Transference Psychosis, Jason Aronson, Ny,NY. 1981. P. 188
[x] Chetnik, Morton, “the Borderline Child”, Nosbpitz, J. D. Ed. In Basic Handbook of Child Psychiatry. Vol 11, Basic Books, NY, NY, 1979 p. 306
[xi] Racker, H. Transference and Countertransference, International U. Press, Inc. NY, NY, 1968, p. 144
[xii] Wray, H. “Has Therapy Gone Astray?”, Psychology Today, A book review. Oct 1988 p. 70
[xiii] Jung, C.G. Memories, Dreams and Reflections, Jaffe ed. Winston R. and Winston C. translators, Vintage Books, NY, NY, 1989. P. 133
[xiv] Kernberg. Op. cit. p. 176
[xv] Larson, E. “Stage II Recovery: Life Beyond Addiction- Self Defeating Learned Behavior”, Videotape. 1988, Kinetic Film Enterprises. LTD. Buffalo, NY.