Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

462 V. TREATMENTS FOR ADDICTIONSknown as compulsions. He pointed out that although addictions and compulsionsare clearly similar to each other in their “compulsive” quality, they havealways, incorrectly, been seen as fundamentally different, namely, because compulsionsare experienced as ego-dystonic—as things one feels compelled to doalthough one does not consciously wish to do them, whereas addictions havebeen experienced as ego-syntonic—as things one does because one consciouslywants to do them. However, addictions commonly move from being egosyntonicto ego-dystonic as people wish to stop their behavior, and compulsionsoften shift from being ego-dystonic to ego-syntonic as people make a virtue oftheir compelled behavior. Another false distinction has been that compulsionsare viewed as compromise formations between a forbidden wish and an opposing(superego) force. But addictions have been viewed as the result of either anego function (e.g., self-medication) or a deficit in ego function (e.g., self-caredeficiencies), rather than being centrally viewed as compromises. However, inhis formulation of addiction (an action driven to correct helplessness and toexpress the narcissistic rage engendered by this helplessness), Dodes describedan inherent compromise formation. This compromise is expressed in the defensivedisplacement of the reassertion of power and the expression of rage to theaddictive behavior. For instance, Dodes described a man who had an alcoholicbinge after he was unable to fire his son from his company, despite the fact theson had embezzled a large amount of money. This man felt it was morally wrongto fire his son, even though he felt a strong impetus to do so, and as a consequence,he rendered himself helpless. This was intolerable, but since he couldnot allow himself to act directly (fire his son), he displaced the need to beempowered to his drinking, which therefore acquired a compulsive character.The addictive behavior, then, reflected a psychological compromise betweendoing what he was driven to do, and forbidding himself to do it. Dodes concludedthat, with no distinction based on ego-syntonicity or on the psychologyof the two diagnoses, addictions are fundamentally the same as compulsions.The important implication of this finding is that addictions should be seen astreatable in traditional psychodynamic psychotherapy as much as are compulsions,which have traditionally been understood to be amenable to a psychodynamicor psychoanalytic approach (Dodes, 1996, 2002, 2003).TECHNICAL ASPECTS OF PSYCHOTHERAPY WITH ADDICTSThere are a number of special considerations in the psychodynamic psychotherapyof addicted individuals (Dodes & Khantzian, 1991). From the formulationsdiscussed previously, it is clear that various meanings and roles of drugs or alcoholneed to be considered in understanding the patient. In addition, addicts arefrequently still abusing substances at the time they are first seen, which poses an