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

464 V. TREATMENTS FOR ADDICTIONSThrough all this early diagnostic and at times confrontational work, as intherapy in general, the therapist’s attitude must be exploratory without beingjudgmental. The patient’s denial or minimization is often closely connectedwith his shame, and throughout this initial evaluation the patient is simultaneouslyevaluating the therapist—in particular, the therapist’s attitude towardthe patient and his addictive problem. To put it another way, the patient isfaced with her own projections onto the therapist, and it is important that thetherapist not accede to the role of a harsh or punitive superego that might beinvisibly imposed.Transference manifestations may also arise from narcissistic deficits, leadingto idealizing and mirroring relationships or fearful, guarded positions againstbeing overcontrolled or overwhelmed. Common countertransference difficultieswith substance abusers revolve around frustration, anger, and guilt, aspatients’ failures to abstain challenge the therapeutic potency of the treatmentprofessional. These countertransference feelings may result in withdrawal, inappropriatelycritical attitudes, or overinvolvement (when therapists attempt toreverse their desire to withdraw). The severe nature of the risks facing addictsmakes the work with them both particularly challenging and rewarding. It isimportant for the therapist to be able to view both the overt behavior and theinner psychopathology of the addict with the same combination of objectivityand compassion that is brought to any patient.Developing a therapeutic alliance early in therapy is also made difficult bythe patient’s frequently ambivalent relationship toward abstention from drinkingor drug use at the same time that the therapist is appropriately concernedwith the patient’s achieving abstinence. It may be ineffective and even counterproductiveto be seen as requiring (vs. suggesting) something the patientdoes not consciously feel is in his best interest. Once the patient concurs withthe diagnosis, he or she has a necessary, though not always sufficient, basis foran alliance with the therapist to achieve abstinence. In fact, the psychologicalissues in abstention are complex.We (Dodes, 1984; Khantzian, 1980) have addressed issues in abstentionwith alcoholics. Patients’ achievement of abstinence hinges not only on theplace of substance use in their psychological equilibrium but also critically onthe alliance with, and transference to, the therapist. Many patients quicklyachieve abstinence upon beginning psychotherapy, in spite of the evidentimportance to them of their drugs or alcohol. But others may continue to usesubstances, although not in a way that is malignantly out of control or that createsan emergency. In a number of these cases, we have helped patients establishabstinence over time, psychotherapeutically. When the therapist focuseson the patient’s failure to perceive the danger to herself that is contained in thecontinued abuse, the therapist’s caring concern may be internalized by thepatient, providing a nucleus for the introjection of a healthy “self-care” function(Dodes, 1984). However, the patient’s ability to perceive the therapist in a