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

21. Individual Psychodynamic Psychotherapy 465benign way that may be internalized depends on absence or resolution of negativetransference feelings at the beginning of treatment.For some patients, early achievement of abstinence is possible because of agenuine therapeutic alliance with the therapist. In other cases, abstinence maybe achieved early on because of unconscious wishes to merge with, or be heldby, a therapist who is idealized, or because of a compliant identification withthe aggressor (Dodes, 1984). When the patient does not initially abstain, subsequentconfrontation may produce abstention, because the patient finally perceivesthe confrontation as a longed-for message of caring that was absent orinsufficient in his childhood (Khantzian & Mack, 1983, also described this kindof parental insufficiency in their discussion of the origin of self-care deficits).From a practical standpoint, the clinical choices involved must depend on theimmediate risks to the patient. If patients drink only intermittently and are ableto participate genuinely in the process of psychotherapy, we have found thatthe psychotherapy can continue. Indeed, the psychotherapy provides an opportunityto explore the issues in the continued drinking, including problems withself-care and the transference implications of the failure to abstain. However,when drinking becomes continually destructive, patients are generally unableto participate in the process, requiring early confrontation around the need tobe hospitalized or to interupt therapy. Over the course of an ongoing psychotherapy,the capacity for abstinence may vary, depending in part on shifts in thetherapeutic relationship (Dodes, 1984). We discuss the question of relapses inan abstinent patient later.Once the patient achieves abstinence, the therapy may broaden to exploreall areas of her psychological life, as in any psychotherapy. Some authors writingabout alcoholism, however, recommend a kind of staging of the therapy.Prochaska and Di Clemente (1985), based on a cognitive-behavioral paradigm,introduced the “stages of change” model to help individuals shift froma “precontemplative” stage (denial) to a “contemplative” (acknowledgment)stage, to initiate a process of engaging in treatment and preventing relapse. Notinconsistent with the psychodynamic approach, the first phase is directedtoward helping the patient develop an identity as an alcoholic (Brown, 1985)focusing on the drinking, on ways to stay sober, and on mourning the lossesincurred as a result of drinking (Bean-Bayog, 1985). Kaufman (1994) similarlystresses the importance of abstinence, stabilization, and relapse prevention andthen, in advanced recovery, the importance of addressing issues of intimacy andautonomy. In our experience, however, it is generally unnecessary and potentiallycounterproductive to attempt to direct the therapeutic process accordingto a preconceived agenda. As with any patient, imposing one’s own focus risksinterfering with the free evolution of the patient’s thoughts toward deeper andmore meaningful understanding of the issues. In our opinion, although someaddicts (like some patients in general) require a more supportive rather than anexploratory approach, or special approaches based on some of the dynamic fac-