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

466 V. TREATMENTS FOR ADDICTIONStors described earlier, this decision should be based on an individual assessmentof the patient’s psychology rather than on a generalization for all substanceabusers. The approach in treatment may, and should, vary according to thestage of treatment and the status of the patient’s abstinence.The idea of imposing structure in psychotherapy with addicts arises in partfrom concerns about the ability of such patients to tolerate the process of therapy.At the heart of this thought is the worry that exploring the importantissues in their lives will lead addicts to resume their substance abuse. Actually,the reverse is often the case: Patients who do not deal with the issues that troublethem may be at much greater risk of continued substance use or relapse.Nonetheless, there may be difficulties with pursuing psychotherapy. At times,therapists fail to attend appropriately to the life-threatening nature of continuedsubstance abuse (Bean-Bayog, 1985) or fail to make the diagnosis (Brown,1985), overlooking the ongoing deterioration of their patients’ lives. Alcoholicsmay also try to use therapy to aid their denial of their alcoholism.However, these concerns largely hinge on failures of the therapist and maybe avoided by a therapist who is attentive to these issues (Dodes, 1988, 1991).For instance, as described earlier, attention must be paid initially to the questionof abstinence (whether or not it can be achieved). Likewise, if a patientmisuses the treatment to rationalize continued drug or alcohol use, an appropriatelyresponsive therapist would recognize this misuse and bring it into thetreatment process to identify and deal with it. Addicts have a wide variety ofcharacterological structures, strengths, and weaknesses, and are in general ascapable of dealing with the issues and strong transference feelings that mayarise in a psychotherapy as patients with other presenting problems. Brown’s(1985) concern that a psychodynamic psychotherapy may distract the alcoholicpatient from his or her task of establishing an identity as an alcoholic may alsobe taken principally as a reminder to the therapist to attend to the patient’salcoholism rather than a contraindication to psychotherapy (Dodes, 1988).In fact, in the ongoing therapy of addicts, once the patient achieves abstinence,the therapist should always be alert to the meanings and purposes of thepatient’s substance use as these become clearer. Part of the advantage of psychotherapywith addicts is that it offers an ongoing opportunity for patients totake firmer control over their addiction, based on understanding and toleratingthe feelings and issues that contribute to it. The therapist’s continual attentivenessto improved understanding of the patient’s drug use also avoids the problemof distracting the patient from his or her addiction.Of course, any therapist can be fooled: Patients who deny, minimize, ordistort the facts about their substance use may render its diagnosis and treatmentimpossible for any therapist. This is a limitation to psychotherapy, as it isto other attempted interventions.Having considered early issues of abstinence and allowing the focus of thetherapy to broaden, we may now consider how the dynamics of addicts may