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

21. Individual Psychodynamic Psychotherapy 467necessitate a modification of approach. In the case of alexithymic patients,Krystal (1982) and Krystal and Raskin (1970) proposed a preparatory stage inwhich patients’ affects are identified and explained—with the goal of increasingego function, which includes improving the use of affects as signals andimproving affect tolerance. McDougall (1984) focused on the countertransferenceproblems produced with such patients. She described feelings of boredomand helplessness, with consequent emotional withdrawal by the therapist, andpointed to the need for the therapist to provide a consistent holding environmentthat may last for years before patients are able to acknowledge their emotions.She also offered an understanding of this process in terms of the patient’screating a “primitive communication that is intended, in a deeply unconsciousfashion, to make the analyst experience what the distressed and misunderstoodinfant had once felt” (p. 399).A contemporary psychodynamic understanding of addicted patients, however,does not usually suggest this sort of modification of approach but, rather, aneed to attend to one or another aspect of the meaning and role of the addictionfor a patient. For instance, for some patients it is particularly important toattend to the object-substitute meanings of alcohol or drugs. In some patients,narcissistic vulnerabilities are of paramount importance, for instance, the collapseof idealized objects, as described by Wurmser (1974), or the role of particularaffective states in precipitating substance use, mentioned by a number ofauthors. With some patients, self-care deficits, as described by Khantzian andMack (1983), are of great significance. From a different perspective, the activenature of addictive behavior in seizing control against an intolerable feeling ofhelplessness, as described by Dodes (1990), is often an important focus. In suchcases, it is important to address patients’ experiences of helplessness and powerlessnessas major factors in precipitating substance use.With patients whose affect management and self-care are seriously impaired(Khantzian, 1986, 1995), it is important for the therapist to be especiallyactive. Excessive passivity with such patients can be dangerous. It is necessaryin these cases to empathically draw the patients’ attention to ways in whichthey render themselves vulnerable as a result of their self-care deficits, and topoint out how these self-care deficits render them susceptible to addictivebehavior. With some patients, it is necessary to explore the details of currentlife situations to help them recognize their feelings and see that these feelingsmay serve as “guides to appropriate reactions and self-protective behaviorrather than signals for impulsive action and the obliteration of feelings withdrugs” (Khantzian, 1986, p. 217).Consistent with the need to maintain an active stance, the therapist mayat times need to serve as a “primary care” physician—especially at the start oftreatment, when he or she must often play multiple roles to ensure that thepatient receives appropriate care from a number of sources (Khantzian, 1985a,1988). This task may include decisions about (and active involvement in