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

468 V. TREATMENTS FOR ADDICTIONSarranging) hospitalization and detoxification, involvement with AA or NA,professionally led group treatments, or pharmacological treatment. However,such an active approach, although possibly life saving, may interfere with thelater development of a traditional psychotherapeutic relationship because ofthe transference and countertransference issues it induces, particularly in regardto the patient’s realistic gratitude. If this gratitude becomes a prominent interferingfactor, referral to another therapist for continued psychotherapy may berequired (Khantzian, 1985a).Just as with the initial attention to abstinence, therapy must focus onrelapses when they occur. Relapses (or the patient’s awareness that he feels agreater urge to use alcohol or drugs) provide an opportunity to learn about thefactors leading to substance use. Frequently patients are unaware of these factors;their lack of awareness contributes to their feelings of frustration and helplessness,and leaves them unprepared for further relapses. A careful, even microscopic,investigation of the feelings, relationships, and events that preceded therelapse are often revealing. Once these issues and affects are clarified, theyoften contribute to an understanding of the patient’s psychology in general,because they center on areas felt to be intolerable by the patient. Commonly,patients bring up their increased thinking about drugs or alcohol when there isan impending relapse. At other times, the therapist may infer an increased riskbased on what he or she knows of the patient’s history and emotional life. Conveyingthis perception to patients is one way to help them learn to attend totheir affects, thoughts, and behaviors, and utilize them as signals. Often, abstinentaddicts have dreams about alcohol or drugs that can indicate that somethingcurrent in their lives is reviving the association with substance use, warningof the risk of relapse.Finally, we should mention organicity. Some treatment providers viewaddicted patients as too impaired in brain functioning, as a result of drug oralcohol abuse (“wet brain”), to be able to utilize a dynamic psychotherapy untilafter a lengthy time of abstinence. Certainly some patients exhibit impairedmemory and capacity for skilled cognitive functions immediately after stoppingdrug or alcohol use. However, in our experience this limitation is frequentlymild or not significant for all but the most severely affected addicts (e.g., alcoholicswith hepatic failure and elevated blood ammonia levels). In fact, as regularlyobserved in inpatient treatment centers, patients can do significant workto understand themselves and the dynamic issues in their families and can alsoreturn to complex tasks within the span of a few weeks immediately followingdetoxification. The implication for psychotherapy is that it is rarely necessaryto wait an extended time to begin because of organic factors. Patients who aretruly impaired because their drug or alcohol use is so continuous that they arealways either high/drunk or withdrawing should not be in psychotherapy tobegin with, because they require hospitalization to break the pattern beforethey will be able to attend to the work of the treatment.