Envelopments: Immersion in and Emergence from Drug Misuse

Introduction

One of the best kept secrets about clinical practice is that psychodynamic psychotherapy can have lasting beneficial effects in the treatment of psychiatric disorders. There is now significant empirical data to support this. Shedler (2010), in an exhaustive and systematic review, has recently presented evidence supporting the rationale for and the effectiveness of psychodynamic concepts and treatment. In a related article in Scientific American, Levy and Ablon (2010) summarized and echoed Shedler’s findings and observations. Early psychoanalytic and psychodynamic treatments rested principally on a passive model of interaction by the therapist in which she/he was detached, remote, and depended mainly on interpretive approaches. In contrast, contemporary psychodynamic theory and practice places greater emphasis on the centrality of emotions, self-regulation, interpersonal relations, the treatment alliance, and here-and-now observations. Emphasis is placed on active support, empathy, a focus on recurrent themes that occur in and out of therapy, and an emphasis on developmental factors to understand current emotional and relational difficulties clients experience in treatment that parallel experiences outside of treatment. Collaborative, active and phase-appropriate therapy is particularly important in assessment and treatment of addictive disorders.

There are few, if any, case reports of individual psychodynamic psychotherapy in the literature working with substance use disorders. In the 1980s the Veterans Administration (VA), University of Pennsylvania Medical Center group demonstrated the effectiveness and efficacy of supportive-expressive psychotherapy with heroin addicts in a methadone program (Woody et al 1986). In that study the authors focus on and emphasize relationship issues that arise in and outside of therapy, and how such a focus helps clients understand the use and the role of addictive substances in their lives. In our own work we have focussed on self-regulation vulnerabilities that involve difficulties in regulating emotions, self-esteem, relationships, and self-care (Khantzian 1995, Khantzian and Weegman 2009). In our experience adopting such a perspective has proven to be instrumental in helping the therapist and client understand and modify the vulnerabilities that predispose addictive behaviour. Furthermore, given the physical and psychically damaging, life-changing consequences of an addictive immersion and adaptation, there is a need to examine and understand the dynamics of these consequences as an essential aspect of the therapeutic work.

In this paper two cases are presented as examples of individuals with addictive disorders for whom a modern psychodynamic approach is utilized. In addition to exploring the psychodynamics of the vulnerabilities predisposing to the addictive problems, the case material also reveals the special sensitivities and practices that are required to deal with the shattered life, self-esteem, relationships, and poor self-care that is so intimately involved as a consequence of an addictive adaptation. Unfortunately, with our modern stress on evidence-based approaches, we have shied away from the case method (practice-based evidence) of dealing with and understanding clinical problems. One aim of this report is to use case material to highlight and demonstrate the rich, instructive, and therapeutic benefit of the client-therapist interactions. Given the nature of addictive vulnerability, our approach is less interpretive and more in the supportive-expressive traditions of Woody et al (1986). Emphasis is placed on safety and working to establish a nonpunitive, friendly, supportive, clarifying, and instructive relationship in the service of establishing and maintaining a strong alliance. This is especially so given the harsh and punitive attitudes the clients, their families, and others experience and communicate to individuals with addictive disorders.

In addition, we sought feedback from our clients about our write up (which is reported upon) on the premise that therapy involves a doublenarrative, that of the client trying to cope with or come to terms with suffering and that of the therapist attempting to understand and alleviate such struggles. We are keen to support the importance of fostering good psychotherapeutic, demystified approaches employed by well-trained therapists. Our goal is to support therapists as they develop an appreciation for their clients’ struggles and to help therapists develop a focus in their interactions with clients. The interactions described provide a means to understand how difficulties in self-regulation—especially in the domain of recognizing, experiencing, and expressing feelings, and problems with self-care—are involved in becoming addicted and how these same vulnerabilities are heightened as consequence of the addiction. In the first case (Ellie), the consuming and enveloping nature of the client’s ongoing cycle of substance misuse is investigated, together and the possible inroads on accessing and modifying the addictive behaviour, albeit truncated by premature termination of treatment. In the second case (Mandy), the dilemmas and daunting challenges of early abstinence are described as the therapist intervenes to help the client emerge from the predisposing and resulting consequences of an addictive adaptation. Reflections on each case are presented to demonstrate how a modern psychodynamic therapist considers the nature of the client’s experience and the rationale for his/her interventions to address vulnerabilities with the addictions and the struggles to emerge from them.

Ellie’s Immersions

When I (MW) first met Ellie, a lively, creative woman in her late 20s, she bemoaned a “horrible year” of accumulating problems that she wanted to “fix,” once and for all. There were many “better things” in life that Ellie saw as eluding her. “I’m not happy with the sort of person I am,” she proclaimed. She presented with periodic, superficial self-cutting as a pattern, alongside other, intimated self-destructive symptoms together, for example, the numbing effects of alcohol binges might facilitate cutting or increase illicit drug use. Ellie spoke of self-cutting with a mixture of alarm and triumph, on the one hand communicating, “this is crazy behaviour, I can’t go on like this,” and on the other, implying, “look what I can and will do!” wielding the behaviour as much a weapon as much as a defence. She was worried about progression into more extreme acting out and serious, “accidental” injury. My initial formulation was that Ellie was locked into pursuing action(s) in an attempt to change how she felt. Whilst cutting and drugging were actions under her discretion and “say,” they provided only temporary relief, effectively eroding personal control and self-efficacy in the longer term. I suggested that she harboured a double attitude, consisting of real concern about what she was doing to herself and its spread, and a dismissive, submissive or defiant stance. Whilst her notion of finding a fix may simply reflect modern parlance, it might suggest the fantasy of finding an easy, once-and-for-all solution.

The first few sessions widened the scope of assessment to better understand Ellie’s self-directed violence and other enactments. One fact of family life was how easily hurtful comments were hurled among family members in an unpleasant compound of vengeance and revenge. Family members seemed brittle and, in the aftermath of upsets, prone to acts of reassurance and material reparation rather than more thorough-going efforts to arrest such patterns, thus increase safety and comfort all round. Ellie easily converted this (nonphysical) hurt and metaphorical violence into violence to self or as prompt for drug/alcohol binges. Afterward she would reassure herself that her actions were not “too bad” or that they had been a “good time” after all. It was as if her body was semi-detachable and hence subject to use as if it were a foreign or alien entity (Bateman and Fonagy, 2004). With self-violence or intoxication becoming habitual forms of resolution, achieving improved affect regulation and inner safety were my main therapeutic concerns. Whether she would be willing to allow her mind to be open to my mind, so to speak, in something more than superficial contact was the question.

Ellie was defensive in response to inquiry about the extent of her drug and alcohol use. She oscillated, wanting and not wanting to talk or know about it, as if any admission would render her drug using vulnerable to my supposed aims and values. (I think she imagined I wanted her to stop all substance use; such an attribution demonstrates the complexity of therapy, once a relational perspective is assumed. Was it, for example, the simple imputation of a wish that she could not herself own? Did she wish to avoid any experience of disparity in her own goals? Was she pressing, desperately or defiantly for an environmental response of interest and concern? And whilst, in theory, I adopted an open, even-handed stance, did I really want her to be the abstinent client she was not, thereby reducing my anxiety associated with her acting out?). In an interesting clue about her capacity to face and not to face difficulties, she relayed a dream about a man she knew who was in serious trouble (just as he was in reality). As Ellie coached him about his problems in the dream, he snapped, “but just look at yourself!” She was shocked by the feedback, which I took to be an encouraging indication of knowing that she was indeed in trouble. The “precontemplation” and “contemplation” states that psychologists of change in the addictions have postulated (DiClemente, 2003) are not hermetically sealed or necessarily sequential. They are contextually produced and maintained positions, for which therapeutic conversation, hopefully, offers space for re-contextualisation and re-evaluation by the client (Weegmann, 2002; Ryan, 2009). Ellie continued to shift back and forth in her concerns, but at least there was movement.

Ellie’s vulnerability and attraction to drug using was vividly illustrated when she spoke about the men in her life. On one occasion, she “found” herself on a weekend date with a man who used large amounts of cocaine. She was torn, joining him in using some of the time. She eventually broke off from him, concluding that she did not want to start “another coke-fuelled relationship.” She was confused about her motives and priorities with men. Was she, for example, merely looking for a fellow drug user and if so, what signals was she giving out? Would a man with no interest in drugs—and there were some—even be attractive as a prospect? With no real direction or firm purpose in her life, she was easily swept by the excitement of the moment, including the rush of new encounters with men and drugs; she was prone to “codependent” patterns, in which she would wrap herself around others in an effort to secure an identity or purpose, or to feel more real. At the same time I thought that she was searching for a different sort of figure, one who could help her not to be distracted by short-term escapades and enticements, but to connect instead to an underlying determination to make something of herself, to protect her interests, and to secure better self-care.

Ellie detailed various drug episodes over the years, including the use of what she called “party drugs” (ecstasy, coke), periods of heavy cannabis smoking, use of “downers” (i.e. drugs which tranquilise or sedate, slowing down the functioning of the brain and central nervous system) and regular, ongoing binge drinking. She described more recent experiences with ketamine (dubbed Special K), with its strangely attractive, dissociative effects. She explained “K holes” (a popular terminology depicting dissociative anesthesia and hallucination-type experiences), which offered “out of body” highs reinforced by others who were also having “a great time.” I wondered if I was the bore, intended to feel excluded from the party.

More worrying still, Ellie ruminated about opiates, particularly heroin. Although she had not used it so far, she made it clear that there would be “no problems” in finding it. I openly expressed disquiet, asking whether she was really prepared to throw all harm avoidance and judgment out of the window. I could not tell if she was playing, albeit dangerously, with thoughts—a posture in fantasy—or if she were really tempting providence, and I concluded that she might not herself know. Ellie’s favourite film was Drugstore Cowboy, a bleakly glamorous crime movie in which a “family” of addicts travels around robbing pharmacies and hospitals. In one scene, a stash of stolen pills and preparations is spread out, there to be marvelled at and reviewed, in a hierarchy of use value. It was the sheer, coloured variety of the scattered drugs that caught her eye—“just like Smarties,” she remarked, missing the irony. We explored her implicit hierarchy of interest and the compound of fear and fascination that drugs aroused. (Having subsequently seen the film, I was all too aware of the film’s casualty, a young woman who joined the criminal company naively through her drug-using boyfriend and who, whilst the others are on a job, experiments with, but tragically misjudges, the potency of a drug, resulting in death by overdose. Chillingly, the others see this as an inconvenience rather than an occasion from which to recoil with horror and distress; Ellie made no reference to this).

Six months into therapy Ellie moved areas. Convinced that she could no longer travel to see me, therapy ended abruptly. I was unable to persuade her to agree a period of working-through an ending.

Reflections

Baumeister (1994, p. 284) refers to a human tendency to maintain consistency about troubled, ongoing roles and relationships and that, “people may minimise the costs and exaggerate benefits.” There were, in Ellie’s thinking and social world, for example, “thousands of others out there doing drugs,” others “worse off” (like the man in the dream who ironically repudiates the position she places him in), and the many for whom, “it’s no big deal.” According to Baumeister, people seek help and embark upon change when there is a significant shift in an internal balance of appraisals, a “crystallisation of discontent.” Serious discontent had indeed brought Ellie to therapy, she realised that her ways were not working and recognised a chronic lack of fulfilment in life. In spite of breaking off therapy, she allowed me to get to know her in some depth, more so than with previous professionals.

The worrying side was the continued pull of drug use—anticipating it, pursuing it— together with the fantasy of submission to opiate use. What we shall term “psychic envelopment” refers to more than the growing salience given to drugs by the user, although it includes this. It refers more broadly to a process whereby a treasured activity, preoccupation and value slowly infiltrates other, ordinary activities and motives, to the point that one’s whole being is coloured and charged by its presence. With envelopment, drug use subserves more and more aspects of personal functioning. In other words, drug use is tethered to psychosocial needs, either in the form of self-medication for emotional problems and psychic deficits or as a consequence of chronic usage and highly reinforced associations, or moreover, as an invidious combination of both (Khantzian, 1987a). With serious dependency, the likelihood of the latter makes it difficult to distinguish causes and consequences of addiction, like separating the “dancer from the dance”.

Neuropsychological models of addiction use not dissimilar military or strategic metaphors, proposing the ‘commandeering’ of brain functions and the ‘hi-jacking’ of neural circuits, reward pathways and so on (Panskeep, et. al., 2002; Hyman, 2005; Koob et. al., 2007); here we are emphasising the consequences of a “take over” within her internal world. Ellie was at risk of reliance on drugs to enable and fulfil various “selffunctions” (e.g. to enable soothing, stimulating, and confidence-giving functions of the self), a reliance that would substitute for what could not be done internally (Khantzian, 1985b; Khantzian and Weegmann, 2009). Drug use and self-injurious behaviour arises from and results in a process of “kindling”. As a person is sensitised to drug use, less and less pretext or context is required to activate the behaviour (Twemlow, 2003).

Yet in this and the (as far as I could tell, much reduced) self-harm, Ellie also demonstrated a capacity for pulling back, averting (some) high-risk situations and limiting the damage. There was also confusion, as in the reference to heroin—was she playing and fantasizing or was she was in real danger to progress to that drug? Were the alarms that assure caution and self-care either absent or in temporary abeyance? Something in her could, in some circumstances, mobilise caution. “Drug progression” is not inevitable, and it is quite common for people to use/misuse a variety of drugs at different stages in their lives, only to leave them behind at another. Cultural normalisation of excessive drug and alcohol use makes it more difficult for those using them to pause, evaluate their activities, and judge when to stop or reduce. For most younger people, periods of excessive use are circumscribed and outgrown, whereas others are more problematically drawn and enveloped in what Hyatt Williams calls, “anti-developmental erosions” (1978, p. 310).

In summary, we would suggest that Ellie was living (and thereby constructing) a dual citizenship, as it were, in which she was torn between different and divergent sorts of activity. One might postulate the formation of contradictory parts of the self: one pursuing addictive remedies to life’s problems (getting high, scoring, have a good time, and so on) and the other set on learning and growth (doing courses, career aspirations, etc.). The former may triumph over the latter and, offering various seductions and rationalisations, convince the user that there is nothing to really worry about (Weegmann, 2004). Reinforcement reduces a person’s resources and bypasses the mind. With or without previously adverse life experiences, addiction seriously damages reflective capacity, a mindless succumbing which collapses, “the dialectical”, and hence flexible, “relationship of the psychic positions” (Bergstein, 2003, p. 1295).

Therapy sought to promote self-governance through a combination of goal (motivational) clarification and containment of confusing, overbearing emotions. It is important to encourage clients to have better conversations with themselves about their conscious and could-be conscious choices, or about the thoughts and feelings that are present (or absent) that are involved in the choices they make. Efforts to make emotions safer, more accessible and distinguishable, can reduce the need to act upon them and hence allow greater circumspection about inner and affective life (Khanztian and Mack, 1983; Fonagy, et. al., 2003). The net result of this dual-track approach might, one hopes, allow Ellie more judgment, safety and “say” in what goes on inside and around her.

Ellie’s Response

In Ellie’s written response to this paper, she commented, “The main thing I glean from it is there are lots of questions …. It’s all questions and no answers really, and that is totally accurate as how I see myself.” Agreeing with our formulation that she resembled two persons struggling for different things, e.g. to quote, “Am I a druggy waster or do I want a career?” She added, “As you know I have experience of both sides of each of the questions above, but still don’t know the answers to any of them.”

Mandy’s Emergence

Mandy, an energetic, professionally driven woman in her mid–20s, was referred to one of us (MW) following a suicidal crisis. She had hovered near the edge of a balcony, which resulted in a dramatic confession to her unsuspecting family of addiction problems and a decision to stop all substances. Mandy was dependent on alcohol and cocaine. She described a “high-energy” frantic life, “full of deceptions and cover-ups.” Everything came crashing down when it became impossible both to sustain drug use and everyday functions.

It is an essential part of psychotherapy in early recovery from substance misuse that clients are helped to re-establish normal and day-at-a-time functioning. Her addictions had been exhausting and depleting, but she experienced abstinence as an unfamiliar, bewildering life-space, akin to an assault on mind and body. Without chemical means, she had little idea how to manage herself and no notion of a “nonusing” identity; “I hardly know this person in my skin,” was her way of putting it. Everything was difficult, from sleep to appetite to routine, with the inner addict, as it were, quick to take advantage of the discomfort with enticing thoughts such as, “surely using is better than this,” that using “just once wouldn’t harm,” and so on; drug temptations entered into every crack of doubt or discomfort. Fortunately Mandy was watchful of such self-seduction and knew that any return to using would be disastrous, though this did not (initially) alleviate the inner torment of such temptations. On bad days, it seemed that there was no compensation for the loss of substances in her life. On good days, however, the simple relief at not having to chase one high after another was enormous.

Searching for evocative metaphors to help her conceptualise and hence, manage her ordeal, I framed her experience as a faltering emergence from an incredibly long, exciting and dangerous journey, which had in reality constituted an extended detour from real contact with herself and others; she found the comparison frightening and illuminating, perhaps for the very reason that is was a “frightening illumination,” representing the “lost years” of using. In waking up to all that she had done and been (and not-done and not-been), she was faced with a concentrated life review. This was a formidable task, and meanwhile her (supportive, guilt-filled) family faced a comparable life review, in which they struggled with searching questions such as: how did they not know, why did they not notice the tell tale signs, what were their failings? They had misread her troubles, but she was an expert at dissimulation. In the aftermath of the stopping crisis, Mandy described psychotherapy as the time she had never allowed herself; “I never stood still in 10 years,” she said. She was in search for a container—an effort that was frantic at first—to secure a figure of help who would be cognisant of, yet separate from, the immediate pressures of family. It was as if she had no respite, no restful spaces in her mind. Contemporaneously, Mandy attended Narcotics Anonymous, seizing the newcomer suggestion to attend “90 meetings in 90 days.” I encouraged her to talk about the NA meetings in detail, rather than to keep them separate from our therapy sessions.

Mandy explored her recent and distant history in increasing depth. She detailed the “madness” of using and its consequences, including, money and job problems (remarkably, she always worked, or over-worked, sustained by stimulants and a drive for perfection), shame-filled promiscuity, and futile efforts spent trying to cover her tracks. Discontinuation left an enormous gap in how she spent her time and raised awareness of unattended needs and truncated psychic development. She spoke about early relationships and certain traumas associated with them; this was sometimes prompted by the listening and identification culture of NA. Whilst in general I do not actively explore early loss in early recovery, there are some clients, and Mandy was one, for whom such work is unavoidable because it is so prominent in their conscious sufferings. In one NA meeting, for example, a man expressed gratitude that he could resume his role as responsible, loving father, thanks to recovery. Her first reaction was one of envy, although not entirely, bitterness as to why (in the past) she was not a beneficiary of similar love and reliability. Mandy was clearly in touch with highly sensitive disappointments and unaddressed grief. I pointed out that the ability to have such feelings at all was encouraging, crucial as they are as the mind’s communications and protests, and it was also proof that drugs had not irrevocably damaged her inner life. Indeed, in the fathering example, she demonstrated many grades of feeling and evaluation, including jealousy and appreciation—the man was providing something she had longed for and she was pleased he could turn his life around. She also felt guilt about her initial feelings of resentment towards him. “This may seem an odd expression,” I said, “but I think you are struggling with a special kind of ‘beautiful pain.’” By this I was trying to convey the mixed nature of her suffering and her capacity to see and long for the good. I reflected upon some typically ironical wisdom from NA/Alcoholics Anonymous, about the “trouble” with recovery: The good news is you get your emotions back; the bad news is you get your emotions back” (it can be quoted either way round). Of course, these were not just issues “out there,” but enfolded with developing therapeutic intimacy; typically, Mandy found it difficult to allow a caring situation to emerge or to acknowledge one when it did, as if she did not feel she deserved it.

As Mandy grew used to abstinence from drugs, and able to face greater awareness of the ruptured trajectories of earlier development, she became more comfortable with and able to enjoy being clean. Traumas and lost time notwithstanding, she felt enormous appreciation for family, friends, and NA peers (including her sponsor). Yet the multiple transitions from living “a life of secrets and deceptions,” to one where she could feel too much like an “open book,” monitored by others, was complicated. Internal wishes to excel in recovery, as she had tried to do with everything else in her life, including previous drug use (i.e. to out-use and out-drink her drug-using peers), were considerable. At times like these, she found it hard to let me see any “mess,” as if she were taking flight into health and wishing to excel as my client. Internal shame about who she had become during years of using, the depths to which she had plumbed, was considerable. Quoting Bachelard’s metaphor of human beings as “semi-open creatures” (1958, p. 222), I articulated Mandy’s dilemma about what might or might not be seen in therapy, and explained the degrees of safety about issues that might reach my ears, even if she could or would not share these at NA. Not only this, but also shame at how she had treated others shaded into guilt. We found ourselves referring several times to a form of survivor guilt that often afflicts addicts in earlier (and sometimes later) stages of recovery from drugs: “Why should I now enjoy good things and my families’ love, when I have misused them for so long?” Therapy ended, by agreement, after 14 months, with Mandy continuing to work on her recovery through NA.

Reflections

Mandy’s emergence from drugs was dramatic, not so much the result of a dawning crystallisation of discontent, but the outcome of a serious crisis; of in NA language, “hitting rock bottom.” Thankfully, she pulled back from the brink (in more than one sense), yet her world was in disarray. We understood Mandy’s use of psychotherapy as providing a form of (a) “parenting,” but to her as an adult, so that she could resume a process of long-stalled psychic development, and (b) “partnering,” with someone helping alongside her, assisting her to face fears of emotional intimacy, and thus developing greater, deeper contact, and trust with(in) self. One could argue that involvement in NA, which includes meetings, sponsor and the reading of literature, provided similar resources, but more on this shortly.

It is useful to remind ourselves that drug users are ordinary people who resort to what Mitrani (2001)—in dealing with other sorts of pathology— calls “extraordinary protections.” Often, but not invariably, these are borne as consequence of early misadventures, but importantly, in the case of addictive careers, of later ones. Chronic drug misuse is itself traumatising, as the personality is progressively, “drained of vitality, of identity, of inner richness” (Wurmser, 1980, p. 41). Earlier we proposed the metaphor of envelopment as apposite to addiction, in that the chronic reinforcing properties of drug use result in emotions, values, priorities, and problems being wrapped up to the point of oblivion and nonrecognition (usually called denial) and hence, nonmanagement (resulting in dysregulation). The act of stopping exposed Mandy to all the rawness of a poorly-managed emotional world. As drug envelopment progressively infolds the self around an axis of problematic, self-defeating “solutions,” the person in early recovery hardly knows who she is. In terms of Mandy’s identity, “coming clean” signalled the beginning of an enormous task of rebuilding her life and ordinariness. Knowing what she did not want (i.e. a return to using) was one thing, but experiencing positive wants, normal needs, and carving out a new trajectory of self, was quite another. As noted, she placed great demands on herself, to excel and be self-sufficient, a characteristic sometimes associated with long-term cocaine users (Khantzian, 1987). Living in the absence of stimulating substances forced new (or renewed) dependence on family and nondrug using social circles as a means of re-starting her life.

One way of seeing recovery is as the reversal of envelopment, an unfolding (cf. the image of “being straight,” a “straightening out” of one’s life) in which the person gradually puts herself together. For this, the person requires an (other), and it is in this context that we pay tribute to cardinal role of NA for many (but not all). Narcotics Anonymous can be thought of as rehabilitation without the building—a recovery of the mind. As mutual-support and personal programme of recovery, NA offers a form of apprenticeship, one based upon interpersonal identification and learning. Abstinence and basic acknowledgment of unmanageability (powerlessness) is the precondition, for without this nothing can be built; the drug user urgently needs to see who and what (the disordered self and addiction) she is up against. As group tradition and learning, there is an interesting and essential “I/We” dynamic at the heart of fellowship experience, which enables members to simultaneously appreciate their unique situation and responsibility and their commonality with others addicts. As Ricoeur puts it, reflecting philosophically on human interdependence and mutual vulnerability, viewing “Oneself as Another”(1995). A further parallel can be sought in the psychoanalytic research of Emde (2009, p. 558), who proposes the socio-emotional concept of ‘we-ego’, where “the development of self and the development of the other did not develop separately but were two sides of the same coin” NA is a preeminently a form of socio-emotional (re-) development, countering the infolded, envelopments (’self-will run riot’) of the addict and acting as a powerful corrective to isolation and denial (Khantzian, 1989; Weegmann, 2009).

It is common for members of fellowship groups to seek professional help and, particularly when there is mutual respect between the approaches, each can be strengthened by the other. Mandy sought privacy as there were matters that she did not want to share in meetings, and whilst her sponsor encouraged daily sobriety and crisis resolution, she felt the need for detailed reflective space in order to work on the complications of past and present life. As we have seen, one of her private agonies concerned a broken relationship of the past: how to deal with a damaged internal father, with all the associated disappointment, mystery, anger and betrayal. Fortunately, there were many caring figures in her life and so she was never lost in despondency.

Mandy’s Response

Mandy gave a point-by-point response to our paper, commenting,

Conclusions

Addiction is a condition of disordered emotions, relationships, and behaviours. Modern psychodynamic psychotherapy places great weight on maintaining a focus on the painful emotions, troubled relationships, self-esteem, and behaviours that predispose to and are the consequence of addictive disorders. Trauma, grief, and loss so often precede addiction, but invariably they are also the result of addiction (Khantzian and Albanese 2008). Accordingly, recovery from the ravages of addiction requires that matters of comfort and safety be of central importance, as is so evidently necessary with both Ellie and Mandy, especially early in treatment.

The two cases demonstrate how addictions result in a kind of homeostasis, albeit a precarious one. They raise the challenge of understanding what dynamics maintain addiction and what dynamics can be activated to relinquish the hold of an addictive adaptation. The therapist’s empathic attunement to the disorganization and chaos resulting from addiction is often a first and necessary step in recovering. Mandy’s case in particular demonstrates the importance of developmental loss and arrest as a consequence of addiction. Drugs are used to regulate emotions, relationships, and self-esteem over long periods of time, only to diminish and distort them. Both cases demonstrate how psychotherapeutic focus on the distorted feelings, self-esteem, and relationships (both antecedent to and as a consequence of addiction) help to restore or establish a lost or missing narrative about self and others. Margaret Bean Bayog likened emergence from addiction to the lot of holocaust survivors (personal communication). Not inconsequentially and significantly, both the client and therapist refer to survivor guilt referring to the pain and distress experienced in early and subsequent phases of recovery.

Given the often pessimistic (though empirically ungrounded) attitudes regarding the prospects of change in substance mis-users, alas shared by many in the psychodynamic field, it is essential to underline that major change often occurs, though considerable time is required for significant ’crystallizations of discontent’ to ferment. Recovery perspectives are crucial (White, 2000), as the other half of the picture, and a necessary counter-balance to treatment pessimism. In the words of one distinguished, nonanalytic psychologist addressing the dynamics of change: “it allows the field to move from a static, linear and dichotomous view of addiction to one that incorporates the nuances of developmental, longitudinal, multidimensional change perspectives” (DiClemente, 2003, p. 254).