2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43
In this text, I propose to consider addict therapy primarily as a strategic work with a character structure that defines a specific format for the therapeutic relationship.
It is no secret that the most important methodological toolkit of the Gestalt approach is to support the process of awareness. When working with an addicted client, we primarily work with the awareness of the very fact of addiction. We will fail if we come from the side of "harmful consequences", that is, appeal to common sense. Any addict most often knows about the harmful consequences of addictive implementation better than any specialist, since he is faced with them “from the inside”. The trump card that beats any arguments about the dangers of addiction is the belief that this harm can be stopped at any time.
In other words, the addict is confident that he is in control of consumption, when in fact consumption controls it. Confidence in control is a reactive formation to protect against the experience of powerlessness in front of the addicted object, which is repressed into the unconscious. Accordingly, we can maintain awareness of the loss of control over the addictive realization. The Gestalt approach as an existential method of psychotherapy is characterized by an emphasis on the deterioration of the quality of life, which arises during the formation of a rigid way of regulating emotional stress, which excludes the possibility of creative adaptation and full-fledged development.
We note right away that therapy with an addicted client is a rather complex event. This is mainly due to the fact that the relationship with the addicted client strongly threatens the sustainability of the therapeutic identity. What is the reason for this? The first trap that the therapist falls into is that the client's unconscious impotence in the face of addictive behavior becomes part of the therapeutic relationship in such a way that the therapist is endowed with the opposite quality - omnipotence. Namely - the undeniable ability to "cope" with the client's addictive behavior in such a way that he did not take any part in this.
The therapist, who becomes the last hope not only in the eyes of a helpless client, but also in the crowd of his many relatives, is faced with the temptation of a narcissistic challenge - to do what others have failed. He loses his autonomous position and begins to play the role of the Rescuer in the terminology of the dramatic triangle. Of course, the initial narcissistic idealization after a while inevitably gives way to depreciation, since the behavior pattern for the addicted client does not change and he can show his aggression in the only way available in the given conditions - through a breakdown and regaining control over the situation. That is, at first the therapist is given responsibility for sobriety, and then it is passively-aggressively assigned to himself. The winner in such a game is, of course, the addict.
These games, in which the addicted client engages the therapist, are played out on the unconscious realm, there is no malice in it. The client implements a dependent pattern of behavior with the therapist and either succeeds in it (with the unconscious support of the therapist) and becomes even more consolidated in his neurosis, or is faced with frustration and acquires the opportunity for change (if held in therapy). Therefore, the therapist's task is not to enter into an unconscious collusion with the client, since each of us has a dependent radical that responds to non-verbalized client messages.
What does an addicted client do with a therapist? Since addiction arises as a result of untreated separation trauma, the addict in a therapeutic relationship tries to find a lost (and never had a place to be) idealized maternal object that will satisfy his need, firstly, completely, and secondly, at any time. Actually, the object of addiction (alcoholic, chemical, love and any other) becomes such when the client learns with its help to reduce the unbearable anxiety of abandonment.
Therefore, the appeal to the harmful consequences of addiction has no referential meaning, since consumption saves from a much more difficult experience of abstinence, that is, deprivation and the experience of abandonment. This experience is associated with early childhood experience of abandonment, when their own resources are clearly not enough to calm down. Addiction is thus the result of fixation on the experience of emptiness and loneliness in the absence of a caring object.
Thus, the second trap of the therapist is that the client presents an ambivalent message - on the one hand, I want to get rid of the addict object (because for various reasons it has ceased to perform an adaptive function), and on the other, I do not want to experience a state of withdrawal. And then, in essence, the client invites the therapist to take the place of the object of his addiction, to replace one dependent relationship with another. But to do this, the therapist needs to sacrifice his boundaries and ensure that the client does not suffer.
At this point, the therapist can have a strong countertransference - how can I be cruel to this sweet person who looks at me with eyes full of supplication and suffering. If the therapist unconsciously chooses the position of an idealized mother, he thereby maintains a borderline splitting of the addicted client, in which he cannot withstand the bad object and cope with the feelings that arise at that moment. The client's unconscious request and the goals of therapy are in two opposite places and, accordingly, in the position of the therapist, we can support only one vector - either maintain splitting, or strive to integrate it by increasing the tolerance of “split off” experiences.
In a relationship with the therapist as an idealized mother, the client tries to organize what is called direct gratification of the attachment need (which is frustrated in the addict). The client can demand clarity, guarantees, accessibility as if he is in fusion with the therapist and can use his resources as he pleases. Following such a requirement leads to the loss of the therapeutic position. The therapist can only guarantee to the client symbolic satisfaction within a setting that, on the one hand, is predictable and reliable, and on the other, has boundaries.
The setting forms an intermediate space in which the client can receive partial satisfaction and thereby build up the nonspecific strength of the ego, that is, resistance to the experience of anxiety. By creating frustrating tension from the fact that needs are not being met “right now”, the therapist teaches the client self-regulation, that is, he turns out to be a “transient” object between the object of addiction and autonomous existence. Autonomy here does not imply needlessness and counterdependence, it emphasizes the value of choice in the ways of satisfying needs.
Thus, working with an addicted client begins with setting boundaries, since addictive disorder has a borderline structure. By the word boundaries, I mean the whole complex of special therapeutic relationships: the therapist's autonomous position, his ability to withstand client attacks, sensitivity to countertransference, understanding the logic of the development of the dependent pattern. The client, demanding immediate gratification, cannot see the meaning of the therapeutic strategy, and rebel against what seems to him harmful and useless.
The therapist invests his understanding and his resilience in the client and thereby maintains the reliability of the relationship. The good object for the client should not come from the destruction of the bad, when the therapist succumbs to the attacks and becomes the symbolic ideal breast. This outcome supports borderline splitting. In the logic of the proposed therapeutic relationship, a good object appears as a result of the therapist demonstrating resilience and reliability and thereby offering the client the opportunity to contact his bad parts for which he thinks he should be rejected. The old experience of splitting off and isolating the “bad self” is being rewritten by new relationships of acceptance and integration.
In my opinion, the described part of the work is the most important because it creates a framework for further activities, which are purely technical, and include the study of bodily experience, the detection of a frustrated need, facilitation of a creative rather than addictive contact cycle, and so on. The therapist must be sensitive to the client's unconscious request, which is carefully hidden behind sophisticated ways to maintain an addictive way of contact.
The therapist, in a sense, is a vehicle for the emergence of new existential values in the field of relations, around which the client can reassemble his identity. Addiction is the fixation of mental development at the stage of forced attachment, while the therapeutic relationship offers an opportunity to take the growth process off the pause and maintain its intention towards free and creative interaction.
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