12 Steps And Psychoanalysis. Prospects And Features Of Work In Russia. Subjective Experience

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

I want to note right away that I myself am not a psychoanalyst, and, I think, in this connection it is appropriate to explain why I undertook to write this article. For the last 10 years I have been working with chemically dependent people, mainly drug addicts, and their loved ones, those who are called codependents. Since 2000, I have been working as a psychologist at the Megapolis Medexpress rehabilitation center in Zelenogorsk. Since 2005, I began to look for the possibility of psychotherapeutic support. My colleague, who also worked with addicts, and, by the way, he himself had experience in chemistry. addiction, at that time he was finishing VEIP, and talked about his training and the specialists of VEIP. So I got into the "analysis", and there I also found the possibility of supervision.

Recently, taking this opportunity, I tried to systematize my experience and, I believe, it may be of interest to a reader who is engaged in or intends to work with chemistry. dependent and codependent.

However, in the beginning, I would like to talk a little about the theory. The fact is that in the process of my work, I collaborated for a long time with recovering drug addicts and alcoholics who were representatives of the communities of Narcotics Anonymous, Alcoholics Anonymous (hereinafter abbreviated as AN and AA), Al-Anon, etc., and came to the conclusion, that this collaboration and my understanding of the “12 step program” (hereinafter abbreviated as “12 steps”) used by these communities was very effective for work. At the same time, I was faced with an absurd fact for me: many of the psychologists and psychoanalysts do not know what the "12 steps" are, or do not even know about their existence, although they exist in Russia and, in particular, in St. Petersburg for 20 years. From psychoanalysts, I heard doubts about the “psychoanalyticity” of such an approach, which, allegedly, is the reason for avoiding studying it.

I began to study literary sources and it turned out that these are mainly psychoanalytic sources. For the first time, I found the 12 Steps review from E. Burn, a representative of transactional analysis: “The best hope for addicts is group therapy in combination with individual psychotherapy or self-help groups like Alcoholics Anonymous and Synanon. The usefulness of psychoanalysis in this area has not been proven "(E. Byrne," Introduction to Psychiatry and Psychoanalysis for the Uninitiated ", 1947).

Ernst Simmel, in his article "Alcoholism and Addiction" in 1948, writes: "The reactive alcoholic needs supportive psychoanalytic therapy. In his Ego, the preconscious must be made mainly conscious and integrated. He must realize and verbalize his conflicts and, thus, learn to interpolate his thinking between impulse and action instead of drinking (“experimental way of acting” - according to Freud).

While studying the brochure of Alcoholics Anonymous, I was surprised to find that the therapeutic principles applied in psychotherapeutic attempts are generally consistent with psychoanalytic findings. This is not surprising, since Alcoholics Anonymous was created by alcoholics for alcoholics and, therefore, it came from an unconscious understanding of the latent id drives in alcoholism and the tendency of the alcoholic ego to protect itself from them."

Of course, Simmel himself admits that his understanding of the "12 steps" is very superficial, based on the study of the brochure. However, it is generally correct. And most importantly, in my opinion, it is devoid of bias. Here I risk sounding obsessed with the 12 Steps, but I can assure you that I am not a representative of this program, just as I am not a psychoanalyst.

Simmel asks the following question: “… does our theory, derived from psychoanalytic research, offer any possibility of applying it to the therapy of a group of patients in order to cope with the universal danger that alcoholism poses? … The answer to this question is yes, because, which is rather strange, it has already been used intuitively and successfully in … Society of Alcoholics Anonymous."

In fact, this is not entirely accurate information. The fact is that one of the founders of A. A., a recovering alcoholic, stockbroker Bill Wilson turned to K. Jung for help and carried on correspondence, the most famous of which is Jung's letter to Wilson (Letter to Bill Wilson, 1961. Alcoholics about himself. Collection of biographical stories of recovering alcoholics and expert articles) with reflections on one of their former clients. It is logical, in my opinion, to assume that K. Jung's influence on the development of A. A., the formation of the work of groups, and therapeutic principles was not limited to this letter, but it should also be clarified that initially Jung admitted his inability to help him. However, after the founding of A. A., Jung called Wilson “one of the founders of A. A.” and hailed his work. I think it is most appropriate here to talk about one of the first experiences of successful cooperation between a psychoanalyst and a recovering chemist. addicted.

In our country, to this day, there are very tense relations between doctors, psychologists and chemists. dependent consultants. At the same time, we seem to forget about the common goal that unites us - to do our job effectively. In a sense, this reminds me of the struggle between representatives of the Moscow and Leningrad schools of psychology, Freudians and Jungians, sharp-pointed and blunt-pointed people in Gulliver's Journey, who recently began to recover alcoholics and drug addicts in self-help groups and, forgive, use alcoholics and drug addicts in a communal apartment. Moreover, if a chemically independent person manages to cooperate in practice with a chemical. dependent, then, in reality, we all only gain from this. And for a beginner to recover, the presence of such a chemically independent, understanding the peculiarities of the disease (and not just reading about them and feeling for himself what a group and psychotherapy is) and accepting the addict as he is, has an important therapeutic value in terms of improving self-esteem and working with feelings of guilt.

Experience in group therapy is of particular importance. However, it should be noted that, as Irwin Yalom wrote, “different types of therapy groups favor different sets of therapeutic factors … Alcoholics Anonymous and Rehabilitation Societies mainly prefer to operate on factors such as inspiration, communication, universality, altruism and certain aspects of group cohesion. (I. Yalom. Group psychotherapy: theory and practice. 2000). Of course, these groups differ from psychoanalytic groups, but the same I. Yalom writes further that only a mature group is capable of accepting a psychotic, which is essentially a chem. dependent. He has a tendency to act destructively on a group of ordinary people. I suppose that the reason for this is all the same resistance. A mature group can also be useful in terms of 1) motivation to seek help from groups like him, 2) as support in parallel, and 3) in terms of socialization for a person who has already recognized the need for himself to solve the problem of addiction in appropriate groups in as a basic foundation for further changes. However, it will not replace a self-help group for him, just as it will not replace a psychologist with a recovering chemist. addicted.

In 2001, the joint work of American and Ukrainian specialists "Individual Counseling for Drug Addicts" (Delina E. Mercerer and George Woody. Individual Drug Counseling, University of Pennsylvania / Philadelphia Veterans' Administration Medical Center, 1999), where, in my opinion, for the first time, the features of working with chem. addicted. Let me quote some quotes from there: “In our opinion, a deep understanding of addiction and the tools of recovery, as well as the ability to empathize with the patient, are essential attributes of a full-fledged professional addiction counselor.

One, but not the only, way to acquire this knowledge and skills is to be in

recovery yourself … In practice, we take this into account, demanding from a professional

participating for at least five years in the recovery process. In institutions, where many consultants work, the optimal situation is whe

the team is formed from a number of both recovering and independent i

past consultants, as it increases the level o

mutual learning

… The peculiarity of domestic narcology is that it owes its origin to psychiatry. A feature of Russian psychiatry was a rather obvious neglect of psychology and, especially, psychoanalysis … Our task, of course, does not include a detailed analysis of this phenomenon, but we believe it is not superfluous to note that the role of a consultant should also be assessed from a psychodynamic (i.e., analytical) position.

At one time, Sigmund Freud discovered such a phenomenon as transference (transference, transfer) … the Consultant needs to know about the existence of this phenomenon, take it into account and dispose of it …."

And here it is already pertinent to say about the following spheres of activitythat open up to psychologists and psychoanalysts with the study of the 12-step program:

1.supervision and psychotherapy for counselors

I will return to the “Individual Counseling”: “… In Ukraine, the specialty of a consultant does not yet exist in the state register, so doctors and paramedics, psychologists, persons with diplomas of social workers and recovering former patients with at least 3 years of sobriety in recovery program and have received special training."

On my own behalf, I want to say that in Russia a consultant as a profession, as well as in Ukraine, has a very uncertain status. Where they get their education - wherever they can, many - nowhere. I have encountered situations where people who have a year of sobriety or even less work as consultants, and even interns with sobriety for a period of several days. The issue of supervision and therapeutic support in a situation of high competition among rehabilitation centers is very problematic: consultants are afraid to “wash dirty linen in public”, they are afraid to share their experience, they are afraid of losing their jobs. The bosses of the rehabilitation centers are mostly inclined to emphasize that those who work as consultants do not know how to do anything else, thus taking advantage of the initial blurring of the “I” image of chem. addicted. It is difficult for them to access self-help groups due to their status as a counselor. In general, the situation is not easy and in many respects absurd.

And with all this, there are consultants who, in spite of everything, provide very serious and real therapeutic assistance to many chemists. addicted, and for more than one year, acting mostly intuitively, without the necessary therapeutic support and supervision. The situation is gradually changing in some reabs. centers, Ballint groups and psychotherapists appear, but, as a rule, this happens after some kind of crisis.

2. motivation for recovery. Let me return again to the text of the “Individual Counseling”: “… in the case of drug addiction the patient usually has motivational ambivalence, i.e. he would like to simultaneously stop using drugs and at the same time continue their "controlled" use. Working with the past and fantasies - which is paramount in the format of psychodynamic psychotherapy - provokes at the initial stage the mechanisms of psychological defense and adds the patient's argumentation for continuing to use psychoactive substances."

And here it is appropriate to make some clarifications. In this case, we are talking about the "initial stage" of recovery, that is, about 1-3 years of sobriety.

The fact is that for chem. addicted at the beginning of recovery is very characteristic of the following rationalization: "What do you understand, because you did not use." In this case, I succeed most effectively in helping him see his resistance by speaking about the experience known to me personally of recovering people, although I myself have not used VIS (substances that alter consciousness) or offer him to communicate with such recovering people. As a rule, the aforementioned ambivalence prompts him in such a situation to find a reason for himself “now” not to turn to other addicts, but to overcome his rationalization and continue working with me. In some cases, with very strong external motivation, he can really turn to recovering, which in this situation is very useful for him, and in addition, it will strengthen his trust in me, which will help him in the future, since, as a rule, he will need my help, but not at the initial stage, but when he gains a certain amount of sobriety.

It is appropriate here to briefly talk about the structure of the 12-step program. The format of this article does not allow me to tell about it in full, and I will again use the text of “Individual Counseling”: “Procedurally, in fact, any situation can be resolved positively, using an appropriate lesson or lessons from more than 65 years of improving philosophy 12 Steps. In fact, these steps provide a gradual, evolutionary approach to recovering from chemical addiction. The steps are organized in a certain order: from the most important, main, basic, towards further changes that a person, motivated to recover, goes through and integrates into the process of his life. In fact, the 12 Step program, being at first a therapy program, becomes a rehabilitation program, and later the spiritual foundation of life. The experiences of other people who resist their addiction offer a certain perspective to the person seeking recovery. This helps addicts to get rid of unwanted options for psychological defense, to see their addiction (as well as other psychological problems) in the light of reality.

This approach also requires addicts to acknowledge the existence of a Higher Power and the willingness to believe in it, guided at least by the fact that such a method of action has proven its usefulness in achieving a healthy lifestyle (Galanter). It is very important to remember that despite the frequent mention of God or a Higher Power, the 12 Steps is not a religious program. This is a spiritual program. The difference is that unlike any religious system that refers to the concept of deity, in the 12 Step Program God participates implicitly - “as we understand Him.” The program assumes that each participant can, if he wants, find support in God What exactly this image will be, what concrete it can be embodied in is a purely personal matter. Moreover, even the concept of "God" can be replaced by the concept of "Higher Power", ie "Power is more powerful than our own." Thus, we are talking about certain psychological parameters of the personality, certain gnostic structures, similar to the one that psychology calls the super-ego, the presence of which in human nature does not cause doubts even among inveterate materialists."

Here I would clarify the following points. On average, it takes a year to develop one step. In order to maintain and maintain your sobriety, in principle, the first 3 steps are sufficient and a psychologist is not needed in their elaboration, people who have experience of use and recovery are needed there. And without them, it is dangerous to approach the 4th, because in practice, when faced with difficult emotional experiences without sufficient stress resistance and experience of seeking help, if necessary, the patient refuses from therapeutic principles and returns to use.

In general, with regard to working with chem. addicted in the direction of overcoming resistance and strengthening motivation are of great importance:

- Sincerity and the ability to self-disclose. BUT, of course, to the extent that it is necessary for the client. Chem. the addict is extremely hypersensitive to lies and dishonesty of any kind, while, on the one hand, he unconsciously constantly tries to push the therapist into countertransference reactions, and, on the other hand, highly values the therapist's personal experience in terms of psychotherapy. That.:

- If the therapist, in the context of the conversation, is able to mention his own experience of individual, and especially group therapy, this also strengthens the patient's confidence in him. At the same time, it is important that this experience be in reality, otherwise it is chemical. the addict will feel insincerity and many of the previous efforts will "come to naught", and also so that the therapist himself is aware of the significance of his experience.

· Work with elements of the 4th step.

However, if a person is consciously ready to not only maintain his sobriety, but also to work with the reasons that led him to use VIS, then he proceeds to the 4th step. In Narcotics Anonymous Steps Guide, Step 4 describes how to deal with the following feelings: resentment, guilt, shame, fear, as well as relationships with people, sexual relations, and abuse. This work, which is of particular value for a person who is inclined to change his feelings with the help of substances, is of particular value, and, I believe, the help of a psychoanalyst in this situation would be more than appropriate. However, I will once again emphasize the need and importance of the analyst's knowledge of at least in general terms the 12 steps, which would help to overcome resistance at the initial stage of work and strengthen confidence in the psychotherapist, and the psychotherapist would give certain information to understand chemistry. addicted.

· Work with loved ones chem. addicted. This area is perhaps the most necessary for the work of a psychoanalyst, and for several reasons. -

- Firstly, in most cases it is the close ones who turn to for help, only the request sounds “parental”, as if we are talking about a small child: “Do something with him / her, I’ll be patient, everything is with me in order". It is with the person who asks for help that it is necessary to begin therapy, that is, with relatives and friends. This seemingly obvious fact is often ignored. But it is with the help of work with loved ones, the so-called. Are "codependent" and it is often possible to create motivation for recovery in a chemical addict.

- secondly, although there are self-help groups for codependents, in comparison with groups of alcoholics or drug addicts, these are the weakest and most immature groups, although, of course, this is my subjective opinion. E. Byrne described AA and NA groups as groups where people tend to engage in rescue and missionary work, however, being personally acquainted with representatives of these communities, I can say that today AA and NA are rather groups of spiritual growth and missionary work is not an end in itself there. but a tool for harmonious development. But what happens to people at the Al-Anon and Nar-Anon groups (groups for relatives), unfortunately, today leaves much to be desired. And those psychoanalysts who understand the 12 steps, in my opinion, are able to provide real help in this direction.

In conclusion, I want to say that the fear and prejudice that exists in our society regarding chemical.addicts in general and representatives of the 12 steps in particular, only enhance the development of alcoholism and drug addiction, although personally I am rather optimistic in this regard: everything is changing, over the past 20 years in St. Petersburg alone there have appeared about 15 known and registered in the world community of NA groups, approximately 25 groups AA and Al-Anon. People remain sober for years, for those I know personally, the terms of sobriety reach 15 years, and at the same time, none of them live worse or, at least, the same way. The 12 steps has become a phenomenon that you may not know about, but you can know, and this knowledge gives interesting perspectives.