ISTDP and Addictions II

What do we mean by the superego in drug addiction? Is it just that the patient has an internal judge? Is it that he is too harsh on himself? It’s more complicated. The superego is really a bunch of memories of early relationships. We can enact those memories in three ways.

Let’s suppose the addict had a harsh, rejecting mother who beat him severely. He has a bunch of memories of that relationship. The patient can enact that early relationship with his drug counselor in three ways.

1)    He judges himself harshly in session.

2)    He fears that you, other people in recovery, or the staff will judge him harshly.

3)    He judges you, the other people in recovery, and the staff harshly.

Many addicted people suffer from severely unregulated anxiety that leads to projection and regression. Their drug use may be a form a severe self-punishment. In treatment, they may project that others judge them. Believing these projections, they get into fights and arguments with the supposed “judges.” Or they may shift and judge others harshly as if to say: “I can see you are going to judge me, so I’ll take the initiative and judge you first!”

The frequency of projection on staff and fellow addicts in recovery can make treatment impossible. Thus, any therapist working with this group must identify projections and restructure them. Otherwise, the patient will remain suspicious of fellow addicts and the recovery staff as potential judges. In my book, Co-Creating Change, you can read about how to restructure projections.

Many addicts can look as if they are highly resistant, claiming to have no problem, refusing to engage in therapy, claiming that they were sent by someone else, or asserting that they have no need for therapy of any kind. However, it is important to assess whether the patient is indeed a highly resistant patient with a neurotic character structure or a fragile patient with a fragile character structure. Otherwise, therapists may mistakenly challenge these patients, leading to misalliances and ruptures in treatment.

The highly resistant patient with a neurotic character structure will claim to have no problem and no need for therapy. As you mirror his denial, you will see his anxiety show up in his striated muscles. As you persist, he will move from denial to defenses such as vagueness, intellectualization, and rationalization. In other words, he will use repressive and tactical defenses. As you continue to explore with him, his defenses will form a kind of wall where he remains detached, passive, and uninvolved.

The seemingly high resistant patient with a fragile character structure will also claim to have no problem and no need to therapy. However, as you mirror his denial, you will find that he uses denial, projection, projective identification, and splitting as his primary defenses. In other words, he uses regressive defenses. Since he projects a great deal, you may not see any access to striated muscles. At the slightest rise of feeling and anxiety, he projects, preventing any rise in feeling. As you block his projections, his anxiety will rise, but then he will resort to regressive defenses such as more projection, splitting, projective identification, and acting out. As you continue to deactivate his denial, projection of awareness and will, and projective identification, you will often find an underlying paranoid transference where he fears you will attack him. Then you must restructure that underlying projection to establish finally a therapeutic alliance.


In the highly resistant patient with a neurotic character structure, the repressive and tactical defenses function as a “wall” to ward off feelings toward the therapist. In the seemingly high resistant patient with fragile character structure, regressive defenses create a “wall” to ward of an underlying projection.


In the highly resistant patient with neurotic character structure, we ask for feelings toward the therapist in order to facilitate a breakthrough to the unconscious. His tolerance of feelings is very high. In the seemingly high resistant patient with fragile character structure, any rise of feelings leads to projection. The patient cannot tolerate a rise of feelings that would lead to breakthrough. Thus, the therapist must restructure the patient’s regressive defenses and build his affect tolerance so he can tolerate his feelings without using regressive defenses. Once he can do that, then the therapist can use the graded format to build the patient’s capacity higher and higher until he can tolerate a breakthrough to unconscious feelings.


With the highly resistant patient with neurotic character structure, we can clarify and challenge defenses and confront the destructiveness of his defenses. With the seemingly resistant patient with fragile character structure, challenge is contraindicated because the sharp rise of feelings that would result would lead to more projection and then acting out on the basis of those projections. Instead, the therapist must mirror denial, mirror splitting, and block projections until the underlying projection emerges. Restructure the underlying projection of the paranoid transference, and then establish a conscious therapeutic alliance. Then continue to use the graded format, using inviting feeling and clarifying the function and prices of the defenses to build the patient’s capacity to tolerate the experience of his feelings.


The tragedy of much work with addicted patients is that the failure to assess the underlying character structure that creates the picture of “resistance” leads to premature challenge, projection, misalliances, and treatment failures. My next DVD for sale on the ISTDP Institute website will be of such a patient. On that DVD you will be able to see how we work with fragile character structure in a patient with a paranoid personality disorder. In the meantime, always assess the pathways of anxiety discharge and the types of defenses the patient uses so that you can choose the type of treatment most appropriate for the patient in front of you.






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