ISTDP and Addictions

“Can you do a post on using ISTDP with addictions clients? I work at a private in-patient addictions center. Although addicts vary a lot in their traumatic history and attachment problems, they consistently are unable to sit with their emotional experience. The addiction almost always boils down to a powerful avoidance of the self. It can be difficult to work experientially because withdrawal states compound anxiety greatly. Mindfulness, breath work, IFS, and focusing can work wonders in many people. Another constant is a powerful superego. ISTDP’s emphasis on staying with the alliance and the client’s will has helped me a lot. I mistakenly thought I could go where I wanted as long as I was very empathic. But empathy doesn’t work unless the alliance is formed and maintained. Thank you for any help in using ISTDP for addictions.” Thanks to one of our community members from Maryland for this question!

If we leave the medical aspects of addiction to the side, let’s focus on the psychological treatment of people who suffer from addictions. First of all, the triangle of conflict is this: they experience feelings; feelings trigger high levels of anxiety; and, among their defenses, they use drugs to numb away their feelings and anxiety.

Their low affect tolerance manifests in behaviors: impulsive speech, acting out, racing speech. These are, of course, regressive defenses. In session, the patient may impulsively speak over you as soon as she has a feeling. The patient, having difficulty tolerating his feeling, may stand up from his chair and walk around the room. As soon as the patient has a feeling, he becomes anxious, and his speech starts racing.

Their low affect tolerance also is manifest in their defenses: projection, denial, and splitting. A patient who sees that he has a problem suddenly projects, asking, “Do you think that’s a problem?” Or he sees a problem, becomes anxious, and uses the defense of denial, “Yeah, I use drugs, but that’s not causing any problems on my job.” Or he sees a problem, becomes anxious, and then uses the defense of splitting. “I could have a problem with drugs, but who knows? I don’t know. You’re the expert on this!”

When regressive defenses of racing speech, acting out, impulsive speech, projection, denial, and splitting do not work sufficiently to help the patient avoid the experience of his feelings and anxiety, he will use drugs to numb away his feelings and anxiety.

Unless we help the patient learn to bear his feelings and regulate his anxiety, his risk for relapse into drug addiction will remain high. It is easy to judge these patients for being unable to sit with their experience. But we must remember that their experience of anxiety is often extremely high and would be unbearable for anyone. That’s why anxiety identification and regulation is essential for this group of patients. You can see how to do that in my DVD of the Fragile Patient on my website

Getting started can be hard with these patients. Why? Forming a relationship triggers high levels of feeling and anxiety which they have trouble bearing. Thus, to avoid those feelings they often start by denying that they have a problem, or they project that someone else thinks they have a problem. If they have no problem, they have no need to depend upon you. Thus, no feelings arise over depending on you.

Th: What’s the problem you would like me to help you with?

Pt: I don’t have a problem. [Denial]

Th: And yet you are here. [Note the contradiction between what he says (no problem) and does (comes to a therapist’s office)]

Pt: Well the rehabilitation people thought I should be here. [Projection]

Th: They may have thought it was a good idea for you to come [Block projection], but we still don’t know why you came.

Pt: I don’t know. Things are going great. [Denial]

Th: That’s wonderful. [Mirror denial]

Pt: [fidgets in chair] What do you think I should work on? [Projection]

Th: I have no idea. [Block projection] It may be you don’t have a problem. [Mirror denial]

Pt: That’s what I think. [Denial]

Th: That’s a wonderful position to be in. [Mirror denial]


Maintain your stance until the patient reveals a problem to work on. This could take as long as an hour. My forthcoming video of the addict who claimed he had no problem shows how I work with a patient for fifty-one minutes before he admits to having a problem! There is no rush. Do not push the patient to admit to a problem. If you confront the addict, his feelings and anxiety will rise, often leading to acting out and risk of relapse. Instead, patiently stay where he is, mirroring his denial and blocking his projections. Eventually, the problem will emerge.


Next, we find out whether it is his will to work on the problem. After all, just because he has a problem doesn’t mean he wants to work on it with you!


Pt: Yeah, the drugs are a problem, but that’s not something I want to work on with you. [Denial of will to work on the problem]

Th: Ok. [Pause for the patient’s response. His anxiety will rise as he begins to realize that you won’t argue, as he begins to realize that you will explore nothing unless it is his will to do so.]

Pt: Ok, what?

Th: If you don’t want to work on your problem, you don’t have to. It’s your life and your decision. [Blocking the projection that you are going to force him to look at something he does not want to look at.]

Pt: But aren’t you supposed to dig? [Projection of will onto the therapist]

Th: No. That’s not my job. If you want to dig within yourself and reveal what you’ve dug up so we can help you with what’s inside of you, we can do that. But if there’s digging to be done, only you can dig in you. That’s not something I have the right to do. [Blocking projection]

Pt: But aren’t we supposed to dig? [Projection]

Th: It’s not a matter of what we are supposed to do. The question is: what do you want to do? And you may not want to dig within yourself. You may not want to work on this problem. [Block projection]


Again, keep blocking the projection of will until the patient decides that it is his will to work on his problem with you. Don’t move forward unless the patient wants to move forward. His problem, his decision.


Once he decides it is his will to work on his problem, you can move forward. However, once you do so, the patient may become overwhelmed with anxiety. Then we use the graded approach and anxiety regulation, which you have read about in my book, Co-Creating Change: Effective Dynamic Therapy Techniques.


With addicts there are a few special techniques that can be extremely important. For them, feelings and anxiety rise very rapidly. When this happens, patients can move to projection within a few seconds, leading to a misalliance. As soon as you see a sign of anxiety in the patient, intervene. Intervene before the patient goes to the next sentence and defense. Intervene before the “fire” gets worse. As soon as you see a sign of anxiety, ask: “Are you aware of feeling anxious right now?” As soon as the patient says yes, interrupt and ask: “Where are you feeling the anxiety in your body right now?” Block all defenses and projections to keep the patient’s attention focused on the experience of anxiety. The patient will be able to bear the physical sensations alone if you block all the defenses and projections. If the patient keeps talking, the defenses and projections will worsen the experience of anxiety making it unbearable. Thus, your rapid blocking of defenses will help the patient keep his attention focused on the physical sensations of anxiety.


If his anxiety does not come down within a few minutes, his projections are probably sustaining the projective anxiety. Thus, find out what projections the patient is using that make him afraid of you (projective anxiety). Then restructure those projections and anxiety should finally drop. Remember: your empathy will not help if the patient is in relation to a projection instead of you. If he is in a misalliance with a projection, he will experience your empathy as your attempt to trick him into trusting you. It’s not enough that you are empathic; the patient must first be in relation to you.

This post got long quickly. Next time we’ll talk about superego pathology and the secret addiction, which drugs merely cover.








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