During the twenty years that I have worked with people with drug problems; my conviction has grown that psychoanalytic thinking about these issues offers the most powerful framework for helping people address them.

A psychoanalytic perspective sees an understanding of the total person as relevant to one's personal difficulties and the treatment process: needs, feelings, self-image, expectations of others, ideals, strengths, vulnerabilities, interpersonal skills, judgments, coping skills, and environmental factors.

Based on this, psychoanalytic treatments are thoroughly individualized treatments. Thus, psychoanalytically informed treatments can vary widely in their appearance from the classical four- to five-times-per-week psychoanalysis to once weekly, behaviorally oriented therapy, and everything in between, depending on the needs of the client.

This individualizing of the treatment process, the emphasis in matching the treatment to the needs of the client, and the primacy placed on the therapeutic relationship as anchor in the process and area for exploration of the issues are all in accordance with the framework of harm reduction.

The treatments described in the stories in this book all have psychoanalytic elements. The variety in the stories reveals the diversity of forms that psychoanalytic psychotherapy can take.

Yet all share the commitment to the central psychoanalytic idea that problematic drug use reflects personal meanings that are not fully in the user's awareness and that the process of bringing these meanings more fully into awareness opens up possibilities for positive change.

BRIEF OVERVIEW OF PSYCHOANALYSIS

Since Freud established psychoanalysis at the turn of the twentieth century , many different schools of psychoanalytic thought have evolved, each emphasizing different elements in its theories of human functioning or therapy.

The thread that runs through the variety of psychoanalytic approaches that currently exist is the idea that human behavior is shaped and driven by a number of different elements within each individual that are personally meaningful and that a conscious awareness of these meaningful elements increases our possibilities for greater choice and freedom in our lives.

This perspective begins in the late 1890s with what is to me the most important of Sigmund Freud's {1895) contributions to understanding of human suffering: his discovery of what he called the "dynamic unconscious."

Simply put, he proposed that there are forces-dynamics-partially outside of our awareness, that motivate our behavior:' By forces he meant needs, wishes, judgments, and beliefs. In short, he discovered a hidden dimension of personal meaning within human behavior.

Further, he suggested that these forces are kept out of our awareness by another part of the mind, another force called "ego defenses," because they are threatening to us and cause anxiety, guilt, or shame. The anxiety-provoking threat leads to various defensive ways of keeping these aspects of ourselves out of awareness.

The defenses also operate out of awareness. As long as these dynamics remain outside of awareness we are relatively powerless over them. Their ability to push us into compulsive or impulsive behavior gives rise to intense inner pressures and creates painful feelings of anxiety, guilt, shame, and despair, all for no apparent reason.

Following this idea, psychoanalytic treatments then generally have the goal of helping people to become more consciously aware of these inner motivations and ...

.......I selected Mark Sehl's story of Mrs. G. to illustrate the topic of this chapter because it describes a psychoanalytic treatment that breaks many of the traditional ideas about what psychoanalysis is and challenges the myth of the passive uninvolved analyst. Yet it remains true to the psychoanalytic project of uncovering the hidden meanings of the patient's alcohol problems and, in this case, leads to a stable abstinence.

It is the story of an elderly woman who suffered from severe "alcoholic" drinking and depression. Using a psychoanalytic harm reduction approach that initially accepted Mrs. G.'s drinking, the treatment led to her stopping drinking, a lifting of her depression, and a general improvement in her health and quality of life. Sehl used an approach informed by the school of modern psychoanalysis, founded by Hyman Spotnitz (1985).

Mrs. G.: One Woman's Struggle for Dignity by Mark Sehl

When I first met Mrs. G. she was literally lying in her urine, saying she didn't want to go on living any longer. She wasn't eating, the apartment smelled, and neighbors were complaining of the odor. Mrs. G. told me that she couldn't walk because she had fallen and broken a hip while she was intoxicated. The patient said she was just a social drinker and complained that the home attendants were refusing to let her have any more to drink.

Mrs. G. said that she had two cocktails a day, while to make sure l understood the point the home attendant was shaking the empty quart of scotch behind the patient's back. I said to Mrs. G. that on the one hand she seemed not to be concerned about her drinking, but on the other hand she was telling me she hurt herself badly due to drinking. I was hoping she I could grasp the contradictions in her statements.

It is important to understand some of the events that led up to Mrs. G.'s deterioration. This 83-year-old woman came to the attention of the agency several years before I began my employment there. A concerned friend referred Mrs. G. for help. At that time, Mrs. G. required home care assistance due to her inability to care for herself after a hip operation. There was a passing mention of alcohol consumption on the intake form.

Several months later Mrs. G. was hospitalized for severe depression. The precipitating event was the loss of her dog. The evaluating psychiatrist diagnosed the situation as severe reactive depression with alcohol habituation and suicidal ideas.

He recommended treatment for the depression, control of alcoholism, psychotherapy and antidepressant drugs, and coordination of health care and social rehabilitation. Mrs. G. was assigned shopping and home attendant services by the agency, but as far as I could ascertain, neither psycho- therapy nor consultation regarding alcoholism treatment was ever mentioned in the record.

Not long after her return home Mrs. G. was ambulating badly, had swollen legs, refused to leave her home, and was combining high doses of aspirin with alcohol. By the following year, the patient had completely deteriorated. In other words, within one year the client was almost non-ambulatory. The agency terminated shopping and home care services because the patient was now on Medicaid, which provided daily home attendant care.

Three years later the same family friend contacted the agency again complaining that home attendants were going home early. In addition, she was concerned .......

Psychotherapy managed to stabilize this client's life. She did not have a drink in fourteen months. Instead of a thirst for liquor, she became in her words "people hungry ." She progressed from a state of self-absorption to having a desire to be more connected to people. In her words, "it's not so good to be so used to being alone. "

Mrs. G. was able to walk on her own, had a nutritious balanced diet, and developed a more satisfying relationship with the home attendants. In many ways she regained her sense of pride and self-worth.

Countertransference is a very useful tool in understanding ourselves and our clients. The therapist needs to be aware of attitudes and reactions that can interfere with the treatment-reactions such as having too much invested in the success of the treatment.

Also, there is a tendency to infantilize older adults because of their more helpless and dependent state. I have experienced professionals who, on their first meeting, automatically address older adults by their first names when they would not normally do this with a younger adult population.

This treatment was successful because I accepted the patient's expression of angry feelings. If I needed only to feel successful or was threatened by negative, critical feelings, I might not have been able to tolerate Mrs. G.'s angry feelings. Mrs. G.'s ability to be angry at me, the one she depended upon, served to lift 'her depression, and it helped to foster a sense of identity and inner strength.

It is important to remember that Mrs. G. had experienced a number of losses in her life- three husbands, her sisters, and her dog. It was the loss of her dog that triggered one hospitalization for depression. She felt vulnerable to the expectation of losing me if she did something she felt I wouldn't like. Mrs. G. did mention that her parents were very strict, controlling, and impatient with her.

One might hypothesize that as a child Mrs. G.'s expression of negative feelings or misbehavior was met with punishment and/ or abandonment. Framed in the context of fear of punishment and vulnerability to loss, it was essential that Mrs. G. find a place to experience being able to be angry at someone upon whom she felt dependent and survive. When this capacity is not achieved within the safety of the client-therapist relationship, the self- attacks and self-depreciation related to depression and low self -esteem may remain unchanged.

Mrs. G. benefited from professional therapeutic intervention because the funds and professional expertise were in place at that time in that agency.

As a result, Mrs. G.'s condition improved remarkably. She stopped drinking. As a consequence, her incontinence diminished and she was able to regain her appetite. She could walk again, freeing her up to leave her apartment for the first time in two years.

She became people hungry. Above all instead of feeling ashamed and hopeless, Mrs. G. regained her dignity and self-respect.

> From Chapter 2 of the book Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, by Andrew Tatarsky.