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Symposium on clinical judgment in relational psychoanalysis: The problem of technique. Introduction
(2002)
A view of chronic drug use that draws on central assumptions in relational theory is proposed. Namely, chronic substance use is seen as being driven by conflicting and unresolved relational dynamics that derive from the early organizing relationships in a person's life. In the case of the substance user, the terms of this conflict find concrete expression in characteristic acts of drug use that serve to perpetuate it through the combined effects of reinforcement and disguise. The goal of treatment is for patient and therapist to find the components of the relational bind that are embedded in the drug use, to reformulate these forces in symbolic terms, and to revisit them in the dynamics of the transference, alongside opportunities for new exchange. Seen this way, the treatment needs of substance users can best be met by a relational model of psychoanalysis, augmented by other approaches needed to address addiction. In particular, the relational emphasis on the role of enactment as a vehicle for the expression of unsymbolized experience, and therefore the source of the phenomena to be analyzed and understood, makes this model especially well suited to substance-using people.
In my. Reply to commentaries by Glen Gabbard and Mark Gerald I offer further views on the implications of an integrative approach to treatment of substance-using patients, and the role of countertransference in that approach. I also address the phenomenon of >leverage,< examined by Gerald for the particular role it plays in the treatment of chronic drug use. I consider the use of leverage within the context of discussing the broader therapeutic effort to help substance-using patients achieve integration.