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Narcotic addiction and family process: Death wish or countertransference
Journal of Substance Abuse Treatment, Printed in the USA. All rights reserved.
ORIGINAL
Vol. 4,
0740.5472/87$3.00 + .OO Copyright 0 1987Pergamon Journals Ltd
pp. 29-36, 1987
CONTRIBUTION
Narcotic Addiction and Family Process: Death Wish or Countertransference
FELICITY NEWBRO TURNER, MA AND LYNNE SALTZ, MA North
Charles
Institute
for the Addictions, Affiliated with Department of Psychiatry, A Program of the Cambridge Hospital, Lesley College
Harvard
Medical
School
Abstract - This article critically examines the literature which suggests that families of narcotic addicts push their addicted member toward death. Following an overview of the conventional literature on the family treatment of drug addiction, an alternative perspective is proposed to more fully understand how these families are preoccupied with death. The “suicide-like” quality of addiction is probed both in terms of the intention to die and the countertransference possibilities. The notion of a family “death wish” has the potential to be misinterpreted by the countertransference response of an unseasoned treatment provider. Clinicians are cautioned that this notion can be a potential threat to the patient’s life. Implications are presented for the supervision of the family treatment of narcotic addiction. Keywords-Addiction,
countertransference,
family therapy,
grief, suicide,
supervision.
man & Stanton, 1978; Stanton et al., 1982). More specifically, the family unconsciously wishes the addict to die so that it can use the addict’s death to reenact the deaths of other significant family members. The addict symbolically becomes a martyr whose death permits the family an opportunity to vicariously master its unresolved grief (Coleman, 1975). This article will suggest that the unconscious wish in these families for the narcotic addict to die (Stanton et al., 1982) must be understood to be an ambivalent wish. Accompanying a review of the literature of family treatment of addiction, this paper will suggest an alternative explanation for the observed systemic preoccupation with death themes. As Marris (1971) demonstrated, a preoccupation with death, even to the extent of suicidal gestures, is not always linked with the wish to die. Furthermore, this paper suggests that the high level of anxiety treatment providers experience in working with narcotic addicts (Stanton et al., 1982; Vaillant, 1981) can also lead to a dangerous conception of the family’s wish to see the addict dead. For example, clinicians working with suicidal patients (Maltsberger & Buie, 1974) have reported that stress can lead the treatment provider to the misconception that the patient
INTRODUCTION PRACTICE OFTEN FOLLOWS THEORY; however, many of the therapeutic techniques for treating families of narcotic addicts have come before theory building. Recently accumulating clinical impressions have generated certain hypotheses regarding the treatment of addictions that require further consideration. Several theorists (Boszormenyi-Nagy & Spark, 1973; Coleman & Stanton, 1978; Noone & Reddig, 1976) have proposed that an unresolved grieving process in families is responsible for pathological homeostasis. As an outgrowth of this explanation of family pathology, Stanton and his colleagues have proposed that families of narcotic addicts purposefully push the addict toward death in an attempt to resolve grief. Support for this notion has been based on the clinical impression that often such families are preoccupied with death (Cole-
Special thanks are extended to Howard Shaffer without whose encouragement and suggestions this paper would not have been written. Requests for reprints should be sent to Lynne Saltz, MA, North Charles Institute for the Addictions, 260 Beacon Street, Somerville, MA 02143.
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F. Newbro
really wants to die and perhaps should die. The danger in the toxic therapeutic relationship is that a patient may be pushed into a fatal attempt. Similarly, we suggest the notion that families want to see an addieted member die can be the result of countertransference rather than a pragmatic understanding of the families’ homeostasis; we caution that this is a potentially dangerous notion. A revised understanding of the attendant anxiety in the treatment of narcotic addicts and their families can facilitate an enlightened perspective for the supervision of this work. We propose that a “chaining effect” (Mueller & Kell, 1972) is likely to affect four levels of the process: (1) the family manages its anxiety by considering the possibility of death, (2) the therapist takes on the anxiety and endorses the inevitability of the lost life, and (3) the supervision accepts the fatalistic attitude, thereby giving the final seal of approval to the addict’s death. When the process reaches a fourth level-(4) that of the patients’ giving up on themselves-the danger of a fatality is magnified. The seasoned supervisor who recognizes this parallel process by its emotional charge (Searles, 1955) is able to turn the process around. Thereby, the potentially dangerous situation becomes a rich source of information for the astute clinician. Through a review of the literature this article addresses family systems theory as it relates to treating narcotic addiction, and the effects of countertransference on the treatment. The final section sets forth the clinical implications for supervision and describes the chaining effect.
FAMILY SYSTEMS THEORY NARCOTIC ADDICTION
AND
As family treatment for addictive behaviors gained conceptual acceptance, clinicians increasingly prescribed family therapy for treatment of narcotic addiction (Alexander & Dibb, 1977; Klagsbrun & Davis, 1977; Noone & Reddig, 1976; Stanton et al., 1978). This approach to treatment is conceptually similar to that presented by Haley (1973) for schizophrenics; “identified patients” help keep their families together by allowing the members to unite over their incapacitation. For example, an unstable dyadic relationship of the parents alone is stabilized by a move toward a triadic relationship consisting of the parents and the addict. An addict who begins to succeed-either at work, socially or in terms of drug use-is becoming less dependent on the family. At this point, crisis is likely to occur in the family. Tensions may arise between the parents, an illness may occur in the family or difficulties may develop with a sibling. The development of these difficulties suggests that not only does the addict fear separation but so does the family.
Resistance
Turner and L. Saltz
to lndividuation
The narcotic addict is often part of an enmeshed family. In a study comparing mothers of adolescent drug addicts to mothers of adolescent schizophrenics and mothers of “normal” adolescents, Attardo (1965) retrespectively measured the mothers’ “propensity for symbiotic relating.” All the mothers had relatively similar levels of “symbiotic needs” for the first five years of the child’s life; later the needs of the “normal” mother decreased while the “symbiotic needs” of the drug abusers’ mothers remained the highest of the three groups-higher than those of the mothers of schizophrenics Resistance to individuation in a narcotic addict’s family is highlighted by the likelihood that the future addict first became a behavior problem for the family during adolescence, a time when the addict would otherwise have begun to separate (Seldin, 1972; Wurmser, 1974). Another often observed phenomenon is that a majority of narcotic addicts live at home or are in frequent contact with their families of origin well into their 20’s and 30’s (Bale, Cabrera, & Brown, 1977; Chein, Gerard, Lee, & Rosenfeld, 1964; Ellinwood, Smith, & Vaillant, 1966; Goldstein, Abbott, Paige, Sobel, & Soto, 1977; Noone 8~ Reddig, 1976; Stanton et al., 1982; Vaillant, 1966). “Heroin provides a solution at several levels to the dilemma of whether or not to allow him independence. Paradoxically, it permits him to simultaneously be close and distant, ‘in’ and ‘out’, competent and incompetent, relative to his family of origin. This is ‘pseudoindividuation’” (Stanton et al., 1978, p. 125). Narcotic addiction can be a partial solution for a family having difficulty separating. The aggression often observed in addicts’ interactions with their parents allows the addict an illusion of individuation (Ganger and Shugart, 1966; Stanton et al., 1978). A drug seeking lifestyle offers the addict a peer group, thereby providing the feeling of being individuated from the family. However, these peer relations often keep the addict dependent on the family because they reinforce the addiction. Furthermore, conjugal liaisons, which might help addicts individuate from their families, are often less meaningful to the addict than the relationships with their parents. The rate of marriage for male addicts is half of what would be expected and the rate of multiple marriages for both sexes is above average (Stanton et al., 1978). Pathological
Homeostasis
One explanation for a family’s inability to separate lies in the notion of the uncompleted life cycle. Symptoms appear when there is an interruption in the unfolding life style of a family (Haley, 1973). These families are rigid, inflexible, and resistant to change. They may
31
Death Wish or Countertransference not complete a life cycle if, at a particular developmental stage, they are unable to negotiate the tasks required by that stage. For example, a family can be stuck in working through the stages of a grieving process. Family pathology has been conceptualized as maintained for the purpose of handling previous losses (Boszormenyi-Nagy & Spark, 1973; Paul & Grosser, 1965). Symbiotic transactions in families amount to a mechanism capable of preventing awareness of losses to any individual member. One aim of a symbiotic family organization is the prevention of threatened separation. Families with rigid defenses against separation are warding off a loss that has already occurred (Paul & Grosser, 1965). The first phase of mourning has been called “the urge to recover the lost object” (Bowlby, 1961) and the “denial” phase (Kubler-Ross, 1975). Regardless of how long ago the loss occurred, these families are developmentally stuck in this first phase of the mourning process. They attempt to deny or ward off the previous loss and to “recover” the loss by preventing individuation. Theorists have found that this explanation of pathological homeostasis as due to an uncompleted mourning process suits the family of the narcotic addict particularly well. Both (a) the predominance of death themes observed in clinical work (Coleman, 1978; Noone & Reddig, 1976; Reilly, 1976; Stanton et al., 1982) and (b) the tendency for families to resist individuation (Alexander & Dibb, 1975; Klagsbrun & Davis, 1977; Noone & Reddig, 1976; Stanton et al., 1978) have been well documented.
High Rates of Interpersonal
Losses
The likelihood that families of narcotic addicts are unable to separate because of an incomplete grieving process is supported by the data reflecting their high rates of interpersonal loss. For example, these are families often strained by marital tensions. Families of addicts are more likely to be cut off from their cultural context by virtue of having moved long distances or emigrated (Vaillant, 1973). Addicts are also likely to have had an emotionally distant parent (Chein et al. 1964, Stanton et al., 1982; Vaillant, 1981); there is a higher than average likelihood that these individuals had a substance abusing parent (Alexander & Dibb, 1975; Stanton, 1978); they are likely to have had one absent parent (Alexander & Dibb, 1975; Klagsbrun & Davis, 1977) or a parent who died before the future addict was 16 years old (Coleman & Stanton, 1978; Klagsbrun & Davis, 1977; Stanton et al., 1978) and the rate of early death of paternal grandfather is higher than expected (Stanton et al., 1978). Finally, an association exists between time of initial drug use and an important death in the family (Stanton et al., 1978).
Clinical
Implications
In the case of the family of the narcotic addict, an uncompleted life cycle is likely to be one of grieving (Coleman & Stanton, 1978). For instance, if the parents have chosen the addict to symbolically replace a deceased grandparent a family injunction exists not to repeat the loss. Therefore, the family does not allow the addict to individuate (Reilly, 1976), or grandparents may not allow the parents to succeed at marriage because they cannot stand the loss of their child to a spouse (Stanton, 1978). Such families are seen as unable to express affection due to impaired mourning (Reilly, 1976). Because the parental system is unstable, a lethal symptom is created to focus upon. An unstable dyad draws in a third leg of a stabilizing triangle. When a family is stuck in a developmental stage and drug abuse becomes an indicator of impasse, one of the therapist’s tasks is to clarify loyalty patterns. This may require the resolution of grief that has been transmitted through several generations (BoszormenyiNagy & Spark, 1973; Noone & Reddig, 1976).
THE THEORY OF A “FAMILY DEATH WISH” The comparison of addiction to suicide-like behavior is likely to originate from data that addicts exhibit high death rates and shorter than average life expectancies (Ferguson, Lennox, & Lettieri, 1974; O’Donnell, 1964; Stanton et al., 1978). The notion is not entirely new: Menninger (1938) likened addiction to “chronic suicide.” Currently systems theorists, interpreting the fascination with death that these families exhibit (Coleman & Stanton, 1978; Noone and Reddig, 1976; Reilly, 1976; Stanton et al., 1982), have labeled addiction a “suicidal phenomenon with a family basis” (Stanton, 1977, p. 191) and “more than a propensity for self-destruction . . . a (possibly unconscious) wish for death” (Coleman & Stanton, 1978, p. 80). From this perspective, if the addicted child dies a drug-related death, the family system is still preserved. The mother of a dead addict “only feels capable of expressing her ‘love’ for her addicted [son] while standing over his grave. If he dies, it is as if she can have him forever without the fear of losing him to others” (Stanton, 1977, p. 192). The parent remains obsessed with the dead child. If an addicted family member dies, the surviving members are able to refrain from dealing with other areas of life and remain focused on the addict as before. The idea that families promote suicide can hold the potential for dramatic and deleterious effects on treatment if it is misinterpreted. While suicide and addiction have some common characteristics, the comparison of addiction to suicide has the potential to be dangerous unless the similarities are carefully considered.
F. Newbro Turner and L. Saltz
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SUICIDAL BEHAVIOR
REFRAMED
The concept that “drugs are alternative to or an equivalent of suicide” (Stanton, 1977) would possess more meaning in light of an examination of what suicide attempts indicate about intention to die. Marris (1971) noted that very different patterns of behavior exist between females who actually suicide and those who “gesture,” the latter evidencing a will to live. Marris’ (197 1) examination of suicide attempts by women revealed that a significant number of his subjects did not intend to end their lives but rather to preserve them. Suicide gestures and drug addiction can be reframed as ego-defenses or coping mechanisms (Marris, 1971). Suicide gestures may be self-preservative as they are gestures of autonomy and can function as alternatives to completed suicide. “Deviant behaviors” (e.g., sexual deviance, drug addiction, and suicide) are found to help manage feelings of inadequacy, loneliness and depression. Furthermore, these deviant behaviors are found to be women’s attempts at cutting themselves off from pathological families of origin (Marris, 1971). This perspective does not minimize the inherent danger: (1) gestures are not easily distinguished from the intent to die and (2) miscalculated gestures easily result in death. However, while gestures can prove fatal, it is pragmatic to understand that the motivation and intention for these acts are those of problem solving. Similarly, our thesis recognizes symptoms such as drug abuse as not necessarily the “slow form of self destruction” it is frequently thought to be, but rather possibly therapeutic. While it may be difficult to conceptualize potentially fatal symptoms as methods of managing survival, these symptoms are, to some degree, coping mechanisms. If, in fact, the “self destructive” nature of drug addiction has a “suicidal” quality, the similarity is likely to be in the style of ego-defenses. For example, a heroin addict’s “self-destructive” behavior may be the attempt at differentiation and separation from a pathological family system, rather than a statement of wanting to die. As discussed above, opiate addiction is an attempt at individuation, ‘pseudoindividuation’ (Stanton et al., 1978), or an attempt by the addicted person to cut off from a pathological family. This ‘pseudoindividuation’ quality of addictive behavior is identical to the attempt to be cut off from a pathological family evidenced by suicidal behavior. Therefore addictive behavior is legitimately “suicide-like.” Both addiction and suicide are a move toward autonomy. Both can be seen as desperate attempts at survival. However, neither are profitably understood as unambivalent attempts to die. It is not possible to overemphasize our point that this perspective is not intended to minimize the dangerousness of these “coping mechanisms.” Just as it is
difficult to assess when a suicide gesture becomes a serious intent to die, it is extremely difficult to sort out the ambivalence of a family with the suicidal symptom of narcotic addiction. This ambivalent systemic “coping style” is likely to result in a death. Many narcotic addicts die, From the perspective of this article, another important “suicide-like” quality of addiction is the effect of the attendant anxiety on the treatment provider. Both addicted patients and suicidal patients are likely to cause countertransference anxiety. COUNTERTRANSFERENCE IN THE TREATMENT OF THE NARCOTIC ADDICT Definitions
There is no single definition of countertransference. Classically, it is the analyst’s reaction to the patient’s transference. Contemporary theorists question whether or not countertransference is comprised of all the therapist’s feelings toward a patient or only the irrational feelings. Does it constitute conscious feelings, unconscious feelings, or both? Is countertransference the emotional reactions experienced inside or outside the therapeutic relationship? Is the countertransference evoked by events in the therapist’s personal life, or is it a result of an interaction with the patient? It is beyond the scope of this paper to attempt a resolution of this controversy. The essential point is that: in working with certain populations such as narcotic addicts and suicidal patients, there is a strong likelihood for the treatment provider to experience certain degrees of anxiety. For the purposes of this discussion, countertransference will be considered as the therapist’s emotional reaction to the tensions in the addict, the addict’s family, and the potential risk of the patient’s death. It may be conscious and/or unconscious. Within the context of this definition these emotional responses may be a result of (1) events in the therapist’s personal history, (2) a cultural abhorrence of suicide, or (3) a reaction to the tensions present in the patients and their families. Our attention focuses on the latter of the three. Countertransference in the Treatment of the Suicidal Patient
Because both addicted and suicidal patients threaten the treatment provider with the possibility of death, the level of countertransference anxiety is likely to be high. Maltsberger and Buie (1974) point out that in many suicidal patients, a “transference onslaught” will ensue which will eventually stir up countertransference hate. Maltsberger and Buie describe a transference hate that “relates to a deep sense of abandonment
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Death Wish or Countertransference (or expectation thereof), an intense craving for, yet horror of, closeness” (p. 625) which leads these patients to act in ways that elicit frustration. If the therapist can manage the relationship appropriately and with interest, the patients can learn to manage their own craving and rage. The countertransference hate will be manifest in feelings of malice and aversion. This countertransference can be either usefully or deleteriously managed. “Aversion” is most dangerous because it tempts us to give up the case an consider the patient “hopeless.” It is then that a suicide is likely to be precipitated (Maltsberger & Buie, 1974).
Countertransference
Hate
Our humanity is our instrument. Therapists, as humans, experience every range of emotion including hate and anxiety. Winnicott (1949) suggested, “However much he loves his patients he cannot avoid hating them, and fearing them, and the better he knows this the less will hate and fear be the motive determining what he does to his patients” (p. 69). In his opinion the more regressed a patient is and the more the patient confuses love and hate, the more important it becomes that therapists can tolerate their own capacity for hate. “If the analyst is going to have crude feelings imputed to him, he is best forewarned and so forearmed” (p. 70). Winnicott discussed a patient that he found “almost loathsome . . . until the analysis turned a corner and the patient became loveable, and then I realized that his unlikableness had been an active symptom, unconsciously determined” (p. 70). Similarly, the narcotic addict possesses the capacity to cause anxiety and rage; a seasoned treatment provider can understand the frustration and fury as a clue toward understanding the patient’s way of being in the world. Therefore, the rage becomes information which is a useful tool for negotiating the ongoing treatment.
The “Transference Onslaught” of the Addicted Patient Drug addicts exhibit various anxiety provoking behaviors which are familiar to the treatment provider: alternating between overvaluing and devaluing the therapist; staff splitting; seductive and destructive behavior; struggling about treatment contracts, rules and drugs; convincing the therapist to take responsibility for their drug use; “spilling anxiety,” that is, rushing in with a problem that needs an “immediate solution”; making apparent progress and then backsliding; and threatening their health and life. Unmonitored countertransference can result in treatment based on retribution or abhorrence. Punitive control struggles or giving up the case illustrate such destructive possibilities. In attempting to manage these behaviors so that
the addicts will begin to bear their own anxiety, the therapists are also managing their own responses. Countertransference
Anxiety
Cohen (1955) constructed a definition of countertransference to express what is common to most definitions: “the presence of anxiety in the therapist-whether recognized in awareness or defended against and kept out of awareness” (p. 235). She stated further that a patient’s anxiety, particularly an aggressive patient’s anxiety, can be contagious. If this is taken to mean both those who turn aggression inward as well as those who vent it, we can include most, if not all, narcotic addicts. Furthermore, Cohen itemized several ways in which anxiety is experienced by therapists -as wounded self-esteem (because their helpful intentions are so misinterpreted), retaliatory impulses and/or “a primitive identification with the expressed feelings” (p. 239). Contagious Anxiety of Drug Addicts
in the Treatment
The sociopathic patients Vaillant (198 1) described (often narcotic addicts) are experts at letting anything or anyone else manage their anxiety. This experience is unnerving for those around them. Vaillant compared the neurotic’s defense mechanism to a pebble in their shoes: only they are made uncomfortable. On the other hand, the sociopath’s defense mechanism is like a cigar in a crowded elevator: only the possessor is comfortable while the rest suffer. (Vaillant, 1973). Because sociopaths are well defended against anxiety, it is only in the security of an enforced environment (i.e., prison or methadone program) that they begin to experience and display anxiety. In these settings sociopaths appear similar to borderline personalities (Vaillant, 1981). The therapeutic task for these patients is to begin to experience their own anxiety. Their anxiety should not be controlled or relieved by the treatment provider. The sociopath is as maltreated by too much help as by too little. The patient is served by being allowed to experience stress in the containment of a therapeutic relationship. By refusing to take responsibility for managing the patient’s anxiety the treatment provider shifts the onslaught of anxiety back to the patient. Therefore, the therapist is relieved of the anxiety before it is transformed into hostile or hurtful responses. “We take the sociopath’s defenses personally and condemn them. . . . One reason immature defenses are so taboo is because they are contagious” (Vaillant, 1981, p. 129). The risk, particularly in outpatient settings, is that being so frustrated by the sociopath’s defensive style that the therapist will become punitive. Stanton et al. (1982) aptly describe the addict’s attempt to unload anxiety:
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F. Newbro Turner and L. Saltz
Countertransference in the Treatment of Families of Narcotic Addicts
Maltsberger and Buie (1974) describe therapists’ “aversion” to their suicidal patients, deeming the patients “hopeless.” It is this “aversion” that may precipitate a death. In other words, in order to defend against the anxiety of the threatened death, the family may accept the death as inevitable. It is a defense against the anxiety caused by the enormous responsibility of preventing death. Furthermore, it is a homeostatic mechanism of an overly enmeshed system-a desperate attempt at differentiation. Families may use the crisis of a threatened death to prevent a more disastrous event such as the dissolution of the family. It is a mechanism of a poorly functioning system threatened with self-destruction which is capable of causing the destruction of its addicted member. The situation, which can escalate as loyalties are tested, can be potentially lethal. On the other hand, these systems may use their flirtation with death in the same therapeutic manner that some suicidal females attempt survival (e.g., Marris, 1971).
Stanton et al. (1982) discuss the emotional strain they experience during treatment of narcotic addict families:
Case Illustration
TODD: “I think avoiding power struggles is one of the most important problems with these cases. It is not completely unique to this population; I encounter it also with anorectics, which is another situation where the patient is always looking for a fight. Anorectics, like the narcotic addicts, are in a desperate struggle for autonomy.” (p. 361) LANDE: “The addict was continually seducing and inviting therapist into some kind of struggle-whether over methadone doses, urine results, et cetera. . . . The therapist needed to learn that in any attempt by him to confront the addict, or to manipulate him around these issues, the addict would usually win.” (p. 372).
Thus in entering a power struggle with such patients, the therapist is buying into the patient’s defensive style. Anxieties escalate and psychotherapy becomes psychonoxious.
BERGER: “I have to use the word ‘countertransference’. These families create enormous fantasies of rescue and enormous feelings of frustration in the therapist. I think it has something to do with the horrible nature of what is going on, the sort of slow suicide these men get themselves into, as well as the horrible things the addicts end up doing to their families. It is easy to become enraged at them for being so incredibly destructive. . . It can overwhelm you.” (P. 359)
Difficult emotions have often been noted by therapists treating narcotic addicts. Alexander and Dibb (1975) described their subjective experience of working with addicts and their families. “Overt anger was very rare (except for the occasional outburst of a frustrated therapist)” (p. 503). A great deal of anxiety can be experienced during work with families of addicts. When the therapist’s distress level is too high the danger is to give up on the patient. THE FAMILY’S HOMEOSTATIC MECHANISM It is our suggestion that this defense mechanism, that of giving up on the addict, can pervade all levels of the treatment process. If the therapist’s level of anxiety and rage is capable of causing him to give up on the addict, this possibility also exists for the family. The family can be managing its anxiety similar to (1) the manner in which we perceive treatment providers of narcotic addicts managing their anxiety and (2) the manner treatment providers of suicidal patients which Maltsberger and Buie (1974) suggest. The family can attempt to defend against its anxiety about a member’s potential death by accepting it as inevitable.
Reinterpreted
Vignettes in the literature (Coleman & Stanton, 1978; Stanton, 1977) proposing the concept that “the family wants the addict to die” illustrate how the family instructs the addicted member to die. Looked at from the perspective we have proposed, the vignettes can also illustrate how a family defends against the addict’s pseudo-assertive (aggressive) behavior and against the anxiety of threatened death. In a representative initial session (Stanton, 1977, p. 193), a mother is quoted as saying “But he (the addict) is just gonna do something real bad that’s gonna hurt the all of youse. I mean I don’t care about him dying believe me. Because that would be the best for him and all of us-dying like that (unclear). I’m talking about him hurting somebody else. That’s all I mean. I don’t want to hurt nobody else. Or else (him) getting stuck in jail.”
Stanton’s conceptualization is to take this mother’s statement at face value; that she is willing to see her addict son die. With their practical approach and immediate response, Stanton and his colleagues have been able to prevent many deaths. As mature clinicians they realistically appraise a family’s willingness for a member’s death. They recognize the incipient crisis and take the necessary steps to intervene forcefully. Our reframing of this mother’s situation will not be likely to impact upon the clinical behavior of experienced clinicians. Rather it is a conceptual revision that is more likely to find its use in supervision and for the therapist beginning family work with narcotic addicts. A reframing of this mother’s statement is as meaning that she has accustomed herself to the possibility of her son’s death, although she does not wish him to die. Possibly she is manifesting a defense against a
Death
35
Wish or Countertransference
consistent anxiety: the defense of anticipation, against the possibility of her son’s imminent death. Among the most painful experiences of motherhood is to outlive the child who was to be her contribution to posterity, her hope for immortality. Reconciliation of this loss is possibly beyond reconciliation of her own death. It is possible that such a mother is doing what Maltsberger and Buie (1974) caution against: she is letting her anxiety direct her to give up her son as hopeless. This mother’s decision that her son’s death is inevitable can be, in fact, the same fatalistic decision that therapists make if they lose hope for a family determined to push toward death. It is the therapist’s responsibility to help the family discover constructive means of differentiating. If, when the family has decided that the addict will eventually die, the therapist also gives up, the therapist can be buying into the family’s defensive system. The family has come to the therapist looking for new hope. If the therapist gives up on the family, the family gives up on the addict. The situation may become potentially fatal when the identified patients give up on themselves. IMPLICATIONS
FOR SUPERVISION
In the same manner that Maltsberger and Buie (1974) caution against giving up the patient as “hopeless,” we caution against a simplistic understanding of the notion that “the family of the narcotic addict wants the addict dead.” This notion can lead us toward giving up on the family and the addict. It is helpful both to examine the countertransference, and to imagine what other message the patient’s suicidal behavior is transmitting. Is it a call for help? Is it an attempt to individuate from an enmeshed system? Rather than treatment which is “planned” in reaction to the patient, informed treatment planning can occur. A Chaining
Effect
While therapists describe and define their countertransference, it becomes practical information once it addresses the meaning of what is happening in the therapy. The countertransference is a reflection of the anxiety which exists in the system. Supervision discussions of countertransference are only applicable to the work when this next cognitive step is made. Beyond a subjective description of the felt emotions, it is necessary to understand how it is connected to the tensions present in therapy. What message is being conveyed in the metaphor of the suicidal gesture? Is is a gesture of autonomy? Is the behavior an explosive expression of differentiation by a toxic, enmeshed system? Therapists do the family a disservice by accepting its anxiety rather than facilitating a constructive integration of these felt tensions. Of course, the first step is for the therapist to role model healthy management of anxiety. Can therapists prescribe tasks they have not attempted?
Mueller and Kell (1972) call our attention to a “chaining effect”: “Anxiety, generated in a relationship with a client, moves through the therapist to the supervisor where it is either resolved or spirals back and adversely affects the client” (p. 84). Searles (1955) states: “The processes at work currently in the relationship between patient and therapist are often reflected in the relationship between therapist and supervisor” (p. 135). Furthermore he suggests that the emotions experienced by the supervisor, including fantasies, can provide clarification of the process characterizing the relationship between the supervisee and the patient. This parallel process is not just a supervisory reflection of client-therapist interaction-it works in both directions (Doehrman, 1976). The supervisor stirs the therapist, who then acts out with the patient. Similarly, we suggest that a supervisor who sanctions the notion that “the family is willing the death of a member” has become an unsuspecting participant in a large, spiraling system which is capable of pushing the addict toward death. The supervisor who has embraced this fatalistic notion has given up on the therapy, thereby encouraging the therapist to give up on the family who in turn gives up on the addict. When the addict has fully given up, death becomes inevitable.
CONCLUSIONS In summary, systems theorists have generated fertile hypotheses conceptualizing (a) addiction as pseudoindividuation from a thickly enmeshed system and (b) families as stuck in certain developmental stages due to unresolved grief. These are exciting contributions to the preparadigmatic field of addictions treatment (Shaffer and Gambino, 1984). However, the hypothesis stating “the family pushes the addict toward death,” is an attempt to articulate a phenomenon that is observed in treatment-the systemic preoccupation with death-it becomes a constructive observation until it is brought to the next conceptual level. What may appear to be “a push toward death” can be understood as a systemic attempt at self-preservation. This article is intended to be a warning against a naive interpretation of the suicide-like nature of addiction or an interpretation clouded by a depressive countertransference. Anxiety may lead a therapist to the potentially dangerous perception of a family’s “death wish” or it can become a useful therapeutic tool. The double-edged quality of countertransference is that it can at once bring the most fruitful “felt” understanding of the work and it can be a difficult obstacle. Reich (1951) states that important material for the therapist comes from the unconscious. She believes that this is what Freud meant when he suggested that we listen with free floating attention. The difference between healthy and
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F. Newbro Turner and L. Saltz
unhealthy countertransference is that it is healthy when sublimated and unhealthy when unconscious fantasies are being acted out (Reich, ,195l). The therapist’s emotional response is one of the most important treatment tools and countertransference is an instrument of research into the patient’s unconscious (Heiman, 1950). “Countertransference is no more to be feared or avoided than is transference; in fact it ‘cannot’ be avoided, it can only be looked out for, controlled to some extent, and perhaps used” (Little, 1951, p. 40). Further observation of this particular homeostatic mechanism is required in the supervision of this form of treatment. The parallel process is a systemic articulation of “a primitive identification with the expressed feelings” (Cohen, 1952, p. 239) and contagious anxiety (Vaillant, 1981). Cohen and Vaillant have noted how a therapist can “catch” anxiety. Systems theory can lead us to note how a larger system, the four levels of the treatment process- (1) identified patient, (2) family, (3) therapist,, and (4) supervisor, can “catch” anxiety. However, while the family may develop the deleterious defense of giving up hope for an addicted member, as clinicians we must guard against unconsciously mirroring this defense. This empathic failure, if left unexamined, at best can serve to inhibit successful treatment and at worst can precipitate a death. REFERENCES Alexander, B.K., & Dibb, G.S. (1975). Opiate addicts and their parents. Family Process, 14, 499-514. Alexander, B.K., & Dibb, G.S. (1977). Interpersonal perception in addict families. Family Process, 16, 17-28. Attardo, N. (1965). Psychodynamic factors in the mother-child relationship in adolescent drug addiction: A comparison of mothers of schizophrenics and mothers of normal sons. Psychotherapeutic Psychosomatics, 13, 249-255. Bale, R.N., Cabrera, S., &Brown, J. (1977). Follow-up evaluation of drug abuse treatment. American Journal of Drug and Alcohol Abuse, 4, 233-249. Boszormenyi-Nagy, I., & Spark, G.M. (1973). Invisible loyalties. New York: Harper and Row. Bowlby, J. (1961). Processes of mourning. The International Journal of Psychoanalysis, 42, 317-340. Chein, I., Gerard, D., Lee, R., & Rosenfeld, E. (1964). The road to H. New York: Basic Books. Coleman, S.B. (1975). Death- the facilitator of family integration. Paper presented at the American Psychological Association, Chicago, August. Coleman, S.B., & Stanton, M.D. (1978). The role of death in the addict family. Journal of Marriage and Family Counseling, 4, 79-91. ,Cohen, M.B. (1952). Countertransference and anxiety. Psychiatry, 15, 231-243. Doehrman, M.J.G. (1976). Parallel processes in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40. ‘Ellinwood, E.H., Smith, W.G., ‘& Vaillant, G.E. (1966). Narcotic addiction in males and females; A comparison. International Journal of the Addictions, 2, 33-45. ‘Ferguson, P., Lennox, ‘T., &‘Lettieri,:D.J. (1974). Drugs and death: The nonmedical use of drugs related to all modes of death .(DHEW Pub. No. ADM 75-188). Rackville, MD: National lnstitute on.Drug Abuse.
Goldstein, P.J., Abbott, W., Paige, W., Sobel, I., & Soto, F. (1977). Tracking procedures in follow-up studies of drug abusers. American Journal of Drug and Alcohol Abuse, 4, 21-30. Ganger, R., & Shugart, G. (1966). The heroin addict’s pseudoassertive behavior and family dynamics. Social Casework, 47, 643649. Haley, J. (1973). Uncommon therapy. New York: Norton. Heiman, P. (1950). On counter-transference. International Journal of Psychoanalysis, 31, 81-84. Klagsbrun, M., & Davis, D.I. (1977). Substance abuse and family interaction. Family Process, 16, 149-173. Kubler-Ross, E. (1975). Death, thejinalstage of growth. Englewood Cliffs, NJ: Prentice-Hall. Little, M. (1951). Countertransference and the patient’s response to it. International Journal of Psychoanalysis, 32, 32-40. Maltsberger, J.T., & Buie, D.H. (1974). Countertransference hate in the treatment of suicidal patients. Archives of General Psychiatry, 30, 625-633. Marris, R.W. (1971). Deviance as therapy; The paradox of the selfdestructive female. Journal of Health and Social Behavior, 12, 113-124. Menninger, K. (1938). Man against himself. New York: Harcourt, Brace and World. Mueller, W.J., & Kell, B.L. (1972). Coping with conflict: Supervising counselors and psychotherapists. New York: AppletonCentury-Crofts. Noone, R.J., & Reddig, R.L. (1976). Case studies in the family treatment of drug abuse. Family Process, 15, 325-332. O’Donnell, J.A. (1964). A follow-up of narcotic addicts. American Journal of Orthopsychiatry, 34, 948-954. Paul, N.L., & Grosser, G.H. (1965). Operational mourning and its role in conjoint family therapy. The Community Mental Health Journal, 1, 339-345. Reich, A. (195 1). On counter-transference. International Journal of Psychoanalysis, 32, 25-3 1. Reilly, D.M. (1976). Family factors in the etiology and treatment of youthful drug abuse. Family Therapy, 2, 149-171. Shaffer, H., & Gambino, B. ((1984). Addiction paradigms Ill: From theory-research to practice and back. In The addictive behaviors (pp. 135-152). New York: The Haworth Press. Searles, H.F. (1955). The informational value of the supervisor’s emotional experience. Psychiatry, 18. Seldin, N.E. (1972). The family of the addict: A review of the literature. International Journal of the Addictions, 7, 97-107. Stanton, M.D. (1977). The addict as savior: Heroin, death and the family. Family Process, 16, 191-197. Stanton, M.D. (1978). The family and drug misuse: A bibliography. American Journal of Drug and Alcohol Abuse, 5, 151-170. Stanton, M.D., Todd, T.C., Heard, D.B., Kurshner, S., Kleiman, J.I., Mowatt, D.T., Riley, P., Scott, S.M., & Van Deusen, J.M. (1978). Heroin addiction as a family phenomenon: A new conceptual model. American Journal of Drug and Alcohol Abuse, 5, 125-150. Stanton, M.D., Todd, T.C., &Associates. (1982). Thefamily therapy of drug abuse and addiction. New York: The Guildford Press. Vaillant, G.E. (1966). A 12-year follow-up of New York narcotic addicts: III. Some social and psychiatric characteristics. Archives of General Psychiatry, 15, 599-609. Vaillant, G.E. (1973). A 20-year follow-up of New York narcotic addicts. Archives of General Psychiatry, 29, 237-241. Vaillant, G.E. (1981). Sociopathy as a human process. In H. Shaffer & M. Burglass (Eds.), Classic contributions in the addictions. New York: Brunner Mazel. Winnicott, D.W. (1949). Hate in the countertransference. The International Journal of Psychoanalysis, 30, 69-74. Wurmser, L. (1974). Psychoanalytic considerations of the etiology of compulsive drug use. Journal of the American Psychoanalytic Association, 22, 820-843.
ORIGINAL
Vol. 4,
0740.5472/87$3.00 + .OO Copyright 0 1987Pergamon Journals Ltd
pp. 29-36, 1987
CONTRIBUTION
Narcotic Addiction and Family Process: Death Wish or Countertransference
FELICITY NEWBRO TURNER, MA AND LYNNE SALTZ, MA North
Charles
Institute
for the Addictions, Affiliated with Department of Psychiatry, A Program of the Cambridge Hospital, Lesley College
Harvard
Medical
School
Abstract - This article critically examines the literature which suggests that families of narcotic addicts push their addicted member toward death. Following an overview of the conventional literature on the family treatment of drug addiction, an alternative perspective is proposed to more fully understand how these families are preoccupied with death. The “suicide-like” quality of addiction is probed both in terms of the intention to die and the countertransference possibilities. The notion of a family “death wish” has the potential to be misinterpreted by the countertransference response of an unseasoned treatment provider. Clinicians are cautioned that this notion can be a potential threat to the patient’s life. Implications are presented for the supervision of the family treatment of narcotic addiction. Keywords-Addiction,
countertransference,
family therapy,
grief, suicide,
supervision.
man & Stanton, 1978; Stanton et al., 1982). More specifically, the family unconsciously wishes the addict to die so that it can use the addict’s death to reenact the deaths of other significant family members. The addict symbolically becomes a martyr whose death permits the family an opportunity to vicariously master its unresolved grief (Coleman, 1975). This article will suggest that the unconscious wish in these families for the narcotic addict to die (Stanton et al., 1982) must be understood to be an ambivalent wish. Accompanying a review of the literature of family treatment of addiction, this paper will suggest an alternative explanation for the observed systemic preoccupation with death themes. As Marris (1971) demonstrated, a preoccupation with death, even to the extent of suicidal gestures, is not always linked with the wish to die. Furthermore, this paper suggests that the high level of anxiety treatment providers experience in working with narcotic addicts (Stanton et al., 1982; Vaillant, 1981) can also lead to a dangerous conception of the family’s wish to see the addict dead. For example, clinicians working with suicidal patients (Maltsberger & Buie, 1974) have reported that stress can lead the treatment provider to the misconception that the patient
INTRODUCTION PRACTICE OFTEN FOLLOWS THEORY; however, many of the therapeutic techniques for treating families of narcotic addicts have come before theory building. Recently accumulating clinical impressions have generated certain hypotheses regarding the treatment of addictions that require further consideration. Several theorists (Boszormenyi-Nagy & Spark, 1973; Coleman & Stanton, 1978; Noone & Reddig, 1976) have proposed that an unresolved grieving process in families is responsible for pathological homeostasis. As an outgrowth of this explanation of family pathology, Stanton and his colleagues have proposed that families of narcotic addicts purposefully push the addict toward death in an attempt to resolve grief. Support for this notion has been based on the clinical impression that often such families are preoccupied with death (Cole-
Special thanks are extended to Howard Shaffer without whose encouragement and suggestions this paper would not have been written. Requests for reprints should be sent to Lynne Saltz, MA, North Charles Institute for the Addictions, 260 Beacon Street, Somerville, MA 02143.
29
30
F. Newbro
really wants to die and perhaps should die. The danger in the toxic therapeutic relationship is that a patient may be pushed into a fatal attempt. Similarly, we suggest the notion that families want to see an addieted member die can be the result of countertransference rather than a pragmatic understanding of the families’ homeostasis; we caution that this is a potentially dangerous notion. A revised understanding of the attendant anxiety in the treatment of narcotic addicts and their families can facilitate an enlightened perspective for the supervision of this work. We propose that a “chaining effect” (Mueller & Kell, 1972) is likely to affect four levels of the process: (1) the family manages its anxiety by considering the possibility of death, (2) the therapist takes on the anxiety and endorses the inevitability of the lost life, and (3) the supervision accepts the fatalistic attitude, thereby giving the final seal of approval to the addict’s death. When the process reaches a fourth level-(4) that of the patients’ giving up on themselves-the danger of a fatality is magnified. The seasoned supervisor who recognizes this parallel process by its emotional charge (Searles, 1955) is able to turn the process around. Thereby, the potentially dangerous situation becomes a rich source of information for the astute clinician. Through a review of the literature this article addresses family systems theory as it relates to treating narcotic addiction, and the effects of countertransference on the treatment. The final section sets forth the clinical implications for supervision and describes the chaining effect.
FAMILY SYSTEMS THEORY NARCOTIC ADDICTION
AND
As family treatment for addictive behaviors gained conceptual acceptance, clinicians increasingly prescribed family therapy for treatment of narcotic addiction (Alexander & Dibb, 1977; Klagsbrun & Davis, 1977; Noone & Reddig, 1976; Stanton et al., 1978). This approach to treatment is conceptually similar to that presented by Haley (1973) for schizophrenics; “identified patients” help keep their families together by allowing the members to unite over their incapacitation. For example, an unstable dyadic relationship of the parents alone is stabilized by a move toward a triadic relationship consisting of the parents and the addict. An addict who begins to succeed-either at work, socially or in terms of drug use-is becoming less dependent on the family. At this point, crisis is likely to occur in the family. Tensions may arise between the parents, an illness may occur in the family or difficulties may develop with a sibling. The development of these difficulties suggests that not only does the addict fear separation but so does the family.
Resistance
Turner and L. Saltz
to lndividuation
The narcotic addict is often part of an enmeshed family. In a study comparing mothers of adolescent drug addicts to mothers of adolescent schizophrenics and mothers of “normal” adolescents, Attardo (1965) retrespectively measured the mothers’ “propensity for symbiotic relating.” All the mothers had relatively similar levels of “symbiotic needs” for the first five years of the child’s life; later the needs of the “normal” mother decreased while the “symbiotic needs” of the drug abusers’ mothers remained the highest of the three groups-higher than those of the mothers of schizophrenics Resistance to individuation in a narcotic addict’s family is highlighted by the likelihood that the future addict first became a behavior problem for the family during adolescence, a time when the addict would otherwise have begun to separate (Seldin, 1972; Wurmser, 1974). Another often observed phenomenon is that a majority of narcotic addicts live at home or are in frequent contact with their families of origin well into their 20’s and 30’s (Bale, Cabrera, & Brown, 1977; Chein, Gerard, Lee, & Rosenfeld, 1964; Ellinwood, Smith, & Vaillant, 1966; Goldstein, Abbott, Paige, Sobel, & Soto, 1977; Noone 8~ Reddig, 1976; Stanton et al., 1982; Vaillant, 1966). “Heroin provides a solution at several levels to the dilemma of whether or not to allow him independence. Paradoxically, it permits him to simultaneously be close and distant, ‘in’ and ‘out’, competent and incompetent, relative to his family of origin. This is ‘pseudoindividuation’” (Stanton et al., 1978, p. 125). Narcotic addiction can be a partial solution for a family having difficulty separating. The aggression often observed in addicts’ interactions with their parents allows the addict an illusion of individuation (Ganger and Shugart, 1966; Stanton et al., 1978). A drug seeking lifestyle offers the addict a peer group, thereby providing the feeling of being individuated from the family. However, these peer relations often keep the addict dependent on the family because they reinforce the addiction. Furthermore, conjugal liaisons, which might help addicts individuate from their families, are often less meaningful to the addict than the relationships with their parents. The rate of marriage for male addicts is half of what would be expected and the rate of multiple marriages for both sexes is above average (Stanton et al., 1978). Pathological
Homeostasis
One explanation for a family’s inability to separate lies in the notion of the uncompleted life cycle. Symptoms appear when there is an interruption in the unfolding life style of a family (Haley, 1973). These families are rigid, inflexible, and resistant to change. They may
31
Death Wish or Countertransference not complete a life cycle if, at a particular developmental stage, they are unable to negotiate the tasks required by that stage. For example, a family can be stuck in working through the stages of a grieving process. Family pathology has been conceptualized as maintained for the purpose of handling previous losses (Boszormenyi-Nagy & Spark, 1973; Paul & Grosser, 1965). Symbiotic transactions in families amount to a mechanism capable of preventing awareness of losses to any individual member. One aim of a symbiotic family organization is the prevention of threatened separation. Families with rigid defenses against separation are warding off a loss that has already occurred (Paul & Grosser, 1965). The first phase of mourning has been called “the urge to recover the lost object” (Bowlby, 1961) and the “denial” phase (Kubler-Ross, 1975). Regardless of how long ago the loss occurred, these families are developmentally stuck in this first phase of the mourning process. They attempt to deny or ward off the previous loss and to “recover” the loss by preventing individuation. Theorists have found that this explanation of pathological homeostasis as due to an uncompleted mourning process suits the family of the narcotic addict particularly well. Both (a) the predominance of death themes observed in clinical work (Coleman, 1978; Noone & Reddig, 1976; Reilly, 1976; Stanton et al., 1982) and (b) the tendency for families to resist individuation (Alexander & Dibb, 1975; Klagsbrun & Davis, 1977; Noone & Reddig, 1976; Stanton et al., 1978) have been well documented.
High Rates of Interpersonal
Losses
The likelihood that families of narcotic addicts are unable to separate because of an incomplete grieving process is supported by the data reflecting their high rates of interpersonal loss. For example, these are families often strained by marital tensions. Families of addicts are more likely to be cut off from their cultural context by virtue of having moved long distances or emigrated (Vaillant, 1973). Addicts are also likely to have had an emotionally distant parent (Chein et al. 1964, Stanton et al., 1982; Vaillant, 1981); there is a higher than average likelihood that these individuals had a substance abusing parent (Alexander & Dibb, 1975; Stanton, 1978); they are likely to have had one absent parent (Alexander & Dibb, 1975; Klagsbrun & Davis, 1977) or a parent who died before the future addict was 16 years old (Coleman & Stanton, 1978; Klagsbrun & Davis, 1977; Stanton et al., 1978) and the rate of early death of paternal grandfather is higher than expected (Stanton et al., 1978). Finally, an association exists between time of initial drug use and an important death in the family (Stanton et al., 1978).
Clinical
Implications
In the case of the family of the narcotic addict, an uncompleted life cycle is likely to be one of grieving (Coleman & Stanton, 1978). For instance, if the parents have chosen the addict to symbolically replace a deceased grandparent a family injunction exists not to repeat the loss. Therefore, the family does not allow the addict to individuate (Reilly, 1976), or grandparents may not allow the parents to succeed at marriage because they cannot stand the loss of their child to a spouse (Stanton, 1978). Such families are seen as unable to express affection due to impaired mourning (Reilly, 1976). Because the parental system is unstable, a lethal symptom is created to focus upon. An unstable dyad draws in a third leg of a stabilizing triangle. When a family is stuck in a developmental stage and drug abuse becomes an indicator of impasse, one of the therapist’s tasks is to clarify loyalty patterns. This may require the resolution of grief that has been transmitted through several generations (BoszormenyiNagy & Spark, 1973; Noone & Reddig, 1976).
THE THEORY OF A “FAMILY DEATH WISH” The comparison of addiction to suicide-like behavior is likely to originate from data that addicts exhibit high death rates and shorter than average life expectancies (Ferguson, Lennox, & Lettieri, 1974; O’Donnell, 1964; Stanton et al., 1978). The notion is not entirely new: Menninger (1938) likened addiction to “chronic suicide.” Currently systems theorists, interpreting the fascination with death that these families exhibit (Coleman & Stanton, 1978; Noone and Reddig, 1976; Reilly, 1976; Stanton et al., 1982), have labeled addiction a “suicidal phenomenon with a family basis” (Stanton, 1977, p. 191) and “more than a propensity for self-destruction . . . a (possibly unconscious) wish for death” (Coleman & Stanton, 1978, p. 80). From this perspective, if the addicted child dies a drug-related death, the family system is still preserved. The mother of a dead addict “only feels capable of expressing her ‘love’ for her addicted [son] while standing over his grave. If he dies, it is as if she can have him forever without the fear of losing him to others” (Stanton, 1977, p. 192). The parent remains obsessed with the dead child. If an addicted family member dies, the surviving members are able to refrain from dealing with other areas of life and remain focused on the addict as before. The idea that families promote suicide can hold the potential for dramatic and deleterious effects on treatment if it is misinterpreted. While suicide and addiction have some common characteristics, the comparison of addiction to suicide has the potential to be dangerous unless the similarities are carefully considered.
F. Newbro Turner and L. Saltz
32
SUICIDAL BEHAVIOR
REFRAMED
The concept that “drugs are alternative to or an equivalent of suicide” (Stanton, 1977) would possess more meaning in light of an examination of what suicide attempts indicate about intention to die. Marris (1971) noted that very different patterns of behavior exist between females who actually suicide and those who “gesture,” the latter evidencing a will to live. Marris’ (197 1) examination of suicide attempts by women revealed that a significant number of his subjects did not intend to end their lives but rather to preserve them. Suicide gestures and drug addiction can be reframed as ego-defenses or coping mechanisms (Marris, 1971). Suicide gestures may be self-preservative as they are gestures of autonomy and can function as alternatives to completed suicide. “Deviant behaviors” (e.g., sexual deviance, drug addiction, and suicide) are found to help manage feelings of inadequacy, loneliness and depression. Furthermore, these deviant behaviors are found to be women’s attempts at cutting themselves off from pathological families of origin (Marris, 1971). This perspective does not minimize the inherent danger: (1) gestures are not easily distinguished from the intent to die and (2) miscalculated gestures easily result in death. However, while gestures can prove fatal, it is pragmatic to understand that the motivation and intention for these acts are those of problem solving. Similarly, our thesis recognizes symptoms such as drug abuse as not necessarily the “slow form of self destruction” it is frequently thought to be, but rather possibly therapeutic. While it may be difficult to conceptualize potentially fatal symptoms as methods of managing survival, these symptoms are, to some degree, coping mechanisms. If, in fact, the “self destructive” nature of drug addiction has a “suicidal” quality, the similarity is likely to be in the style of ego-defenses. For example, a heroin addict’s “self-destructive” behavior may be the attempt at differentiation and separation from a pathological family system, rather than a statement of wanting to die. As discussed above, opiate addiction is an attempt at individuation, ‘pseudoindividuation’ (Stanton et al., 1978), or an attempt by the addicted person to cut off from a pathological family. This ‘pseudoindividuation’ quality of addictive behavior is identical to the attempt to be cut off from a pathological family evidenced by suicidal behavior. Therefore addictive behavior is legitimately “suicide-like.” Both addiction and suicide are a move toward autonomy. Both can be seen as desperate attempts at survival. However, neither are profitably understood as unambivalent attempts to die. It is not possible to overemphasize our point that this perspective is not intended to minimize the dangerousness of these “coping mechanisms.” Just as it is
difficult to assess when a suicide gesture becomes a serious intent to die, it is extremely difficult to sort out the ambivalence of a family with the suicidal symptom of narcotic addiction. This ambivalent systemic “coping style” is likely to result in a death. Many narcotic addicts die, From the perspective of this article, another important “suicide-like” quality of addiction is the effect of the attendant anxiety on the treatment provider. Both addicted patients and suicidal patients are likely to cause countertransference anxiety. COUNTERTRANSFERENCE IN THE TREATMENT OF THE NARCOTIC ADDICT Definitions
There is no single definition of countertransference. Classically, it is the analyst’s reaction to the patient’s transference. Contemporary theorists question whether or not countertransference is comprised of all the therapist’s feelings toward a patient or only the irrational feelings. Does it constitute conscious feelings, unconscious feelings, or both? Is countertransference the emotional reactions experienced inside or outside the therapeutic relationship? Is the countertransference evoked by events in the therapist’s personal life, or is it a result of an interaction with the patient? It is beyond the scope of this paper to attempt a resolution of this controversy. The essential point is that: in working with certain populations such as narcotic addicts and suicidal patients, there is a strong likelihood for the treatment provider to experience certain degrees of anxiety. For the purposes of this discussion, countertransference will be considered as the therapist’s emotional reaction to the tensions in the addict, the addict’s family, and the potential risk of the patient’s death. It may be conscious and/or unconscious. Within the context of this definition these emotional responses may be a result of (1) events in the therapist’s personal history, (2) a cultural abhorrence of suicide, or (3) a reaction to the tensions present in the patients and their families. Our attention focuses on the latter of the three. Countertransference in the Treatment of the Suicidal Patient
Because both addicted and suicidal patients threaten the treatment provider with the possibility of death, the level of countertransference anxiety is likely to be high. Maltsberger and Buie (1974) point out that in many suicidal patients, a “transference onslaught” will ensue which will eventually stir up countertransference hate. Maltsberger and Buie describe a transference hate that “relates to a deep sense of abandonment
33
Death Wish or Countertransference (or expectation thereof), an intense craving for, yet horror of, closeness” (p. 625) which leads these patients to act in ways that elicit frustration. If the therapist can manage the relationship appropriately and with interest, the patients can learn to manage their own craving and rage. The countertransference hate will be manifest in feelings of malice and aversion. This countertransference can be either usefully or deleteriously managed. “Aversion” is most dangerous because it tempts us to give up the case an consider the patient “hopeless.” It is then that a suicide is likely to be precipitated (Maltsberger & Buie, 1974).
Countertransference
Hate
Our humanity is our instrument. Therapists, as humans, experience every range of emotion including hate and anxiety. Winnicott (1949) suggested, “However much he loves his patients he cannot avoid hating them, and fearing them, and the better he knows this the less will hate and fear be the motive determining what he does to his patients” (p. 69). In his opinion the more regressed a patient is and the more the patient confuses love and hate, the more important it becomes that therapists can tolerate their own capacity for hate. “If the analyst is going to have crude feelings imputed to him, he is best forewarned and so forearmed” (p. 70). Winnicott discussed a patient that he found “almost loathsome . . . until the analysis turned a corner and the patient became loveable, and then I realized that his unlikableness had been an active symptom, unconsciously determined” (p. 70). Similarly, the narcotic addict possesses the capacity to cause anxiety and rage; a seasoned treatment provider can understand the frustration and fury as a clue toward understanding the patient’s way of being in the world. Therefore, the rage becomes information which is a useful tool for negotiating the ongoing treatment.
The “Transference Onslaught” of the Addicted Patient Drug addicts exhibit various anxiety provoking behaviors which are familiar to the treatment provider: alternating between overvaluing and devaluing the therapist; staff splitting; seductive and destructive behavior; struggling about treatment contracts, rules and drugs; convincing the therapist to take responsibility for their drug use; “spilling anxiety,” that is, rushing in with a problem that needs an “immediate solution”; making apparent progress and then backsliding; and threatening their health and life. Unmonitored countertransference can result in treatment based on retribution or abhorrence. Punitive control struggles or giving up the case illustrate such destructive possibilities. In attempting to manage these behaviors so that
the addicts will begin to bear their own anxiety, the therapists are also managing their own responses. Countertransference
Anxiety
Cohen (1955) constructed a definition of countertransference to express what is common to most definitions: “the presence of anxiety in the therapist-whether recognized in awareness or defended against and kept out of awareness” (p. 235). She stated further that a patient’s anxiety, particularly an aggressive patient’s anxiety, can be contagious. If this is taken to mean both those who turn aggression inward as well as those who vent it, we can include most, if not all, narcotic addicts. Furthermore, Cohen itemized several ways in which anxiety is experienced by therapists -as wounded self-esteem (because their helpful intentions are so misinterpreted), retaliatory impulses and/or “a primitive identification with the expressed feelings” (p. 239). Contagious Anxiety of Drug Addicts
in the Treatment
The sociopathic patients Vaillant (198 1) described (often narcotic addicts) are experts at letting anything or anyone else manage their anxiety. This experience is unnerving for those around them. Vaillant compared the neurotic’s defense mechanism to a pebble in their shoes: only they are made uncomfortable. On the other hand, the sociopath’s defense mechanism is like a cigar in a crowded elevator: only the possessor is comfortable while the rest suffer. (Vaillant, 1973). Because sociopaths are well defended against anxiety, it is only in the security of an enforced environment (i.e., prison or methadone program) that they begin to experience and display anxiety. In these settings sociopaths appear similar to borderline personalities (Vaillant, 1981). The therapeutic task for these patients is to begin to experience their own anxiety. Their anxiety should not be controlled or relieved by the treatment provider. The sociopath is as maltreated by too much help as by too little. The patient is served by being allowed to experience stress in the containment of a therapeutic relationship. By refusing to take responsibility for managing the patient’s anxiety the treatment provider shifts the onslaught of anxiety back to the patient. Therefore, the therapist is relieved of the anxiety before it is transformed into hostile or hurtful responses. “We take the sociopath’s defenses personally and condemn them. . . . One reason immature defenses are so taboo is because they are contagious” (Vaillant, 1981, p. 129). The risk, particularly in outpatient settings, is that being so frustrated by the sociopath’s defensive style that the therapist will become punitive. Stanton et al. (1982) aptly describe the addict’s attempt to unload anxiety:
34
F. Newbro Turner and L. Saltz
Countertransference in the Treatment of Families of Narcotic Addicts
Maltsberger and Buie (1974) describe therapists’ “aversion” to their suicidal patients, deeming the patients “hopeless.” It is this “aversion” that may precipitate a death. In other words, in order to defend against the anxiety of the threatened death, the family may accept the death as inevitable. It is a defense against the anxiety caused by the enormous responsibility of preventing death. Furthermore, it is a homeostatic mechanism of an overly enmeshed system-a desperate attempt at differentiation. Families may use the crisis of a threatened death to prevent a more disastrous event such as the dissolution of the family. It is a mechanism of a poorly functioning system threatened with self-destruction which is capable of causing the destruction of its addicted member. The situation, which can escalate as loyalties are tested, can be potentially lethal. On the other hand, these systems may use their flirtation with death in the same therapeutic manner that some suicidal females attempt survival (e.g., Marris, 1971).
Stanton et al. (1982) discuss the emotional strain they experience during treatment of narcotic addict families:
Case Illustration
TODD: “I think avoiding power struggles is one of the most important problems with these cases. It is not completely unique to this population; I encounter it also with anorectics, which is another situation where the patient is always looking for a fight. Anorectics, like the narcotic addicts, are in a desperate struggle for autonomy.” (p. 361) LANDE: “The addict was continually seducing and inviting therapist into some kind of struggle-whether over methadone doses, urine results, et cetera. . . . The therapist needed to learn that in any attempt by him to confront the addict, or to manipulate him around these issues, the addict would usually win.” (p. 372).
Thus in entering a power struggle with such patients, the therapist is buying into the patient’s defensive style. Anxieties escalate and psychotherapy becomes psychonoxious.
BERGER: “I have to use the word ‘countertransference’. These families create enormous fantasies of rescue and enormous feelings of frustration in the therapist. I think it has something to do with the horrible nature of what is going on, the sort of slow suicide these men get themselves into, as well as the horrible things the addicts end up doing to their families. It is easy to become enraged at them for being so incredibly destructive. . . It can overwhelm you.” (P. 359)
Difficult emotions have often been noted by therapists treating narcotic addicts. Alexander and Dibb (1975) described their subjective experience of working with addicts and their families. “Overt anger was very rare (except for the occasional outburst of a frustrated therapist)” (p. 503). A great deal of anxiety can be experienced during work with families of addicts. When the therapist’s distress level is too high the danger is to give up on the patient. THE FAMILY’S HOMEOSTATIC MECHANISM It is our suggestion that this defense mechanism, that of giving up on the addict, can pervade all levels of the treatment process. If the therapist’s level of anxiety and rage is capable of causing him to give up on the addict, this possibility also exists for the family. The family can be managing its anxiety similar to (1) the manner in which we perceive treatment providers of narcotic addicts managing their anxiety and (2) the manner treatment providers of suicidal patients which Maltsberger and Buie (1974) suggest. The family can attempt to defend against its anxiety about a member’s potential death by accepting it as inevitable.
Reinterpreted
Vignettes in the literature (Coleman & Stanton, 1978; Stanton, 1977) proposing the concept that “the family wants the addict to die” illustrate how the family instructs the addicted member to die. Looked at from the perspective we have proposed, the vignettes can also illustrate how a family defends against the addict’s pseudo-assertive (aggressive) behavior and against the anxiety of threatened death. In a representative initial session (Stanton, 1977, p. 193), a mother is quoted as saying “But he (the addict) is just gonna do something real bad that’s gonna hurt the all of youse. I mean I don’t care about him dying believe me. Because that would be the best for him and all of us-dying like that (unclear). I’m talking about him hurting somebody else. That’s all I mean. I don’t want to hurt nobody else. Or else (him) getting stuck in jail.”
Stanton’s conceptualization is to take this mother’s statement at face value; that she is willing to see her addict son die. With their practical approach and immediate response, Stanton and his colleagues have been able to prevent many deaths. As mature clinicians they realistically appraise a family’s willingness for a member’s death. They recognize the incipient crisis and take the necessary steps to intervene forcefully. Our reframing of this mother’s situation will not be likely to impact upon the clinical behavior of experienced clinicians. Rather it is a conceptual revision that is more likely to find its use in supervision and for the therapist beginning family work with narcotic addicts. A reframing of this mother’s statement is as meaning that she has accustomed herself to the possibility of her son’s death, although she does not wish him to die. Possibly she is manifesting a defense against a
Death
35
Wish or Countertransference
consistent anxiety: the defense of anticipation, against the possibility of her son’s imminent death. Among the most painful experiences of motherhood is to outlive the child who was to be her contribution to posterity, her hope for immortality. Reconciliation of this loss is possibly beyond reconciliation of her own death. It is possible that such a mother is doing what Maltsberger and Buie (1974) caution against: she is letting her anxiety direct her to give up her son as hopeless. This mother’s decision that her son’s death is inevitable can be, in fact, the same fatalistic decision that therapists make if they lose hope for a family determined to push toward death. It is the therapist’s responsibility to help the family discover constructive means of differentiating. If, when the family has decided that the addict will eventually die, the therapist also gives up, the therapist can be buying into the family’s defensive system. The family has come to the therapist looking for new hope. If the therapist gives up on the family, the family gives up on the addict. The situation may become potentially fatal when the identified patients give up on themselves. IMPLICATIONS
FOR SUPERVISION
In the same manner that Maltsberger and Buie (1974) caution against giving up the patient as “hopeless,” we caution against a simplistic understanding of the notion that “the family of the narcotic addict wants the addict dead.” This notion can lead us toward giving up on the family and the addict. It is helpful both to examine the countertransference, and to imagine what other message the patient’s suicidal behavior is transmitting. Is it a call for help? Is it an attempt to individuate from an enmeshed system? Rather than treatment which is “planned” in reaction to the patient, informed treatment planning can occur. A Chaining
Effect
While therapists describe and define their countertransference, it becomes practical information once it addresses the meaning of what is happening in the therapy. The countertransference is a reflection of the anxiety which exists in the system. Supervision discussions of countertransference are only applicable to the work when this next cognitive step is made. Beyond a subjective description of the felt emotions, it is necessary to understand how it is connected to the tensions present in therapy. What message is being conveyed in the metaphor of the suicidal gesture? Is is a gesture of autonomy? Is the behavior an explosive expression of differentiation by a toxic, enmeshed system? Therapists do the family a disservice by accepting its anxiety rather than facilitating a constructive integration of these felt tensions. Of course, the first step is for the therapist to role model healthy management of anxiety. Can therapists prescribe tasks they have not attempted?
Mueller and Kell (1972) call our attention to a “chaining effect”: “Anxiety, generated in a relationship with a client, moves through the therapist to the supervisor where it is either resolved or spirals back and adversely affects the client” (p. 84). Searles (1955) states: “The processes at work currently in the relationship between patient and therapist are often reflected in the relationship between therapist and supervisor” (p. 135). Furthermore he suggests that the emotions experienced by the supervisor, including fantasies, can provide clarification of the process characterizing the relationship between the supervisee and the patient. This parallel process is not just a supervisory reflection of client-therapist interaction-it works in both directions (Doehrman, 1976). The supervisor stirs the therapist, who then acts out with the patient. Similarly, we suggest that a supervisor who sanctions the notion that “the family is willing the death of a member” has become an unsuspecting participant in a large, spiraling system which is capable of pushing the addict toward death. The supervisor who has embraced this fatalistic notion has given up on the therapy, thereby encouraging the therapist to give up on the family who in turn gives up on the addict. When the addict has fully given up, death becomes inevitable.
CONCLUSIONS In summary, systems theorists have generated fertile hypotheses conceptualizing (a) addiction as pseudoindividuation from a thickly enmeshed system and (b) families as stuck in certain developmental stages due to unresolved grief. These are exciting contributions to the preparadigmatic field of addictions treatment (Shaffer and Gambino, 1984). However, the hypothesis stating “the family pushes the addict toward death,” is an attempt to articulate a phenomenon that is observed in treatment-the systemic preoccupation with death-it becomes a constructive observation until it is brought to the next conceptual level. What may appear to be “a push toward death” can be understood as a systemic attempt at self-preservation. This article is intended to be a warning against a naive interpretation of the suicide-like nature of addiction or an interpretation clouded by a depressive countertransference. Anxiety may lead a therapist to the potentially dangerous perception of a family’s “death wish” or it can become a useful therapeutic tool. The double-edged quality of countertransference is that it can at once bring the most fruitful “felt” understanding of the work and it can be a difficult obstacle. Reich (1951) states that important material for the therapist comes from the unconscious. She believes that this is what Freud meant when he suggested that we listen with free floating attention. The difference between healthy and
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F. Newbro Turner and L. Saltz
unhealthy countertransference is that it is healthy when sublimated and unhealthy when unconscious fantasies are being acted out (Reich, ,195l). The therapist’s emotional response is one of the most important treatment tools and countertransference is an instrument of research into the patient’s unconscious (Heiman, 1950). “Countertransference is no more to be feared or avoided than is transference; in fact it ‘cannot’ be avoided, it can only be looked out for, controlled to some extent, and perhaps used” (Little, 1951, p. 40). Further observation of this particular homeostatic mechanism is required in the supervision of this form of treatment. The parallel process is a systemic articulation of “a primitive identification with the expressed feelings” (Cohen, 1952, p. 239) and contagious anxiety (Vaillant, 1981). Cohen and Vaillant have noted how a therapist can “catch” anxiety. Systems theory can lead us to note how a larger system, the four levels of the treatment process- (1) identified patient, (2) family, (3) therapist,, and (4) supervisor, can “catch” anxiety. However, while the family may develop the deleterious defense of giving up hope for an addicted member, as clinicians we must guard against unconsciously mirroring this defense. This empathic failure, if left unexamined, at best can serve to inhibit successful treatment and at worst can precipitate a death. REFERENCES Alexander, B.K., & Dibb, G.S. (1975). Opiate addicts and their parents. Family Process, 14, 499-514. Alexander, B.K., & Dibb, G.S. (1977). Interpersonal perception in addict families. Family Process, 16, 17-28. Attardo, N. (1965). Psychodynamic factors in the mother-child relationship in adolescent drug addiction: A comparison of mothers of schizophrenics and mothers of normal sons. Psychotherapeutic Psychosomatics, 13, 249-255. Bale, R.N., Cabrera, S., &Brown, J. (1977). Follow-up evaluation of drug abuse treatment. American Journal of Drug and Alcohol Abuse, 4, 233-249. Boszormenyi-Nagy, I., & Spark, G.M. (1973). Invisible loyalties. New York: Harper and Row. Bowlby, J. (1961). Processes of mourning. The International Journal of Psychoanalysis, 42, 317-340. Chein, I., Gerard, D., Lee, R., & Rosenfeld, E. (1964). The road to H. New York: Basic Books. Coleman, S.B. (1975). Death- the facilitator of family integration. Paper presented at the American Psychological Association, Chicago, August. Coleman, S.B., & Stanton, M.D. (1978). The role of death in the addict family. Journal of Marriage and Family Counseling, 4, 79-91. ,Cohen, M.B. (1952). Countertransference and anxiety. Psychiatry, 15, 231-243. Doehrman, M.J.G. (1976). Parallel processes in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40. ‘Ellinwood, E.H., Smith, W.G., ‘& Vaillant, G.E. (1966). Narcotic addiction in males and females; A comparison. International Journal of the Addictions, 2, 33-45. ‘Ferguson, P., Lennox, ‘T., &‘Lettieri,:D.J. (1974). Drugs and death: The nonmedical use of drugs related to all modes of death .(DHEW Pub. No. ADM 75-188). Rackville, MD: National lnstitute on.Drug Abuse.
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