Psychiatric Annals

The Disease Concept of Alcoholism and Drug Addiction I 

Personal Reflections: The Disease Concept of Drug Addiction and Alcoholism

Howard P Rome, MD

Abstract

The contributors to this issue emphasize that a critical factor in all discussions in recent vears of the treatments proposed for addiction to alcohol and various drugs is the ambiance of the selling in which what is intended to be therapy lakes place. This is discussed in psychoanalytic terminology as reflecting on the interpersonal relationships between members of the treatment team and the patient - transference-countertransference relationships.

According to the authors' findings, ironically, the feeling atmosphere is one of highly charged negative affects. These emanate from what they interpret as a pervasive sense of pessimism attributable lo a recognized high incidence of recidivism. The hostile implications with their demeaning connotations mirror the patient's low self-esteem and guilt, social opprobrium, shame at the manifest lack of self-control, and the consequent need for selfflagellation. The counter transference is expressed in overt and subtle ways. The authors contend that the primary therapist, as well as his team, tend to reflect this hostile attitude. Such discrimination bodes for an unfavorable prognosis. Consequently, the resulting opprobrium is conducive to a heightened risk of self-destructive behavior, including suicide. The authors have the impressions that such disparagement is responsible for the patient's withdrawal, diminished participation, and feeling of futility.

Given this chain of events, several programmatic coping arrangements are recommended as a preferred way of managing the therapeutic regimen. Inpatient care in a supervised, monitored, hospitalcustodial setting is a lesser risk than an outpatient placement in which supervision is necessarily limited. Active participation in a comprehensive socialization program that encourages group discussions as well as attention to rehabilitation measures is prescribed. Such measures include frank discussion with the patient of his unique problems. This is coupled with attention to nutritional needs, physical fitness, and recreational and vocational instruction. The aim of such a program is to provide insight into the salient features of denial, guilt, shame, and loss of control and selfesteem.

The authors continue to emphasize the profound effect of a destructive counter-transference. Most patients enter a treatment setting with suspicion and formidable defenses expressive of their denial. These have been fostered as a consequence of importuning by their family and friends. The patient interprets these well-intentioned efforts as belittlement. The authors describe another problematic dimension. In most instances there is a preexisting comorbidity that colors the patient's defensive reactions. The suggestion is made that an understanding of its contribution is an essential ingredient of therapy.

The contributors address not only these component issues, but also summarize an extensive medical literature authenticating relevant characteristics. In addition, they discuss, in a commendable fashion, relative and derivative aspects of the phenomenology of therapy of the addiction process. Such important aspects as the concepts of disease, dependency, tolerance, withdrawal, and recommendations of management procedures for their resolution are detailed.

In summary, the authors' portrayal of the dynamics of therapeutic intervention in the problems of alcohol and drug addiction are comprehensively addressed. It is a representative compendium of present-day current issues in these frequently encountered disorders.…

The contributors to this issue emphasize that a critical factor in all discussions in recent vears of the treatments proposed for addiction to alcohol and various drugs is the ambiance of the selling in which what is intended to be therapy lakes place. This is discussed in psychoanalytic terminology as reflecting on the interpersonal relationships between members of the treatment team and the patient - transference-countertransference relationships.

According to the authors' findings, ironically, the feeling atmosphere is one of highly charged negative affects. These emanate from what they interpret as a pervasive sense of pessimism attributable lo a recognized high incidence of recidivism. The hostile implications with their demeaning connotations mirror the patient's low self-esteem and guilt, social opprobrium, shame at the manifest lack of self-control, and the consequent need for selfflagellation. The counter transference is expressed in overt and subtle ways. The authors contend that the primary therapist, as well as his team, tend to reflect this hostile attitude. Such discrimination bodes for an unfavorable prognosis. Consequently, the resulting opprobrium is conducive to a heightened risk of self-destructive behavior, including suicide. The authors have the impressions that such disparagement is responsible for the patient's withdrawal, diminished participation, and feeling of futility.

Given this chain of events, several programmatic coping arrangements are recommended as a preferred way of managing the therapeutic regimen. Inpatient care in a supervised, monitored, hospitalcustodial setting is a lesser risk than an outpatient placement in which supervision is necessarily limited. Active participation in a comprehensive socialization program that encourages group discussions as well as attention to rehabilitation measures is prescribed. Such measures include frank discussion with the patient of his unique problems. This is coupled with attention to nutritional needs, physical fitness, and recreational and vocational instruction. The aim of such a program is to provide insight into the salient features of denial, guilt, shame, and loss of control and selfesteem.

The authors continue to emphasize the profound effect of a destructive counter-transference. Most patients enter a treatment setting with suspicion and formidable defenses expressive of their denial. These have been fostered as a consequence of importuning by their family and friends. The patient interprets these well-intentioned efforts as belittlement. The authors describe another problematic dimension. In most instances there is a preexisting comorbidity that colors the patient's defensive reactions. The suggestion is made that an understanding of its contribution is an essential ingredient of therapy.

The contributors address not only these component issues, but also summarize an extensive medical literature authenticating relevant characteristics. In addition, they discuss, in a commendable fashion, relative and derivative aspects of the phenomenology of therapy of the addiction process. Such important aspects as the concepts of disease, dependency, tolerance, withdrawal, and recommendations of management procedures for their resolution are detailed.

In summary, the authors' portrayal of the dynamics of therapeutic intervention in the problems of alcohol and drug addiction are comprehensively addressed. It is a representative compendium of present-day current issues in these frequently encountered disorders.

10.3928/0048-5713-19910401-05

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