Love and Hate in Methadone Maintenance

During a thirty-four-month period that I worked in a methadone maintenance clinic, I observed certain recurring patterns of behavior which I shall relate to descriptions of ego defense mechanisms in the psychoanalytic literature. The behavior I observed in the clinic setting parallels the descriptions of transference phenomena that have been observed in the psychoanalysis of patients with so-called borderline personality organization. Leon Wurmser has related compulsive drug use to “narcissistic crises” in the lives of the individual drug abuser. Wurmser states that he has never seen a compulsive drug abuser who was not emotionally deeply disturbed, and he links this disturbance to the borderline type of psychopathology. In spite of such observations, most of the psychological treatment of addicts is left to those persons in the treatment hierarchy who have the least knowledge and experience in psychotherapy. There are no serious attempts to gain access—for addicts—to the best forms of psychotherapy available, partly because of the process that involves denying that addictive illness has psychological origins but also because of the extremely trying nature of therapy with borderline patients, even if they are not addicted to heroin.

Transference phenomena are observable in patients’ transactions with clinic staff members and with the clinic itself, as well as in their relationships with individual therapists. Whenever there are rapid shifts in the way patients perceive others, whenever strong affective states such as love or hatred are predominant (and especially when there is rapid alternation between the two), and whenever there is a powerful projection of hostile, aggressive impulses from the patient to someone else, it is safe to say that transference phenomena are present. The patient does not perceive these responses as unusual or strange. In fact they are natural for him or her and characterize the styles of relating to others that he/she has developed from ea