In-Patient Treatment of Substance Abuse

The Moderator, Patricia Grieve, opened the panel by introducing Wilhelm Burian and Gerardo Rubinstein. She highlighted the importance of an opportunity to discuss the application of psychoanalytic concepts to the in-patient treatment of problems because, by and large, they are not seen as responsive to traditional psychoanalysis. Burian then described a psychoanalytically informed, one-year in-patient programme for substance abuse, during which patients participate in group work, group therapy, psychoanalytic psychotherapy and the therapeutic community of the treatment centre. The programme is based on the principle that treating drug dependency inevitably involves the treatment of antisocial personality as well. Burian emphasised the complementary interplay of all elements in the treatment programme, specifically pointing out the importance of not seeing one aspect of the treatment as more important than any of the others.

Turning to conceptual considerations, he described the original and modern psychoanalytic concepts of a stimulus barrier, emphasising that current formulations are of a far more complex protective mechanism that must regulate aggression as well as libido. In his view, the addict must rely on developmentally immature psychic structures to fend off primitive, threatening affects and psychic fragmentation, which is a goal that drugs can also temporarily accomplish. In fact, drugs serve multiple functions that include blocking the perception of disruptive affects, dulling the result of painful affects and providing affective nourishment. In his view, the effect of drugs is ‘not merely analgesia but a much more highly complex phenomenon including sadistic and masochistic wish-fulfilment, and the fantasised reunion and merging with the nurturing mother’. Essentially, he concludes that almost all drug-dependent people have a borderline personality organisation, as formulated by Kernberg.

Burian explicated three clinical concepts that are key to understand