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October 11, 1990. AN APPLICATION OF ANALYTIC PRINCIPLES TO THE PSYCHOTHERAPY OF ALCOHOLICS. (The Maurice R. Friend Lecture.) Austin Silber, M.D.
Dr. Silber described the evolution of an analytically informed, once-a-week psychotherapy that was, by intention, supportive and educational. Both the technical approach to treating alcoholic patients in the clinic and strategies for teaching the method to student therapists evolved gradually. In the initial years, therapists were encouraged, early in treatment, to focus on the patient's expressed anxiety and to view this manifest affect as reflecting the alcoholic's fear of internal aggression. It was noted that the developmental histories of these patients frequently revealed phase-inappropriate, frustrating, and/or overstimulating experiences, particularly during the preoedipal years, which contributed to considerable latent aggression experienced by the patients as anxiety. It was one of the early tasks of treatment to bring this aggression to the patients' awareness in a way they could tolerate. To do this, therapists were instructed to identify situations where anxiety was linked to a figure of secondary importance in the patients' contemporary lives, such as a friend or boss (rather than a parent or spouse). This provided a less intense setting in which the therapists could tell the patients that they were fearful of experiencing their rage at this person and instead felt anxiety. By interpreting the fear rather than the wish, the therapists acted in consonance with the patients' egos. Where depressive affect was more prominent than anxiety, the therapists were advised to focus on the underlying guilt and to interpret it to the patients as a manifestation of the wish to be punished for aggressive wishes and actions.
By beginning the treatment in this intentionally manipulative way, Dr. Silber explained, an element of magic was introduced, and the therapists quickly became omniscient and powerful figures for