Prologue: An Introduction to the Substance Use and Misuse Edition of Psychoanalytic Inquiry

Classical psychoanalysis has had a long, problematic history in relation to working with substance use. It wasn’t long ago that the narcissist was deemed un-analyzable and excluded from psychoanalytic treatment, as was the alcoholic or substance user until they were able to achieve and maintain sobriety. Very few analysts treated the active substance user; many still don’t. If and when they did, their attitude toward their patient was too often one of disdain and resignation, an unfortunate legacy of their ingrained sense that the substance user was an incorrigible “nuisance” (White, 1998). Although early theorists did offer many useful theories about the etiology of alcoholism and substance use (Freud, 1905/1953; Kohut, 1977/1994; Krystal & Raskin, 1970; Wurmser, 1974), the available interventions at the time were clinically irrelevant. The substance user experienced the scientific objectivism of the analyst as emotionally mis-attuned, even injurious. In addition, the interpretation of transference, the provision of insight, and the mandate to renounce childish behaviors – consistent with the idea of repudiating one’s instinctual life – were interventions that activated powerful transferences of resentment and defiance for many patients. These dynamics would not only lead to interruptions of these treatments but would also put the substance user at a greater risk for relapse. The deep tragedy here is that the failure of these therapies was quite often blamed on the patient, and their broadly defined “resistances” were the explanation given for the ineffectiveness of what we understand today as a mismatched therapeutic approach and the absence of attuned responsiveness on the part of the therapist.

Over many decades, the traditional addiction field and the tenets of Alcoholics Anonymous have reinforced these problematic assumptions about the character of the alcoholic and substance user (Jones, 2009). These treatments are most often uniformly reductionistic as they h