“Analyses which lead to a favorable conclusion in a short time are of value in ministering to the therapist’s self-esteem and substantiate the medical importance of psychoanalysis; but they remain for the most part insignificant as regards the advancement of scientific knowledge. Nothing new is learnt from them. In fact they only succeed so quickly because everything that was necessary for their accomplishment was already known. Something new can only be gained from analyses that present special difficulties, and to the overcoming of these a great deal of time has to be devoted”
— Sigmund Freud
One of the basic criticisms of psychodynamic or analytic treatments, particularly as they pertain to addictions, is that they don’t do enough, aren’t urgently focused enough, to arrest the escalation of problems associated with addiction. The epistemological approach (knowing, understanding) isn’t sufficiently pragmatic to halt unnecessary suffering for those directly afflicted, or their impacted others. Or, a more ontological approach, wherein emphasis lies in exploring a person’s being—discovering who they are as an emerging self—misses the severity of problems that addicted patients present.
I understand. As a patient in analysis, a past and present practitioner of analytic psychotherapy, and as a current candidate in full analytic training, I get that changes (or progress) in analytic treatment can seem “glacial”, as some put it. So, what would be the rationale for an analytic treatment of an addictive pattern, which is the matter of concern as addressed in mine and Joe Farley’s book, Getting Real About Sex Addiction. Well, sidestepping for now the questions of whether sex addiction is a legitimate diagnosis, or the linking question as to whether it merits an urgent, detoxifying focus comparable to say, chemical dependency, I’d like to offer more of a perspective than a rationale.
I’ve worked in the field of addiction, either directly in hospital-based programs, or peripherally in my private practice, for roughly twenty five years. In that time, I have, like many other psychiatric or mental health professionals, known countless individuals to go in and out of treatment multiple times, whether in rehab or therapy, upon slipping and/or relapsing, reflecting a chronic, repetitive problem. This observation is nothing new. Anyone who has ever attended a 12-step meeting will attest to hearing rhetoric asserting that addiction is a progressive, relapsing, even “incurable” disease, etc. Yet the crossover fields of addiction and chemical dependency treatment continue to offer as its dominant paradigm a short-term approach that ever treats the incoming patient as a so-called “newcomer”. Though acknowledgement of a relapsing pattern may be given by interventionists in such programs, their approaches tend to operate as if the patient is ever starting over.
I say the following: particularly when someone presents for therapy observing that their so-called addiction has lasted for years, with only sporadic interruptions due to painful consequences, followed by decisive interventions, why not suggest the following plainspoken yet analytic prescription: “Let’s explore the root of the problem. Let’s go deeper this time”. Does this proscribe some of the following tasks that are offered with virtue-signaling language: boundary-setting, relapse prevention plans, 12-step meeting attendance, medication consultation and regimens; the “inclusion” of an impacted partner in treatment? Of course not, though that last one is particularly tricky, as undue disclosures, explanations of pathology, achieved collaterally or directly, may thwart confidentiality and contaminate transference (development of a patient-therapist relationship). *Incidentally, disclosure exercises may also conflict with 12-step principles, an implicitly individualized model in which participants are typically urged to consider partners’ needs “none of your business”. Next, I hear some who suggest that a separation from the “triggering” environment is necessary for acting out persons, hence referrals to intensive outpatient programs or residential facilities. Okay, but with respect to sex addiction especially, such options are expensive and are thus available only to the wealthy. What’s that? I hear you scoff. Isn’t psychoanalysis expensive, especially if it lasts for years?
Not necessarily. Many analysts or analytically-oriented clinicians are quite flexible with those with low-fee needs, especially if they commit to multiple-sessions per week treatment. I’d be willing to bet that many such clinicians are more affordable than an average, one meeting per week, certified sex addiction specialist, and certainly more affordable than an out-of-state residential or short-term intensive program. Besides, what would you rather spend your money on? Thousands of dollars for an episode of treatment that will be over in a month, or the same amount (roughly) for something that may proceed more practically, more steadily, with more room for thought versus shoot-from-the-hip judgement, for over a year? I know. Get it over with quickly, some would counter—professional and lay-persons alike. But does anyone think it ironic that a condition epitomized by a mindset of immediate gratification would be treated with an approach that mirrors that thinking? Also, again with respect to sex addiction (versus chemical dependency), urgent, intensive interventions designed to arrest behavior ASAP are more about placating the anxiety of impacted others—not a requisite detox from a life-threatening withdrawal syndrome, or the imagined dangers of a sexual overdose.
Chill, one might say, crudely. Time to slow down, just a little at least, and think, and allow time to pass, which means space for a person’s motivation for care to intertwine with what is truly there within them: a pattern of defense that manifests habitually, often unconsciously, and sometimes dangerously. This pattern of defense is a character trait in all likelihood, not just a feature of “addiction”, and it reveals itself over time if someone is there to notice it regularly. Time. And Transference, actually. This is also why I place less stock in psychological testing, whether a comprehensive, “battery” of questions that may capture contradictions, indicating conflict, or a simple effort to elicit memory and conscious reflection, such as the HB-19 (regarding hypersexual behavior) inventory. Though I don’t have specialized training in psyche testing anyway, my basic objection is that such testing explores a patient’s mind outside of context—that is, outside of the flow of therapeutic relationship (known as Transference), and is therefore artificial. Simply put, patience and conscious witnessing are the two ingredients that counter the addict’s propensity to hide, facilitating change with lasting effect.
Consider two psychic defense concepts, one of which is decidedly psychoanalytic (displacement), while the other has a psychoanalytic pedigree but has been co-opted by other models: the aforementioned “acting out”. In sex addiction treatment, the term “acting out” denotes a sexual act, or a pattern of sexual activity, that is deemed inappropriate, exploitative, adulterous, etcetera. In psychoanalytic terms, it means replacing thoughts and feelings with action. Now consider two popular phrases whose ethos contradict each other: “actions speak louder than words” (positive connotation assigned to “action”), and “think before you act” (negative connotation assigned to “action”).
Analytic treatments privilege thinking, not to be confused with intellectualism, observing that addicts, in particular, act rather than think or feel, largely to their detriment. Still, they (would-be addicts) tend to enter treatment extolling the values of action in general, thinking it’s best to keep busy, don’t let idle hands…you know the rest.
They’ve been there before. Those who have rinsed and repeated, done this cycle of keeping busy, overworking, then feeling entitled to binge on pleasure and seek inappropriate rewards may take notice. Back to that notion of “chill”, which doesn’t mean lounging on a non-analytic couch smoking something that used to be illegal. It means not acting, not acting out that is, which doesn’t just mean not looking at porn, not finding a massage parlor, or not checking out the profiles on Tinder. What next? Well, imagine you, the would-be analytic patient, are laying on an analytic couch, or (okay, let’s defer to Covid for now), speaking on the phone with an analytic practitioner, someone trained to observe the mind as it is working moment to moment, feeling it’s anxiety and restlessness, poised to act out a state of unease…about anything. You start speaking of something that, by implication, causes anxiety. But you took care of it! You paid that bill, you made that call, sent that e-mail, or said that peace to someone who was giving you grief. Next, you moved on to the next subject. Have you? Have your thoughts and feelings really moved on? And did you notice something else? The thing you were anxious about pertained to the person you were talking to, only you didn’t really go into that–that relationship with that professional who is really in your head, which is…what you asked for? You vented about someone or thing else, which is called a displacement. That means a way to avoid the conflict you are feeling, which leads to a climactic theory: addiction has two names, two categories of motive. One we know easily: pleasure seeking. The other is conflict avoidance, the escape from unpleasure, as Freud will have put it. And you know the rest.