Director, L. (2000) - Understanding and Treating Adolescent Substance Use

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PEP Web - Understanding and Treating Adolescent Substance Use: Systems, Families, and Individual Meaning
Director, L. (2000). Understanding and Treating Adolescent Substance Use: Sy... J. Infant Child Adolesc. Psychother., 1:97-110.
(2000). Journal of Inf ant, Child & Adolescent Psy chotherapy , 1:97-110
Understanding and Treating Adolescent Substance Use: Systems, Families, and Individual Meaning
Lisa Director, Ph.D.
Introduction
Let me start with a vignette: On a weekday afternoon, a group of ninth-grade girls hangs out on a neighborhood stoop. One girl pulls out a bag of marijuana and begins rolling joints. A boy from their class walks by and is invited to join in. Pretty soon, all the kids are stoned. A teacher walks by and sees them smoking. Technically, they're not on school grounds, but they're only a block away. Technically, they're not cutting class, because they have this last period free, but school is officially still in progress. The teacher reports them to the principal, who promptly suspends them from school. A follow-up letter informs the kids and their parents that they are required to undergo a drug evaluation, including a drug test, the results of which must be sent to the school. They are also required to follow any recommendations coming out of the evaluation, and are placed on behavioral probation for the rest of the year. This kind of incident is very common as a starting point in any treatment that revolves around drugs. What I like about the story is that it highlights the way that the issue of drugs inevitably cuts across several areas of human life and interest. Here, for example, a number of questions arise: Is the school within its rights? Are they violating the kids' rights? How should the parents respond? What is their role in their kids' behavior that day anyway? What steps should the families take? And, most important, do these kids have a drug problem? Do any of them? How can that be determined? This is what I love about drugs. In clinical practice, the problem of drug use is unique in that it sits astride several different domains of human experience.
This paper was originally delivered as a talk in the Scientific Lecture Series of the Institute for Child, Adolescent, and Family Studies of New York, M ay, 1999.
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Leon Wurmser (1977), a psychoanalytic theorist on addiction, observed this, viewing drug abuse as occupying a crossroads, of sorts, between several fields. Think about it: When someone gets high, the law, government, popular culture, ethics, physiology, family life, and individual psychologyall come into play. And the problem-solving skills and perspectives of each of these disciplines are needed to effectively address the problem. This is why an integrative, multidisciplinary approach is so vital in understanding and treating the problem of drug use. Though this seems self-evident, it is easier said than done. The various professions that possess specialized knowledge and resources about drug use are totally polarized from one another. There is almost no communication, let alone collaboration, among, say, the public policy-makers, the clinicians treating drug use, the neuroscientists studying its effects on the brain, and the researchers testing new pharmacotherapies to combat it. If this seems unlikely, think of the comments that Mayor Guiliani made about methadone this year: they were totally divorced from clinical reality and proven, scientific fact. We need the benefit of several theoretical perspectives to develop an effective response to drug abuse. Of all the groups who stand to contribute to this effort, our grouppsychoanalytically minded psychologists and therapists who have expertise in treating drug useis most likely to be ignored. Why is that? This is a time of heightened concern about drugs, with drug use on the rise throughout the 90s among teenagers, especially among younger kids, ages 12 and up. At such times, there is a tendency to panic, to seize on simple answers, and to demand action. We've got to do something, people say, to curb the spread of alcohol and drugs: design a new ad campaign,
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impound cars, invent a breakthrough patch or pill. What do we have to contribute at such a time, those of us who offer substance users psychotherapy, driven mainly by an interest in their minds? What we have to offer is the benefit of our perspective and particular understanding of drug use. Let me say what I mean when I refer to our particular understanding of drug use: first, drawing on our psychological expertise, we bring to this problem an awareness of the diversity of drug userswho are often mistaken for a single groupand an awareness of the manifold forms of drug use among them, which are often mistaken for a single phenomenon. Second, through our knowledge of development, we know that drug use in kidsthough never unimportantis often a temporary phenomenon, set
in motion by the developmental forces that challenge adolescents, and that they try to manage without the use of a fully formed personality at their disposal. Seen in such a light, drug use in kids can be an attempt to boost ego function, further separation-individuation, supplement regulation, and assist in the process of identity formationto name just a few possibilities. Wieder and Kaplan (1969) captured the developmental fit between drug use and teenagers when they wrote of the way that drug use could serve as a kind of prosthesis for the immature psychic structure of adolescents. However, barring more underlying deficit, once more stable character evolves in early adulthood and beyond, it is often the case that such drug use tapers off. Finally, our psychoanalytic perspective leads us to appreciate and seek out the unique meaning and function of drug use in each individual drug user's life. Individual difference and meaning are not idle concerns in our effort to get a handle on the so-called drug crisis. It is only by recognizing the importance of finding out the dynamic meaning and usefulness of each individual's drug use that we can answer questions like: Which kids are really at risk? Who is in the process of developing a real drug problem? What is the nature of his or her vulnerability? Fed by what set of internal forces? Supported by what additional factors from without? What steps need to be taken? This is what our group has to offer: the understanding that drug use becomes a problem when it takes on essential, dynamic life, and the skills needed to assess that development in people. Educating others about this is very importantfirst, because this perspective helps to defuse the panic that arises around drug use, especially among parents, and second, respect for the importance of dynamic meaning and inquiry should have a place in the responses that schools, institutions, and families fashion to any incidence of drug use. I'd like to illustrate some of my thoughts on this subject by discussing aspects of my work with an adolescent substance user. This happens to be the boy who drifted onto the stoop I described earlier, who was referred to me for evaluation and then psychotherapy.
The School
The administrator who coordinated the school's response to this incident was humane and concerned. Though the disciplinary steps he took raised a number of questions for the parents involved, he was acting in accordance with clearly articulated policies distributed in the form of handbooks to parents and
students, for their review and signatures of agreement, before the start of school. But let me say a word about drug testing. Drug testswhich usually involve taking samples of patients' urineare often misunderstood. When properly used, drug tests can play an effective role in the treatment process, in a number of ways: as a measure that is part of a comprehensive evaluation; as an educative experience in and of itself; as a structuring device that can augment an existing psychotherapy; and as a component of an intensive treatment program. But, for the purpose of evaluation, proper use of a drug test involves obtaining several samples from a person, over a period of time, to capture a fair and representative sample of his behavior. One drug test is meaningless. The very set-up subverts the pursuit of meaning that should take priority in any assessment of using behavior. The presence or absence of drugs on one occasion doesn't tell you whether a person has a problem or, for that matter, what kind of problem he has. It only tells you whether a person has used, prior to that occasionand that is often already known, as was the case here. Sometimes it even fails to tell you that. For example, I have a patient whose drugs-of-choice included short-acting narcotics who never
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tested positive on any of his drug tests because the drugs had already left his system, despite the fact that he was using these drugs intravenously to the point of unconsciousness and near-overdose. Conversely, as many people know, the active ingredient in marijuana is fat-soluble, and because of this can linger in the body and show up in urine tests long after being consumed. To paraphrase an old proverb: one positive urine does not a pothead make. When institutions use drug tests, it is often the case that they are employing them to serve as tokens of their authority and instruments of clout. But used in this way, drug tests only serve an agenda of power and control, not an agenda of understanding. Institutionsand familiesoften turn to drug tests in a misguided effort to find a shortcut through the difficult process of talking with kids about their drug and alcohol use. But surveillance is not a good substitute for communication, and only leads to the very secrecy it seeks to surmount.
Parents and the Evaluation Process

Tommy, an attractive 15-year-old boy, came to the evaluation wearing baggy jeans, shoulder-length hair, and an earring, looking very much like the hippie his mother said he was. His parentswho I'll call Mr. and Mrs.
Thompsonare also attractive people in their mid-40s. Married for 9 years, they got divorced when Tommy, their only child, was 6, and have shared joint custody since, with Tommy alternating weeks at each of their homes. Both are re-settled: Mr. Thompson is remarried, and Mrs. Thompson lives with a woman. She spoke about this in the course of relating the recent history of her personal life and breakup of her marriage, stating that she'd left Tommy's father for a woman. Mr. and Mrs. Thompson's personalities and histories loom large in Tommy's development. They are immensely engaging people, who have led interesting lives. They met as young actors in the theater world, and through their 20s and early years of their marriage they worked together in theatrical productions. They brought Tommy onstage with them when he was a young child. Clearly, his parents have passed on a legacy of creativity and unconventionality to Tommy, who recognizes this himself: I could never lead a run-of-the-mill life, he told me proudly in speaking of his parents' influence. He wants to be a film director. Mr. and Mrs. Thompson are also entertaining people. They are used to performing, and are very comfortable expressing themselves. Admirably, they had found a way to bridge their personal differences to work together around Tommy. In our earliest meetings together, they often vented strong and spirited feelings, even proceeding to argue passionately, and unselfconsciously, in my presence. Mrs. Thompson, in particular, is very colorful: she is irreverent and funny, almost programmed to speak in automatic one-liners. (I remember one time when I called her at home, to try to arrange a 3-way meeting with her, Tommy, and Tommy's fatheralways a scheduling feat. She had apparently been awaiting another call, about her effort to get tickets to a NY talk show, because she dropped the phone, and called to her son, Tommy! It's Dr. Letterman! Dr. Letterman is on the phone! and I felt, at times with the Thompsons, that I could easily be the host of a late-night comedy show.) Mr. and Mrs. Thompson are in recovery. Each has had histories of substance abuse that motivate their concern over Tommy. Mr. Thompson was a marijuana smoker, who acquired a daily dependency in his 20s and 30s for 10 years; he has now been abstinent for over 10 years. Mrs. Thompson first abused amphetamines as an adolescent, when she described herself as being totally rebellious and out of control. She felt she had undiagnosed ADHD that may have accounted for both her difficulties succeeding in school and
for her choice of stimulants. Though she got clean from these drugs, she turned to alcohol and cocaine as an adult. She has now been drug-free for a number of years and attends 12-step meetings. One vignette captures Mr. and Mrs. Thompson's early lives together: On their wedding day, a guest offered Mrs. Thompson a joint, right before the ceremony. She took a few hits, and walked down the aisle high. The next day, on the first day of their honeymoon, Mr. and Mrs. Thompson got busted for possession, but, luckily for them, it was in a country where they got off with only a fine. It makes for a good wedding story, which is exactly the problem for Tommy. Against the exciting backdrop of his parents' early lives, including the very manner in which they got married, what possible incentive could there be for Tommy to be clean
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and sober? In one sense, his own drug use could be seen as a loving tribute to his parents: drugs are a vehicle of identification with themwith his mother, in his rebelliousness, and with his father, in his choice of marijuana as his favorite drug. As an added bonus, drug use enables Tommy to claim identification with both of his divorced parents, and not to have to divide his loyalties between them. It may not seem quaint, but in a sense, Tommy's drug use was an homage to familyand to the particular family he came from, one where individuality was prized. Mr. and Mrs. Thompson had been originals; so, too, now was he. Concerning their part in this, Tommy's parents faced a problem that is shared by many parents of teenagers today. Like Mr. and Mrs. Thompson, many of the current generation of parents, now in their 40s and 50s, experimented as teenagers in the '60s, and engaged in extensive drug use then. These parents often don't know how to present their own experiences of adolescence to their children, or at what age such disclosures should take place. And, in light of the choices they themselves made, these parents often don't feel justified setting up rules for their own teenagers to follow where drugs and sex are concerned. This was the case with Mr. and Mrs. Thompson. They felt guilty about their past experiences and the effects on Tommy. And their guilt was compounded by their bad feelings about their divorce, which in turn had dealt another blow to him. As a result, both parents had difficulty setting limits on him, and Tommy sensed this. There are no rules! he announced to me, at a session I had with him and his parents early on in the evaluation, to inquire about the policies they might have set about alcohol and drugs. Tommy's
use of drugs, which was only partly driven by his needs, may have been additionally driven by his parents' inability to resolve their feelings about their own drug use. As an aside, I think it's important to point out that there really is a unique challenge facing this generation of parents, as they confront their kids' experience of adolescence. Such parents often struggle with conflicting values in trying to guide their kids' behavior: for example, while not wanting to condone drug use, such parents often do recognize the importance of taking risks as part of growing up. And so, while not wanting to impose prohibitive rules on their kids, they want to teach their kids the importance of good judgment, concern for safety, and the place of responsibility in making decisions. This is a new message for parents to send, and we need a new language to express it. Here, again, I think we play a valuable role, as therapists who have drug expertise and can provide parent guidance. In Tommy's part of the evaluation, he readily admitted his regular use of marijuana, most weekends over the past year. He matter-of-factly agreed that this amounted to more than experimentation, though not to addiction. Though he occasionally drank, he denied using other drugs. In answering a question that is always key in working with substance users, Tommy warmed to the task of explaining what he especially liked about marijuana: It's fun, it's bad and I like trouble. Pot suited him because it was illegal, and counter-culturaland because it made him a member of a secret society of pot-smoking boys, with whom he shared its exciting rituals. One gesture of his conveyed this: at times when we discussed drugs (and other things), Tommy would pull the sleeve of his shirt down over his hand, then draw his hand up over his face, and continue to talk to me as if behind a mask. It was as if he had dropped into a furtive crouch, and the two of us into a top-secret exchange. Tommy had a history of difficulty with schools. He and his primary school had parted company over his tendency to engage in disruptive pranks; he was asked to leave his next school when he was caught doing graffiti on school property. Now he was facing suspension from a third schooland he was barely 15. Yet Tommy had managed to convince everybody in his life that his drug use was no big deal. No big deal was Tommy's motto, the summary assessment he made of most of the trouble he'd been in these past few years. What was disquieting was the extent to which everybody in his life agreed,
including his former therapist, who thought Tommy was, at most, experimenting, and his parents, who showed concern over his drug use but did not seem to know how seriously to take it. The consensus seemed to be that Tommy was so basically bright, personable, and cooperative his occasional episodes of unruly behavior could be overlooked. It was as if you were dealing with Eddie Haskell, the ever-polite friend of Wally Cleaver's on the Leave it to Beaver show years ago: You knew he was up to something underneath, but how could you fault him, when he was so basically good-natured most of the time? Imagine my own discomfort when I found myself considering an outcome similar to everyone else's in my own assessment of Tommy's drug use. After all, while he clearly used regularly, he showed none of the signs of a serious drug problem: he
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never cut class or avoided any academic responsibilities; he did his homework faithfully; was a B student; never used during the week, and so on. But here was a case where the scale of drug use, per se, was an inadequate measure for determining whether or not this kid had a problem. In his drug use, Tommy demonstrated a pattern of being drawn into episodes of oppositional and aggressive behavior, which invariably led to his being found out and inflicting damage on himself. Drug use was only one of his venues: graffiti, hostile pranks, and bouts of cursing served a similar end. No matter what the venue, Tommy showed signs of expressing a dissociated set of experiences and feelings, including aggression, hostility, selfsabotage, that were notable precisely because they were so at odds with his otherwise agreeable self. Signaling, too, that this other dimension of self-experience was split off from the rest of his personality was the fact that Tommy had no understanding of these episodes, no clue, as he put it, where they came from. They were not subject to his customary thought, or mediated by any understanding at all. At the end of the evaluation, I told Tommy and his parents that I didn't think he had a serious drug problem, but that I thought he had a serious problem that he had consistently minimizedno big dealbecause the extent of his misbehavior, in whatever domain, had always managed to remain circumscribed. I said the measure of his drug use, in and of itself, was a distraction from this greater problem, which threatened to cause him greater damage in his life as the stakes got bigger. I recommended individual psychotherapy, which would allow for continued attention to his drug use, but within the context of a broader treatment.
Course of Treatment
Early on in my work with him Tommy let me know that, alongside his generally cheerful nature, there was another part of him that could not tolerate being told what to do. This idea first emerged in the form of an ideological conviction, as Tommy spoke to me of his belief that no peoplebe they educators, parents, or therapistshad the right to tell any other people what to do. There was an air of rhetorical debate to these early sessions, as Tommy, in true adolescent fashion, defended his beliefs about freedom by coming in and speaking of the French Revolution, or by educating me about the use of veto power by each house of Congress. The issue of freedom became more real to him as Mr. and Mrs. Thompson took steps to set clear guidelines for Tommy's behavior. They now told Tommy that they expected him to abstain from cigarette smoking, drinking, and drugs, and specified consequences if he didn't. Tommy was indignant. He lectured me about the limits of parents' prerogatives to control their children's behavior. Parents could talk about what they felt, but not tell you what to do; they could say what they thought, but not decide for you; they could give you options to consider, but not ones you had to follow. As you can hear, this was more than a case of an overindulged kid chafing at limits. This seemed to be a case of a kid whose autonomy was so fragile that he experienced every rule as an assault, any exercise of authority over him as a threat to his selfhood. Even an improperly worded sentence could intrude on his tenuous sense of self. Seen in this light, drug use was a way for Tommy to try to delineate his autonomy, and to send a message that he could not be controlled. As everyone knows, drug use often offers kids an outlet for expression of their autonomy, but in cases of deeper involvement drug use often suggests serious conflicts about independence. Stanton and Todd (1982) coined the term pseudoindividuation to describe the way that drug use can serve as a playing ground for a youth's independent strivings, all the while delivering sufficient dysfunction to ensure that the youth never leaves home. Tommy's sensitivity to any insult to his emerging sense of self set the stage for showdowns with authority. One dramatic example occurred early this year. Mr. Thompson had promised to take Tommy on a business trip to Brazil. However, following an extended period of sobriety, Tommy was showing signs of getting into trouble again. He came home one night with alcohol on his breath, and Mr. Thompson put his new guidelines into effect, grounding
Tommy for one night that weekend. Tommy was incensed. They can't ground me! They can't tell me what to do! They can try to influence me, but I can veto them! Grounding is pointless; it only guarantees that I will detest them! In this spirit, Tommy pressured his father into letting him choose his own night of the week not to go out, thereby transforming an attempt at grounding into his own decision to stay home. A few days later, when his mother caught him smoking cigarettes and grounded him again for that evening, Tommy announced, I am not honoring your groundation! He left for school and did not return. His parents located him at a friend's house, where he had set up headquarters with his telephone pager. He proceeded to field a
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series of telephone calls from both his parents, who alternately tried to demand, coax, and plead with him to come home. Adding to the tension was the upcoming trip to Brazil, which Tommy now dared his parents to revoke. He was like a little field general that day, firing off communiques and manipulating his troops, all from the safety of his bunker. Tommy won this face-off with his parents over freedom, as he put it. Observing it, I told him that I was very impressed with just how much he was willing to give up in the name of freedom: weekend privileges, various private schools, even a possible trip to Brazil. How was it that there was no other way of proving his freedom other than by doing damage to himself? Because it's more effective, he coolly replied. He explained that he knowingly found ways of hurting himself, in order to show people that they couldn't infringe on his freedom: they could do so only at his peril, or at the peril of their own guilt. Here, Tommy was acknowledging the part that aggression played in the dynamic between him and his parents, and in his choice of symptoms, especially drug use. Leon Wurmser (1978) has written of the role that aggression plays in drug addiction, often appearing in masochistic or sadistic forms. Chronic drug use is, by definition, self-abuse, but most serious drug use also entails a dynamic of self-sabotage or self-sacrifice occurring on a larger, relational plane. This was the case with Tommy, who knew that hurting himselfby getting expelled over drug usewas the surest way of hurting others, namely his parents. Tommy's aggressive showdowns also served another agenda: protection of his developing sense of masculinity. Tommy and I had come to understand that he hated to be told what to do, because it made him aware of feeling helpless, to which he overreacted by lashing out. Tommy took to this idea as our discovery, and noticed that this experience arose for him issues well
beyond the area of his drug use. It comes up a hundred times a day, he told me, and illustrated how, on one occasion, when he'd placed his foot on a girl's chair, and she'd told him firmly to remove it, he felt such a flash of anger that he shot back an offensive reply. I'm a nice guy, but I can be really mean I can be a prick. Underlying Tommy's intolerance of any curtailment of his freedom seemed to be a sense of threat to his masculinity. This issue came into focus around an incident at school. For Tommy, school is the ultimate authority, seeking to control his every thought and behavior through its arbitrary rules. That his suffering over this is more intense than mere, adolescent disaffection might suggest was evident when he returned to school following spring break, and experienced a feeling of oppression more keenly than ever. He spoke of feeling powerless when he realized that, after doing one hour of homework, he still had another hour to goand then another two days in the week, another two months in the year, and another two years until he graduated. I don't think I can make it, he told me, as his face began to twitch. I think I'm going to have a nervous breakdown, and he began to cry. Just days after baring his vulnerability, Tommy was caught in an episode of writing obscene graffiti on the school wall. Along with a group of boys, he ridiculed a female classmate by writing of her that she sucked dick, and by naming a school employee that she supposedly did this with. When a letter was sent home informing Mrs. Thompson of this, she was mortified and upset: she grounded Tommy and demanded to know what had happened. Tommy, in turn, lashed out. He flung the same vulgarity at his mother, and ended with his signature outcry: You can't tell me what to do! This outburst located the eruption of Tommy's aggressive, masculine impulses in a new place: his relationship with his mother. To briefly recap his history, Tommy was a boy who had been brought up by a mother who had, according to her account, left his father for a woman. It was possible that, on some level, Tommy feared that his mother had not only repudiated his father but masculinity in general. His macho posturings could then be seen as serving not only to shore up an emerging masculinityas would be typical of any middle adolescentbut to protect it against serious threat. Tommy needed to come on strongto be a prick, as it wereto defend a fragile position. Here, drug use perfectly suited Tommy's needs, because it offered him a ready-made phallic adventure. Tommy's accounts of smoking marijuana were
replete with male bonding and bravado: he smoked with boys, furtively bought drugs with boys, and purchased them from dealers who were men. When I observed that his enjoyment of pot smoking seemed somehow to be a guy thing, he agreed that he liked marijuana more for the ritual that surrounded it than for the short-lived high it gave him. In this, Tommy was like many substance users, who develop a reliance on a drug-of-choice less for its chemical effect than for its function as an
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indispensable agent in mobilizing aspects of themselves felt to be inaccessible at other times. Pursuit of THC could never make Tommy a pothead; pursuit of manliness could.
Conclusion
This case is ongoing; Tommy is actively engaged in work on these issues. Regarding his drug use, he now smokes marijuana on an occasional basis, which is much less frequently than before. But the very fact that he has not been willing to forego it speaks to the fact that, for Tommy, not only is drug use linked to autonomy, abstinence may be linked to submission which, for him, would undermine sense of self and gender cohesion. Being aware of these implications does not make me inattentive to his behavior. Rather, while being respectful of the place that drug use occupies for Tommy, I continue to track his behavior, using my understanding to frame his drug use in terms of the relevant conflicts for him, and to raise questions about the means he uses to achieve his ends. Not long ago, Tommy told me of an encounter he had with his friends. Tommy often expressed his enjoyment of his friends, and their shared pursuit, by fashioning nicknames for them out of their drugs-of-choice. Joey-the-pothead and Mike-Mr.-Magic-Mushroom were terms of endearment he used for his friends and the interest that bound them together. This time the group invited him along on another of their aimless outings that often resulted in drug use. I said, You know? None of your friends sound like they're into making anything of themselves. He allowed as how he'd been thinking that himself, that lately they had appeared to him to be more like a bunch of functional crackheads, and that he had chosen instead to go home, on this occasion, and do his schoolwork. Throughout this talk, I have been emphasizing meaning as a critical dimension in the phenomenon of drug use, frequently overlooked in contemporary discussion of the problem. That does not mean we should ignore other causes.
Heredity, biology, culture, environmentall contribute to the vulnerability that any one individual may feel to the lure of drugs. For that reason, many have viewed drug use as one of the most overdetermined of problems, without even considering its versatility as a symptom of psychological distress (see, for example, Levin and Weiss 1994 ). But in clinical circles and work with drug users, and in applications of that work in settings like schools, meaning should get its dueand should drive approaches to assessment and treatment. I have been sounding this theme in the hopes of interesting you in the effort to understand drug users, and to engage you in the work of educating others. One obstacle to this lies in the realm of perception: drug users are seen as enemies of meaning. They are dismissed as acter-outers, un-psychologically minded, perennial adolescents even after they've grown upin short, not a group to waste interpretations on. One task we face in imparting our perspectiveto parents, schools, and other cliniciansis the dismantling of stereotype. Drug users themselves are not exempt from these feelings. While it is true, dynamically speaking, that as patients they tend to defensively resort to action and externalization, they also know and come to assume the disparaging characterizations made of them; many an addicted patient has chided me for expecting him to sit and think, when he and I really know all he's capable of is acting out in search of instant gratification. Our biggest challenge, then, is to interest drug users in their own behavior and, ultimately, their inner lives. In offering them the model of our own interest, we hope to engage them in an inquiry that becomes the central therapeutic task, and that serves several functions. First, the shared commitment to inquiry, borne by the therapeutic relationship, provides a holding environment that can act, to some degree, as a check on using behavior. Second, while the interplay of questions and exploration of drug use first takes place between therapist and patient, over time analytic inquiry is internalized, contributing to the growth of the patient's own observing ego function. Next, while I would never be so pollyannish as to claim that offering patients meaning is as gripping to them as getting high, it does have its benefit. Telling a patient that his behavior means something, is telling him that he means somethingwith all the valuation that implies. For drug-using patients, so accustomed to debasement and shame, meaning confers grace, and is a reminder of humanity.
Finally, in seeking with our patients to understand the function of their drug use, we hope to help them arrive at healthier ways of meeting their needs. In this way, though meaning doesn't provide a cure for drug use, it can provide a basis for
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change.
References
Levin, J. D., and Weiss, R. H. (1994). The Dynamics and Treatment of Alcoholism: Essential Papers. Northvale, NJ: Aronson. Stanton, M., and Todd, T. (1982). The Family of Drug Abuse and Addiction. New York: Guilford. Wieder, H., and Kaplan, E. (1969). Drug use in adolescents. Psychoanalytic Study of the Child 24:399-431. New York: International Universities Press. [] Wurmser, L. (1977). Psychodynamics in Compulsive drug use. Research Monograph Series 12:40. Rockville, MD: National Institute on Drug Abuse. Wurmser, L. (1978). The Hidden Dimension: Psychodynamics of Compulsive Drug Use. New York: Aronson.
Article Citation [Who Cited This?]

Director, L. (2000). Understanding and Treating Adolescent Substance Use. J. Infant Child Adolesc. Psychother., 1:97-110
Copyright 2013, Psychoanalytic Electronic Publishing.
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Parents and the Evaluation Process

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Copyright 2013, Psychoanalytic Electronic Publishing.

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