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Methadone Maintenance:  A Freudian Humanistic Approach
(Treatment on the Patient’s Terms)

Don’t distract me with the facts—I seek the truth.

We cannot help those who are ailing solely by means of our impulse to help, but through understanding which comes from knowledge of feelings and relationships.  These I express in the following poem, and are validated in the experiences of a methadone patient whose letter follows the poem.  [Neither of us had read the other’s before writing what we had to say here.  Any serendipitous correlation is part of the reality of the healing relationship; and any love (for love also is part of our reality) was not for a moment physically or emotionally sexual.  (Sometimes, Doctor Freud, not only is a cigar merely a cigar, but human caring is just that, and harmonious into the bargain.)]


For a Patient Maintained on Methadone

Over and over and over and over and over and over and over
you have overlooked me.
Each day I see you and see you in a new way.
I look to someone new in you and speak.
Each day you pretend to listen
and prey on me repeatedly.
I understand something of how you feel,
especially that you suspect I prey on you,
that I repeat my rap on you
over and over and over and over and over and over and over.
You may never see me clearly.
I have no lease on reality,
but I think you’re crazy.
You think I’m dull.
I don’t trust you
to be anything
but unreliable,
self-centered with little self to center.
But I love you.
And you know I love you.
I give you not enough
because nothing is enough
and I do not give you nothing.
So, dully I give nothing to you
in moderate doses,
wishing you would take something
instead of nothing.

The daylight truth is less extreme than verse’s version.
We take turns in trusting and in giving.
And who I wish you be is no different from who you wish you were.
But when you become more whole and leave me
I will miss you less than when you first came to me
and were most distant from me.
And when you leave and are more yourself
(or broken go to heaven)
I will know you better than myself,
and will have been a better mother for you
than my own had been for me.


Comments from a Long-term Methadone Patient

Seeking help, but not trusting or believing that you could do any good.  Attempting to use methadone as a replacement for heroin and preying on you more and more.  I needed your help, but the extreme fear of withdrawal made me prey on doctors and everybody I could.

You see people like me every day.  I know that most addicts play the same game over and over.  Lie, cheat, steal—these are the attributes of the addict.  The simple fact that you put up with this means a lot to me.  I had seen multiple doctors and multiple programs.  The one difference I noticed in you is you first gave me a little trust, and more importantly you allowed me the option to fail and still try again.

Fear was my motivating factor.  With the high levels of heroin that I used, sooner or later I was going to die.  I knew this, but the drug’s power over me made it impossible to think rationally.

Love was something I never felt from my folks, let alone a doctor.  To be truthful, at first I thought you were preying on me.  After a short time I found out that your feelings were sincere and your love true.  This simple truth changed my life and allowed me to trust a little.  As time went on I learned to share myself with you.  I never felt this way before, and it made a great difference.  As an addict I didn’t have any sense of myself.  The real truth was that I was hurting myself and really didn’t know it.

Fear is an overwhelming feeling.  This is the way I felt about detoxifying.  And fear builds on itself.  Agony is the only way I can describe how I felt the first ten days.  But you told me that it wouldn’t last forever and that it would diminish with time.  Much to my surprise, you were correct.  The agony is over, and at the three-week mark I am only in discomfort which I know will, sooner or later, end.

There were a few things I didn’t understand.  First, no matter how much pain medication I took, it didn’t help at all.  This was a great shock to me, being an addict.  Second, my short-term memory loss was extreme, which did bother me greatly.  Your reassurance that this would all pass helped me see detoxifying for what it really is.  The emotional bonding I had to methadone was greater than the emotional bonding a normal person has for its mother.  If you can imagine detoxing from your mother then you will understand what I mean.

Emotional work:  Through my psychotherapist I was able to find out why I had the need to use drugs.  Once I found out why, then I did work on those reasons.  Much of the work we did was mentally very painful, but now I know that it was necessary for my own well-being.  Because of this I don’t feel any craving or desire to use.

I also feel a kind of guilt because I know when this process is over I won’t need you for addiction treatment any more.  It makes me feel like I’m abandoning you, even though this is also part of the process.  I love you and don’t want you to feel dumped.

I’ve learned quite a lot over the last seven years.  You and my psychotherapist have been my teachers.  You’ll always have my gratitude and my never-ending respect for the work you do for addicts.

With love,


Treatment anchored in the patient’s power to choose will be more effective than treatment contingent on compliance with community standards.

All treatments share the purpose of relieving the patient’s suffering.  (We certainly can’t use treatment to make people behave the way we want them to; that just doesn’t work.  And besides, I don’t know for sure how I want each patient to behave.)  Many methods may be valid, may be ways to help the sufferer accomplish treatment goals, more successfully to pursue her or his own life and health in harmony with the social setting, to participate in a living human community.

Variations in treatment approach are, in fact, based on variations in philosophy.  It certainly does matter what are the underlying assumptions, perceptions and concepts of persons and relationships.  The clinician’s feelings, communications and behavior will be guided by the underlying philosophy of treatment.  In other words, our ethical behavior and the effectiveness of our efforts will be determined not only by our intentions, but especially by our clear thinking in building the treatment setting, integrating the basic two parties of the clinical relationship (patient and clinician) in their manifold intricacies.

There are controversies about all treatment choices, varying perspectives and interests.  There are positive aspects of drug use and abuse, or the person who is addicted would not have become addicted.  There are destructive aspects of drug use, or patients, their families, the community as a whole and its institutions would not try to change drug use and dependence.  Certainly without good reason we would not choose to oppose the powerful illicit drug trade nor the powerful pharmaceutical manufacturers.

No treatment modality can eliminate controversy from the drug treatment arena—none is successful enough at curing, nor is any theoretic approach so convincingly comprehensive that it can resolve our conflicts.  Leon Wurmser outlined such political conflicts about methadone maintenance a long time ago1, and those conflicts have not changed.  If we think clearly and communicate respectfully , we do not need to agree about answers so long as we have clarified the questions.

The clinical relationship is the essential tool of all processes of diagnosis and treatment.  Only through our relationship with the patient can we attend to who she or he is as a person, perceiving clinical reality through our own understandings and sensitivities as human beings.  Then we can know, communicate and decide.  The ethical goal of all clinical endeavor is to enable the patient better to make his own choices.

No one becomes a patient who has not in some way chosen to enter that relationship for his own sake, even if it is by virtue of having been arrested or having suffered overdose again but survived to struggle longer.  He may prefer to be well, but suffering this disease of addiction, reluctantly he has chosen treatment as his best option at this time, all things considered.

By the same token, no one who becomes a clinician can effectively serve patients unless he or she is compassionately aware of his or her own propensity to addiction, whatever its nature—even workaholism or pathologic altruism.  A clinician need not be sick to find the capacity for sickness in herself.

Although each patient meets many clinicians, we can clarify our view of the clinical relationship by seeing it as a two-party human relationship.  It differs from ordinary interpersonal relationships mainly in two ways:  that it is lopsided and that it cannot be done intuitively by the clinician.

The clinical relationship is lopsided because it is for the sake of the patient, not for the clinician or the clinic or for any other party.  The clinical relationship demands much more of the clinician or clinical team than to be good persons or to have good intentions, because good or intuitive persons are naturally self-serving, at least to the extent of making trade-offs with the other party.  We cannot succeed in addiction treatment by “making deals” with the patient.

If the patient is down and if we are to help him (which is, in fact, the implied clinical contract) then we must acknowledge a special form of human relationship and interaction.  It demands conscious and careful awareness from each clinician and from the clinical team as a whole, so that eventually the patient may become more autonomous.  (Then we may get the emotional “pay-offs” we had wished, but it comes from the wellness of the person who has been our patient, not from his illness.)

How can we do addiction treatment for the sake of the patient’s self-interest when his self-interest is what brought him to become addicted?  How can we ignore the immediate needs of the clinician who (we hope) shares the interests of the general community against the exigencies of drug trade and drug abuse, and all the repercussions thereof?

Methadone maintenance and buprenorphine maintenance are done only in specially licensed clinical settings which operate under stringent federal and state regulations enforced by several layers of full-time officers.  The purposes of those regulations are simple and clear:  to make reliable treatment available for the addicted person (which may incidentally reduce crime and other public expense); to prohibit inappropriate administration of potent drug to anyone not already a chronic addict, or diversion of drug into uncontrolled illicit markets.

Methadone maintenance regulations require random urine screening for drugs of abuse, and demonstration of clinical progress at self-control for the privilege to come to the clinic less frequently than daily, to be able to carry out some small supply of drug for later self-administration.  These regulations impose some outside behavioral controls meant to protect the society’s interests.  (The patient is pressured to comply with societal expectations or be punished or exiled.  It seems always to have been so.)

Payment for one’s own treatment and minimal rules of decorum and safety tend to protect the interests of the clinical team and its institution.  These provide ground for the patient to try new exercises in compliance (skills required for survival of the patient’s self).

Within these containments clinicians have relative freedom to dedicate most of our energy and attention to the welfare of the patient as he chooses it.  Clinicians do not have to be police.  We can let the interests of society, institution, and clinicians themselves remain in the background as we focus on the welfare and autonomy of the patient.

Chronic opioid addiction is the paradigm about which our treatment is structured (a structure approximately adapted also to the treatment of other varieties of compulsive afflictions).  The substances themselves (diacetylmorphine, oxycodone, hydromorphone, fentanyl, propoxyphene, et c.) are not so directly destructive, but there are contingent potential problems such as overdose, tolerance (which requires an ever-increasing supply), the deadly exigencies of the needle (AIDS, hepatitides, et c.), adulteration and its concomitant variable potency, inadvertent toxicity, requisite evasive life style, constant fear of control (law enforcers, and righteous persons including employers and mothers-in-law), shame, alienation, financial insecurity, physical injury (especially driving a motorcycle), unstable supply, hostile armed suppliers and thieves…

So, I guess opioid addiction is eventually untenable.  I cannot recommend it as a good choice for you, nor can I recommend any other addiction (if I care about you).

Yet these are molecules we have for thousands of years known as miracle drugs for relief of pain!  We have used them to save lives.  How can we now typify them as evil molecules?

Molecules carry no moral charge.  A most dangerous myth of our culture is that there are dangerous drugs.  It is our ways of using drugs which may be dangerous, or our false conviction that they are inherently powerful.  Our behaviors about drugs are certainly destructive, but not the molecules themselves.  Because we fear the effects of our having drugs in our environment (or loaded firearms) we are anxious to control their availability or use.  That is what we mean by “controlled substances”, that our society tries to control what we see as potent and potentially dangerous substances.

Cocaine’s cultural history is instructive.  A hundred years ago it was our modern miracle (though it had already been ancient to other cultures).  When we European types could not control our behaviors in relation to it, we outlawed it.  It didn’t disappear but came to be seen as so low it was hardly sought or found by “white” people.

From the nineteen-sixties cocaine was slower in its market ascension than many other drugs, and by the nineteen-eighties, closer to the peak of its popularity, despite reality to the contrary it was considered a pleasant, non-addictive “recreational” substance.  As a result of a combination of more widespread use and more effective and immediate ways to deliver cocaine to the brain (injection, free-basing and then “crack”), its use became recognized as deleterious.  We then began to see cocaine (and subsequently methamphetamine, another potent stimulant) as “the most strongly reinforcing” drugs2, and now we are horrified by those molecules.

There is no ”worst” drug, nor no “best”.  Molecules are morally neutral, inert.  Only human persons possess moral value, and seem to convey it to their tools, weapons and drugs by projection.  This results in our cultural pendulum-swings, attitudes divorced from reality.  It is our cultural perspective which waffles and wavers according to our impulses of the day, the power of the purveyors and the behaviors of our ephemeral popular heroes.

Chronic opioid addiction is a paradigm of addictions because the administration of such drugs early becomes continuous and daily, tolerance progressive and potentially unlimited.  The effects of the drug itself seem physiologically positive, at least not destructive or debilitating.  (It is the exigencies and appurtenances of the drug which are untenable and intolerable, which cause disease and death.)  Discontinuation of use becomes illness, so supply is essential to wellness (but supply cannot be maintained.3)  With such inexorable dependence comes intense emotional attachment.

Many addictions other than to opioids may seem similar, but are somewhat different in that they require an intermittent discontinuation lest they result in collapse and death.  Some molecules make the user sick or debilitated directly.  One cannot drink alcohol without surcease.  Continuous use of stimulants is madness, for it causes madness.  Enough sedative will render you unconscious, so you must discontinue use until you again awake (if you again awake).

The lack of inherent toxicity of opioids allows repeated and continuous use (we administer ongoing infusions for little old ladies with broken hips), and mounting tolerance demands use several times a day.  It is the same lack of inherent toxicity which allows substitution maintenance with long-acting opioid substances like methadone and buprenorphine.  Such substitute clinical tools are not available or practicable for other sorts of drugs.

With maintenance therapy stability and essentially normal functioning can be maintained, so with chronic opioid addiction other therapies, including psychotherapies, can begin before detoxification.  Because the psychopathology of opioid addiction is profound (but not untreatable) the course of treatment will be long—more than a few months, and extending well beyond physiologic detoxification.

Even though each patient is unique, chronic opioid addiction likely will manifest similar or common symptoms because the conditions of supply and use will be similar for all patients.  I expect an opioid-addicted patient to be preoccupied with getting a stable supply of drug (which cannot be done outside of maintenance programs); to fear beyond the limit of reason intolerable withdrawal (“jonesing”); to be evasive of any scrutiny or intrusion.

Behavioral and emotional pathology of opioid addiction seem common to most all opioid addicts. (“If you’ve seen one, you’ve seen them all.”)  We think we know about “addictive personalities”4 and we stereotype addicted patients’ behaviors as sociopathic.  How can we almost get away with applying regimented protocols to these folks?

Once a person is compelled by his addiction to be preoccupied with procuring and administering drug his behaviors will reflect it.  Because the community about him will do anything to stop him, he must evade detection.  He will do anything to get drug, and he will do anything to protect his supply (except to give up his own consuming of it away to nothing).

He seeks to maintain a semblance of relationship with other persons because he needs to use them to supply his needs.  Despite his normal sentiments for them (especially for his children) his function in relation to them wanes (sooner or later).

He must deny his profound pain and emptiness, his insatiability.  He denies his emptiness and pain not only to others but tries to hide that from himself lest he have to acknowledge the despair of losing identity and self-esteem.  He cannot honestly relate to others, nor can he honestly experience his own feelings.  The person who is addicted suffers an immense and chronic deprivation of honesty.

The addict becomes unrealistic and self-centered, but in order to evade obstruction of his drug use and to procure a supply he must be acutely aware of others in what seems an “insensitive” or unsympathetic fashion.  Where is his locus of focus?  Is he more grandiose or more paranoid?  Is he more rapacious and daring or more dependent and fearful?  Is he more in control (titrating his state of mind, dosing it out carefully—as he pretends) or is he more out of control (having no free choices)?

No one person is thoroughly ill.  No real patient can fulfill our stereotype.  But let us try now to abstract the psychopathology of the chronic opioid addict:  a primitively pained person (or why would he use “pain medication”?) whose unrealistic hidden expectations long since were frustrated so deeply or repeatedly that he has become psychotically preoccupied with relation to drug as if it were a person, and he acts out that crazy behavior.  Indeed, he has become a “drug fiend”.

It is psychotic in my estimation (unrealistic, crazy) to relate emotionally to a substance.  To love a pet is sane because an animal has personality.  To love a person through symbols of that person is sane as long as it is the person rather than the symbols which is cathected.  (I value the picture of my beloved only as it symbolizes my beloved’s self.)  To be in awe of its creator through the realities of the universe is sane.  To love drug is insane, psychotic.

How can we hope to help heal such suffering?  What tools can we use?  What goals shall we adopt?

Now I propose a research project culturally harmonious with our age.  If this is worth pursuing, please feel free to take it and pursue it.  I myself have no wish to do so.

Methadone maintenance or buprenorphine maintenance can stabilize the addiction so that treatment can begin.  The drug will be dispensed according to stringent regulations.  Increasing individual freedom of movement and activity will depend on fulfilling behavioral criteria of treatment progress—“compliance”.

Here is the proposed research project.  Let us take unreliable and uncontrollable human beings out of the clinician roles.  Rather, let us modify an automated bank teller machine, a robot controlled and sterile, so the client’s interaction can be a verbal interchange something like this:

“Please insert your card, enter your personal identification number; put your right thumb down on the scanner and articulate your password so my voice analyzer can identify you…Good morning, Mister Ira Smith, birth date August 12, 1962.  You are indeed a client of the Drugomatic Clinic.  Your fee is due; Please deposit seventy-five dollars in the deposit receptor…Cash only, no checks or credit cards accepted…Thank you…Please remove the receipt for your payment…My random number generator has determined that your urine is to be screened today.  Open the yellow specimen depository door which is just below waist level.  Deposit your specimen now…Thank you, Mister Smith.  Please wait ten seconds while my gas chromatograph analyzes your specimen…Thank you for waiting.  Your urine contains metabolites of methadone in adequate concentration (which shows you have not been selling your take-out doses on the black market), and traces of pseudoephedrine, a legal over-the-counter decongestant or appetite suppressant for which you will not be penalized.  (But I know you’ve been doing speed or smoking ice.)…Please present a valid student identification card or a recent pay-check stub face-down on the scanner at the left side of the console, as proof of your current employment or school enrollment…Thank you, Mister Smith.  You continue your studies at the medical school…Your current methadone maintenance dose is forty milligrams per day.  Do you wish to decrease your dose by ten per cent?  Press “Y” for Yes or “N” for No…Thank you.  Your dose will be diminished…You qualify for take-out doses through the holiday weekend, a total of three containers each of thirty-six milligrams of methadone.  Do you wish to exercise this hard-won and well-deserved take-out privilege?  Press “Y” for Yes, “N” for No…You have opted for your take-out doses.  Please wait fifteen seconds as I measure out and label your medication…Please open the blue dispensing door.  Drink the liquid dose in the blue plastic cup for today’s treatment.  Throw the empty cup in the trash receptacle behind you.  Do not leave trash on the floor; you are being monitored by closed circuit television…Check the three labeled bottles for any leak or deficiency.  Be sure your full name and client number are visible on each bottle.  If you have any question or concern, please push the red button on the console to your right and a real human being will come out here to hassle with you in person…Have a nice day.”

Addiction is an inappropriate conversion of an I-It relationship into the I-Thou mode5, an unrealistic emotional attachment to drug (sometimes in the guise of “Mother/Goddess”).  The underlying psychosis of relationship cannot be healed by protocol, medication or machine.  The client or victim of our impersonal research project may actually become more well, not because of impersonal treatment but in spite of it.  Because he will not be distracted by sadistic or seductive controlling relationships which would recapitulate the childhood experiences which rendered him vulnerable to addiction in the first place, the benign neglect of the impersonal machine will seem a kindness.

Clinical humanism assumes that human needs, constitutions and responses are sufficiently common to be recognizable and understandable as clinical phenomena.  Since the clinician is human also, his or her personal responses are as much clinical phenomena as are the formal professional opinions noted on the chart.  The clinical relationship is lopsided for the patient’s sake, and it is rational from the clinician’s viewpoint, but it is still a human interpersonal relationship.  It is real because of the real persons who are involved in it.  Of course it involves more than merely two persons, but the focus on each real patient had better be primary, or the clinical interaction will become nothing but intra-staff incest, pleasant though it may seem, and the patient will become an emotional orphan or pawn.

Clinical humanism assumes commonness in humanness, but we have just shown it is through unique personality we are human—in our individual uniqueness!  This seeming contradiction is only a semantic problem; there is no real contradiction.  Human needs and conditions are common; human personalities and life-histories are unique.  Just as the solution to a dilemma is in the encompassing and digesting of both its horns simultaneously, the dialectic dissolution of dichotomy is what we do every moment in normal human interaction, especially with polarized and simultaneously confused persons who may be described as suffering from “borderline personality disorder” and other such aberrations.

Psychotherapy of chronic opioid addiction is a process by which emotional investment is gradually shifted from drug to person.  The persons in the clinical setting serve as objects in the transference relationship as clearly as the analyst does in classical Freudian analysis.  The analyst is not “impersonal”, despite shallow stereotypes or American degenerations of the psychoanalytic discipline.

The dispensing nurse in the methadone clinic is no primitive replica of the automated bank-teller; he or she is a person with whom the patient can experience a brief, simple and safe daily interaction which supports and comforts the patient and leads to emotional growth.  Psychotherapy doesn’t have to take an hour a day, nor does it need to be taken lying down.

A blatantly “sociopathic” patient related in a group session that for his first six months of daily methadone dispensing he had perceived Jane as wearing a nurse’s uniform, complete with cap and pin, all white.  She has never worn such a uniform since she left training.  I interpreted to him that he saw anyone who threatened control over him or his drug supply as in uniform with a badge.  Perhaps white was a lighter shade of dark blue.

Provision of methadone is merely a stabilizing tool of treatment which allows the therapeutic relationship to be less vulnerable to disruption.  The relationship will become progressively more clearly interpersonal, the drug will become less important, and detoxification may gradually occur—“the slower the better”.

Calm consistent caring from the clinician acknowledges the realistic situation of the addict, his distorted emotional relationship to drug and the behavioral by-products thereof, which have threatened his very life.  The patient’s acceptance of the humanness of the clinician allows his acceptance of himself as human in his fullest senses.

Acceptance of realistic emotion and relation allows the setting-aside of drug.  Eventually the patient will leave treatment, with some realistic misgivings, but by then his own relationships in his personal life will be more normalized.  He will continue to suffer being human, but he will enjoy it.


Story Time:  a method to accomplish radical psychic change

Few other diseases have such a uniform history as addiction does.  Addiction is a psychosis of relationship brought on by and reinforced by toxicity/withdrawal cycles, brain changes.  Despite its various facets and manifestations, most often addicts can recognize themselves in others’ stories.  (Reliable clarity and recognition will come only during abstinence.)  We are sometimes misled into seeing chasms between different drugs-of-choice when those differences are merely variations in brain effects and cultural exigencies (patterns of use), not differences in basic pathology and behavior. 
The variations of molecules, settings, and behavior patterns are secondary to the basic addictive disease, even though they may dominate our vision because they seem very colorful and dramatic.  The methamphetamine addict, the heroin addict, the alcoholic, the smoker, the compulsive gambler, and a great many others whose compulsive pathologies cause suffering to themselves and those around them share an underlying repetitive habit pattern which distracts them from productive attention to “real” relationships and attachments.
The addict is isolated by her or his addiction, and is especially isolated by an obsessive preoccupation with procuring a supply and using it, and thinking and feeling the addiction rather than thinking and feeling the rest of his or her life and body.   Despite varied appearances, all such sufferers share this common isolation and separation from reality.  When the suffering seems a bit less severe, denial of the addiction can be much stronger; the addict is the last to know how devastated she or he appears to any other who pays attention.
There are some common misleading myths which deserve careful scrutiny, represented in such buzz-phrases as “chemical imbalance”, “addictive personality”, “hedonism”, and “lack of will”.  These phrases appear attractive to us but should scrupulously be avoided as they lead us away from the addict’s recovery.  Rather, these phrases may leave us with a sick person who complies only externally in order to protect and serve the addictive disease.  Even more likely, using these phrases may lead the addict abruptly to run away from a last chance to live.
The right time to elicit an addict’s unique personal story is when he or she is admitted to alcohol/addiction rehabilitation treatment.  That underlying story will be one more note in the harmonious shared story of addiction explored in the group setting.  The group will keep the individual honest because they also know this tune.   This process leads to a sort of personal inventory, the central tool of Twelve Step recovery programs (or equivalent therapeutic touchstones).
I propose a straightforward method of eliciting an honest story from even the most symptomatic addict.  This method begins with as little as a single syllable from the self.  The effectiveness of the method does not depend on the verbal talents or cerebral elaborations of the patient, but on a simple beginning expression (even silence or a refusal to cooperate).  This initial datum is shared with the treatment group who are quite capable of discerning the truth of the addiction story (which they also have lived).  However, what is useful of the story holds the key for treatment, rather than any negative judgment from the group or from the therapist.

I have said I seek to elicit the honest story from the suffering addict, but that isn’t what she or he willingly can offer, for the symptomatic compelled person cannot see clearly what she or he is hiding from those who confront her or him.  Years of practiced duplicity arduously have been contrived and refined to protect the beloved addiction.  This patient is only in treatment because outside pressure is beginning to outweigh the addiction itself, which is crumbling under its own weight.  The infrastructure of the addiction is collapsing (health, wealth, freedom) and the integrity of the façade which has protected the addiction from a disapproving and uncooperative “real” world is now eroding.
However, the patient cannot lie.  Her or his very presence in a treatment setting announces the crisis, and in a sympathetic but knowing human context it is behavior (including appearance, but not appearances) which will declare the patient’s story.  Professionals cannot “see through” duplicity by knowing more than the patient does about addiction, for that is merely a form of trying to out-trick the patient.  However, humbly and matter-of-factly, to attend to the lop-sided self-contradictory discrepancies in the addict’s own story can be a sort of spiritual jiu-jitsu, using patience and lack of force (wu-wei) as a reliable method to allow the imbalance of the addiction to tumble itself down.  (See my chapter on diagnosis via discrepancies, “Dialogue, Dialectic, Drama”.)
When we dismantle pathologic defenses, we are morally required to provide a safety-net of ongoing support.  We must also dedicate ourselves to a life-long process of rebuilding (for these tasks cannot have been completed in twenty-eight days or even in two years).  This long-term commitment to processes of both ongoing diagnosis and treatment cannot be satisfied by the verbal offer “You are sick and broken, so we will fix you” but must be substantiated by non-verbal reassurance in action “We will love you until you can love yourself.”  That love can be amplified, shared and continued in the broad and ubiquitous recovery community.  No addict need go it alone.
The recovering addict will not be dependent forever.  In the treatment group she or he will find that the group itself (not in spite of the professional staff but with their kind guidance) nurtures and supports each otherwise isolated sufferer--and indeed that very patient her- or himself is an essential and potent part of that nurturing group.  (“Wow!  Now I am a real person!”)
So, in a very real sense recovery begins in the realization I am not alone.  That means (as my feelings attest) I was alone (and my disease was intensifying my aloneness).  My belonging to the group offers me enough support to survive for today, and my own participation is a real part of the strength of the group for each of the others and (amazingly) even for my own sake.

Your Story is a Mantra for the Healing of Your Addiction
You must climb from the pits of self-delusion and self-destruction, or die.
You must tell the truth of your own unique story
even if you have to sing it as a mantra of a single syllable, only one note
(for poetry is condensed verbal music, requires no lengthy discussion or elaboration).
Within the group your story is validated
by the power of having been heard;
your honesty is confirmed by resonance with the others.
That harmony shows your unique story
is indeed the shared story;
its uniqueness remains even as it is shown to be held in common.


1Léon Wurmser, M.D, The Mask of Shame, Baltimore/London: Johns Hopkins University Press, 1981 and “Unpolitic Thoughts about the Politics of Drug Abuse Treatment”, Journal of Drug Issues, 3 178-185, 1973

2 Sidney Cohen, MD, Substance Abuse, vol. II, Haworth Press, London, 1985.  Despite Doctor Cohen’s pioneering bravery from the time he returned to California from the Army after the Second World War, which brought him to be known as “the grandfather of addiction treatment”, toward the end of his life and career he was rattled by his inability to understand or control cocaine dependence in his patients (nor could any of us).  I wished to comfort him, but about this he was too frightened to be consoled. 

3 As I learned from a patient who fulfilled the heroin addict’s dream/nightmare.  Despite the risk from both drug dealers and cops, he stole a coffee can full of “China white”, certainly a lifetime supply if only he managed conservatively.  His plan was to taper himself down by careful rationing, diminish his tolerance and need, and to have the opportunity to “chip” only a bit ever so rarely.  Two weeks later he returned to the clinic for methadone stabilization, out of heroin (of course), with a much higher tolerance, happy to be alive without a fatal overdose, terrified of the dealers and of the cops.

4  By “personality” we usually mean a “personality disorder” which is constitutional, either inborn by virtue of genetic aberration or if inculcated post-conception (even in the womb) is essentially indelible.  To say that having suffered addiction leaves a permanent residue is not to say addiction cannot be treated and alleviated.  My experience and understanding inform me that there is no advantage in using concepts such as “addictive personality” or “Once an addict, always an addict.”

5 See Martin Buber’s I and Thou and the thousands of elaborations and commentaries cascading from it, including my own chapter in this book “Buber’s I-Thou Relationship Applied to the Self:  the possibility of true love and true community within someone’s lifetime” and the recent article “Healing relationships and the existential philosophy of Martin Buber”, John G. Scott, et alia, Philosophy, Ethics and Humanities in Medicine 2009, 4:11.

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