PSYCHODRAMA OF ADDICTION: THE FIGHT BETWEEN THE ADDICTIVE
PERSONALITY AND THE TRUE SELF 
I never cease to be surprised when psychodramatically investigating my clients’ addictions. Invariably, the conflict that arises between the drug—the object of the addiction—and the addicted part of the client’s personality is similar to several tragedies described in classical literature. This is the case when referring to Goethe’s version of the Faust myth.
This is the story of the scientist, Faust, who circumvents the laws of the Church in the Middle Ages to search tirelessly and omnipotently for the solution to the mystery of existence. He has knowledge of various sciences, but none of them satisfies his desire to become a kind of “God,” with unlimited access to everything that occurs in nature.
Aware of his human and nonconformist limits, he is approached and seduced by Mephistopheles (the devil). He commits himself to delivering his soul in exchange for knowledge and intense experience of worldly pleasures and in order to have the gift of controlling time and people, causing them to sway according to his wishes.
The result is disastrous. Wherever he goes, Faust spreads unhappiness, and in the end falls victim to his own thirst for omnipotence as he ends up hurting himself and the only woman he truly loves.
Like Faust, the addicted person tries to circumvent the rules of the system. However, in this case, one is trying to circumvent not only an institution, but human nature itself, thereby challenging its essential vulnerability. We humans are powerless when faced with the lack of logic and justice in the distribution of misfortunes and differences¾the family we are born into, health, wealth, beauty, intelligence, etc.¾and faced with a future unknown to us, guaranteeing only our own death, as well as the deaths of those whom we love.
Parodying the Faust tragedy, the true self of a human being sells his soul to the addicted part in exchange for the promise of quick relief of all the sorrows, pain, and frustrations that normal life brings about.
Furthermore, the observation of several clinical cases has made it evident that the potentially addicted person seems to believe that the lives of other human beings are not the same as his own and do not produce the pain and disappointment that he experiences. He therefore feels he is a victim of life, requiring some extra help to finally become “normal.” In fact, he lacks the capacity to elaborate frustrations and grief¾becoming a victim, yes, but of false relief, a victim of the devil-drug that provides a state of temporary well-being and a life sentence.
Why would someone sell his soul to the devil or self-administer drugs that can kill, lead to imprisonment, or jeopardize his health? This is the question that motivated me to study the subject of addictions, about which I will attempt to be as clear as possible over the following pages, as I present the conclusions I reached.
THE HISTORY AND CONCEPT OF ADDICTION (Twerski, 1996)
The systematic treatment of addiction may be associated with the development of the Association of Alcoholics Anonymous (AA) in 1935. This organization arose from the initiative of alcoholism sufferers working together in their efforts to resist alcohol. The symmetry of the participants (there are no doctors, competent speech makers, or health hierarchies) is the main peculiarity of this group. All participants suffer from the same problem. No one is better or worse than any other. This is merely a group of people who support each other and regard each other as equals.
Historically, addiction was thought to be a sign of moral weakness—a practice engaged in by incompetent individuals who cannot deal with reality. Today, we think of it as a physical, emotional, cognitive, and spiritual disease. The research focus on addiction, which was once limited to alcohol and drugs (oral-injectable), has now been expanded to include other compulsive behaviors, such as food addictions, gambling, sex, shopping, work, and petty theft. These behaviors also induce mood swings, social isolation, shame, and despair similar to what is experienced by alcoholics and drug addicts.
Currently, it is understood that all people have the potential to become addicted since addiction is based on the normal desire to go through life with less pain and more pleasure.
OBJECTS OF ADDICTION AND MOOD CHANGES
There are numerous potentially addictive objects: alcohol, cigarettes, food, drugs, gambling, sex, etc. The choice of the object of addiction depends on its availability. It is very common for an addict to replace an addictive object with another; for example, replacing alcohol or cigarettes with food. It is also common for a person to be multi-addicted (Black, 1990: 74).
What all addictive objects have in common is that they produce a quick and pleasant change of mood, which is typically expressed in one of these three directions:
- Excitement – a hypomanic state where the individual feels all-powerful, omnipotent, and complete.
- Satiety – a relaxed state, full of a sense of being, and of anesthetizing against pain and distress.
- Trance – an altered state of consciousness that provides the two previous sensations. It is somewhat hypnotic in nature and creates a rewarding virtual reality where one experiences a state of heightened spiritual awareness.
The seductive and addictive factor of the addictive object rests largely in the fact that it produces these mood changes very quickly. If the effect of the addiction were delayed, the addiction would not occur.
DEVELOPMENT OF ADDICTION
Addiction is a process. It has a definite beginning, though its exact origin is often confusing. It goes through various stages of development and comes to a conclusive end (which sometimes coincides with the death of the individual).
STAGE 1 – INTERNAL CHANGE
Addiction begins when the addict, as well as all normal individuals, experiences a mood change resulting from the object of addiction. The difference is that for him, this quick escape from a painful reality is extremely pleasant and causes an impact of immeasurable intensity. Some gamblers, for example, start to become addicted after the first game in which they won a large amount of money.
From this point, a mental obsession begins to precede and generate the addictive behavior (addictive acting out). In Stage I, the addict behaves within socially acceptable limits. The object of the addiction is like a friend who helps in difficult times—helping the individual to elude and/or cure the pain.
STAGE II – LIFESTYLE CHANGES
Now the addicted person regularly practices his addiction—drinking, eating, buying, consuming pornography, etc. The addictive behavior is ritualized; that is, a sequence of repetitive acts begins to appear. Rituals preserve behaviors and demand that everything be done in the right order; otherwise, they have to start all over again.
The original personality of an individual (the true self) begins to change and accommodate the addicted personality. People who are related to the addict now realize that something is wrong and, simultaneously, he starts to lie to justify or disguise the behavior. The addiction begins to lose its seductive power. It still helps to avoid the originally felt pain, but it also gradually begins to cause some of its own.
STAGE III – TOTAL LOSS OF CONTROL
In this third stage, the addicted side of the personality gains full control over the “true self,” which no longer offers resistance. The well-being once obtained from the object of the addiction succumbs to the stress caused by the accumulated lies, interpersonal relationship tensions, and displeasure at the object’s absence. The addictive acting out starts to bring more pain than pleasure.
The addict is only able to feel peace and security when involved in his addictive rituals. He avoids any close contact that might reveal his total deterioration. On the other hand, he fears being alone, since he is not aware of how to live life itself. He starts to parasitize family members while manipulating them at the same time in order to get them to meet his needs and act as his caregivers. He tends to be viscous, insistent—asking for another chance or playing the victim, while losing jobs, friends, getting in trouble with the law, and reaching overall personal degradation.
TREATMENT FOR ADDICTIONS
Studies of addiction are pessimistic regarding therapeutic successes. The benchmark of 25% of cures is the maximum reported, if all of the following therapeutic strategies are used together: 1) antidepressant medication, 2) attendance at AA meetings, 3) family psychotherapy, and 4) individual psychotherapy. Each intervention removed from this package reduces the chances of success, which is why each will be discussed separately.
Depression among addicts is difficult to diagnose initially, especially because many patients come to the office in a good mood, complaining of a relational problems, and rarely acknowledging that addiction is their main problem. Instead, the object of the addiction is perceived as a friend who circumstantially helps and can be sent away when no longer needed.
Depression is masked by this self-medication, which makes it difficult to address. Topics such as the injustices of life, gambling, harassment from others, etc., usually occupy the discussions during the first sessions. When the drug problem is addressed and abstinence is initiated, emotional chaos occurs and the frequency of depression increases. It takes much patience on the parts of the addict and his/her family and a great deal of consistency from the therapist.
Studies show that many addicts need to “hit rock bottom”; i.e., an extreme experience of destruction of their own life (loss of employment, marriage, or children, being found drunk in the street, being imprisoned for debts, etc.) before they believe that they have no control over their addiction and start wanting to treat it.
These catastrophic experiences are therapeutic because humans often gravitate from a stressful situation to one that is less stressful. Early abstinence is unnatural because it is less satisfying than the high state that the drug provides. It is like asking someone to throw away their most precious jewel. Only after a person reaches “rock bottom” can this relationship sometimes be reversed and the perception of what is worse changed. The addict becomes frightened by his total decay and wants to do everything within his/her power to once again prevent this catastrophic end.
The crisis (the experience of hitting rock bottom) opens a crack in the delirious protective wall of addictive cognition. It is a rare chance of coming in contact with the real self, but as soon as the crisis passes the crack heals and the delusional system takes over again. Unfortunately, most addicts’ families, wanting to protect their image, cover for the addict, and keep him/her from living out this self-destructive experience. The goal in working with addicts’ families is to help them see that their co-dependence ends up harming more than it helps.
If before abstinence, the patient felt the injustice of his/her reality and the lack of excitement in his/her life, their dissatisfaction following abstinence will take on macroscopic proportions. Many authors indicate antidepressant medication as the first step in treatment, even before abstinence, believing that it will help the addict tolerate the pain of facing reality. Antidepressants are highly recommended, as they are not addictive. Benzodiazepines, on the other hand, should be avoided, since they are addictive, and care must be taken to not replace one addiction with another.
Abstinence is a formidable and very difficult challenge, as it requires
- The addict to lose his/her confidence in his/her ability to control the addiction. He/she needs to know that his/her sense of reality is distorted and he/she cannot rely on him/herself. The extreme experience is a painful fall, but it offers a great lesson. The therapist must help the patient reach the appropriate conclusions.
- Addicts to submit their perceptions to those of someone else in order to see if what they perceive truly exists. Addicts must let someone else (spouse, AA leader, therapist, etc.) take control, and this will be especially difficult for those who were brought up in a dysfunctional environment that led him in the opposite direction.
2) ASSOCIATION OF ALCOHOLICS ANONYMOUS (AA)
Addicts confuse and seduce normal people with their addictive logic. Hence, homogeneous group therapy is especially important, as it requires “a confrontation between equals.” This is the first among the various therapeutic factors described below, and it is largely responsible for AA’s worldwide success. The strengths of AA are as follows:
- It enables the individual to see himself reflected on the members of the group, as in a mirror, and this can be extremely therapeutic because it allows others to point out aspects about the addict to which he cannot admit himself.
- The absence of upper/lower hierarchies and the fact that everyone in the group shares the same addiction and the same shame for intra-family abusive experiences facilitates the approach to the problem itself. “I am one of many, not the weak one in the group.” It also favors the recognition of family values and dispels the myths that stimulate the addiction. For example: a man is only a man if he drinks or having things is having love.
- AA’s twelve-step philosophy posits the spiritual power of a superior, protective, and wise entity (it can be God, nature, health, etc.). This spiritual bias is critical in addressing the “basic insecurity of the addict,” who is naturally suspicious of other humans and of himself. During the first meetings, the attendees must recognize that they do not have control over their disease, but that a higher being does, and that being will help them.
- AA’s notion of time –is to live one day at a time and say things like, “Just for today I will not use the object of my addiction.” This perfectly caters to the enormous difficulty the addict has in delaying gratification. His emotional logic contains only the present—the now! This concept of changing time goes along with the familiar argument: “I can stop whenever I want.” In fact, it is possible. All addicts are experts in stopping a million times, making new resolutions for their lives, and resuming the addiction once again. It is a vicious cycle that can continue for years.
- e) The group supports relapses and welcomes restarts. This can be such a difficult situation to face when one has to overcome an addiction.
- f) Finally, AA assists in the breakdown of addictive rituals and encourages the fact that certain locations should be avoided at certain times; for example, bars, bingo halls, shops, being left alone at night at home, etc.
3- FAMILY PSYCHOTHERAPY AND/OR SUPPORT GROUPS FOR FAMILIES OF ADDICTS
Families of addicts often indirectly stimulate the use of drugs and harbor dysfunctional, co-dependent relational psychodynamics, thus contributing to the addiction by inflicting severe suffering on the individual. Drug use may, for example, be encouraged by family habits that are apparently trivial at first glance, such as excessive use of self-medication, social drinking, smoking, use of caffeine as a stimulant, using food for emotional gratification and comfort, overworking, etc. Children and young people grow up watching adults seek relief from their conflicts and pain with these practices, and this can create future models of conduct in which the children seek to engage.
Moreover, being with addicted individuals can be quite destructive to one’s psyche and the added contact may demand the addition of specific support measures. AA includes groups that support the family members of alcoholics and addicts. These are Al-Anon (for family members and friends of alcoholics) and Nar-Anon (groups for addicted people’s families in Brazil). In these groups, you learn to deal with the psychodynamics of co-dependency. Their fundamental teachings are:
- No one is responsible for the disease of another person, nor for his recovery.
- One should not suffer because of someone else’s actions and reactions.
- One should not allow oneself to be used or abused in the interests of another person’s recovery.
- One should not do for others what they should do for themselves.
- One should not manipulate situations so that others eat, sleep, get up, pay the bills, or do not drink.
- One should not cover up the mistakes or carelessness of another person.
- One should not create a crisis.
- One should not prevent a crisis, if the latter is in the natural course of events.
Families are monitored to detect the presence of a certain emotional detachment in order to protect themselves and allow the addict to try to “hit rock bottom,” the extreme experience that can possibly help overcome the addiction. Topics such as loyalty, shame, guilt, and secrets, are shared within the groups, and the results are normally very good.
4) INDIVIDUAL PSYCHOTHERAPY
It is not easy to therapeutically approach people because of the impenetrability of this mindset dominated by a logical and biased way of thinking and because of the changes in the conception of time.
What we have achieved, in general, is an apparent improvement at first, followed by a relapse and abandonment of the therapy. I worked once with an obese man who lost 70 pounds in three years of individual psychotherapy, only to recover them all back in two months and leave the treatment at the end. Preventing relapses must be a constant concern from the very beginning of therapy.
I think the psychotherapist who cares for addicted people needs to be humble enough to admit that he cannot deal with the problem alone. The pleasure that the drug provides is much more enticing than one hour per week of reflective work. The advice of a psychiatrist and the inclusion of AA are necessary, at least at some point, for both the patient and his family to successfully complete therapy.
One should also avoid, at all costs, the seductive role of “savior of the world,” and should not be the controller of drug intake, diet, expenses, etc. to prevent being taken in by the codependent psychodynamics and losing one’s operability. These are issues and practices that can be discussed in psychotherapy, but it is not the therapist’s function to control them.
Winning the trust of the addict is the first step, and he should be warned that he would feel a great deal of discomfort during psychotherapy. In addition, he should be made aware that he may have to be medicated and, that he may at some point need to attend AA. If the patient does not agree to these conditions, it is preferable to not accept him into psychotherapy and to keep “the only remaining bullet” for another time when he really wants to be treated.
THE PSYCHODYNAMICS OF ADDICTIONS – “THE TRUE SELF (“I”) VS. THE ADDICTED SELF (THE ADDICTED SIDE OF THE PERSONALITY)
In working with addicts during psychotherapy, the therapist must understand that two client personalities are present at all times: one that wants to collaborate (“I”) and another that surreptitiously seeks to boycott, lie, and end any effort to push him away from drugs (the addicted side).
The addiction process either starts randomly or as a result of some discomfort. The object or addictive practice creates a sense of well-being or perfection—at least for a while. The “I” feels guilty and anxious. These are initial warning signs that, unfortunately, fail to inspire action over time.
Each time the addiction acts, the addicted personality gains a little more control. The “I” disapproves of this way of acting, feeling and thinking, but it loves the mood change that the addictive object provides. It promises to control the addict with its willpower and sometimes succeeds, but it eventually succumbs to the addicted personality. The “I” gradually becomes less tolerant of the discomfort, and any frustration is experienced as pain, thus signaling the need to seek out the object of the addiction.
Addiction is the denial of emotional pain and a refusal to depend on the help of other human beings for relief. The addict does not care for his wife or children, or even for himself. He ignores the fact that he can get sick or even die. The addicted self dreams of escaping pain, obtaining peace, sensory perfection, and immediate gratification, while the “I” dreams of controlling the addict through the addict eventually losing energy, giving up, and surrendering.
It is a vicious cycle. The more the “I” seeks relief in the addiction, the more shame and guilt he feels and the more he undervalues himself, which increases his pain and initial discomfort. Then, once again, he seeks relief in his addictive practices, and the cycle resumes. Figure 1 illustrates this process:
For psychotherapy to be effective, the patient has to understand this cycle and realize that he has no control over the addiction. The addicted side is much stronger and articulated, and even in abstention will prove a threat to the self.
PSYCHODRAMA AND ADDICTIONS
Studies of traumatized animals and patients (Mary, 2004; Van der Kolk, McFarlane & Weisaeth, 1996) suggest that experiential psychotherapies are more effective than just verbal therapies.
The immediate response to a stressful situation triggers reaction mechanisms of the sympathetic nervous system, known as an “alert reaction.”
The animal’s body prepares for either fight or flight (Cannon, 1939; MacLean, 1952). When it is prevented from reacting, the animal’s brain works through archaic mechanisms (Levine, 1999), causing the “freezing” of vital functions. This device allows the animal, pretending to be dead, to fool its predator into leaving it alone, or at least to gain some times in coming up with another escape strategy.
Apart from a few differences, the same thing occurs with humans. When we are unable to respond, our brain works with its reptilian layer, and the freezing of vital functions manifests itself through shallow breathing and hardened muscles, simulating rigor mortis. Additionally, the individual’s mind is numbed mind, resembling a zombielike state.
However, unlike an animal, the human being doesn’t “thaws” once the danger has subsided by exhibiting observable bodily tremors. Human beings tend to intermediate these physical functions with thoughts, feelings, emotions, and invisible allegiances, which are the products of the two remaining cerebral layers. What remains missing is a combat action, the resumption of control, which is sometimes only achieved many years later, due to the active repetition of violence or abuse, as a way of sometimes clumsily mimicking the abuser, or the one who has control.
Dramatization provides the opportunity for this missing action to occur, thus allowing the muscles a safe discharge from the body’s need for resumed control. It should be noted that psychodrama was one of the first body therapies to be used, and Moreno has already pointed out that the body remembers what the mind forgets, especially events that take place in early childhood—even before the emergence of language. The best way to recapture the memory of actions is through expressive methods that involve the whole person (body and mind) in the action. The following is a description, illustrated with by real case studies, how I use psychodrama to help with this type of problem.
Clients who come to us do not know what psychodrama is, and many do not even know what psychotherapy is. It is quite likely that the vast majority of laypeople think that they should just spend some time with us and tell us about their lives so we can provide them with solutions to their most intimate problems. In addition, some clients are afraid of our profession because we are either seen as wizards who can read souls, or as arrogant people who feel superior to others.
I believe we need to help our patients know who we are, build their confidence in what we do, and help them to become familiar with our working tools. Trust and knowledge are constructed gradually, which is why I perform at least three interviews before accepting a client into a psychotherapy contract. I conduct one or two verbal interviews, a social atom that introduces psychodrama to the patient, and a feedback interview where I summarize my opinion and establish the contract regarding what will be worked on. I specifically perform with the addicted patient, when possible, three different social atoms in addition to the verbal interviews: a traditional social atom; a social atom that occurs during the addiction (Figure 2); and a family atom, or genogram, of the addictions (Figure 3).
1-TRADITIONAL SOCIAL ATOM
Objectives: To explore the sociometric context in which the patient is inserted and to train them for future dramas. It is important to discover their natural auxiliary egos; i.e., understand those who can support the client in the case of depression. In addition, it is helpful to identify which sociometric spaces are missing from his social atom. Sometimes we see an adult surrounded by his/her primary family members but has no friends, as if he/she were a child in the care of his/her family. Drawing the client’s social atoms at the beginning and end of the therapeutic process, according to protocol, and comparing these images can be very useful in assessing the effectiveness of the therapy.
2-THE SOCIAL ATOM DURING ADDICTION
FIG 2-THE SOCIAL ATOM DURING ADDICTION
3- GENOGRAM OF THE ADDICTIONS
Objective: To investigate the presence of addictive habits, compulsive and/or abusive, which act as shame generators in the client’s family atom.
Technical data: The client is asked to rate, on a scale from 1 to 10, the presence of the following behaviors evidenced by some member of his/her family: addictions (drink, drugs, shopping, food, work, etc.); perfectionism; procrastination; anger; victimization; depression; compulsion; suicide; or any other dysfunctional habit.
FIG. 3 – GENOGRAM OF THE ADDICTIONS
Both the social atom during the addiction, as well as the genogram of addictions, help the therapist and client to focus on the extent of damage and family influence. They also help to prevent a relapse, as they materialize, in an obvious manner, people and situations the addict must avoid if he/she does not want a relapse.
AT THE BEGINNING OF THERAPY – SPECIFYING THE TRUE SELF OF THE ADDICT
- USING MASKS
V., 35 years old, unmarried and obese, with two children, owns a company that is facing serious administrative problems. She complains about nocturnal bulimia, which she cannot control. On these occasions, she devours everything that appears in front of her, whether savory, sweet, fruity, ice-cream, etc.
“These are moments of gastronomic madness,” she says. “I put on all the weight I lost previously with diet and exercise.”
In the first few sessions, she said she wanted to work on the “crazy fat person that appears at dawn.” I asked her to imagine the scene in which this “crazy fat person” last appeared. She set up the scene in her home kitchen the night before. She was alone, looking inside the fridge and in the cupboard for anything she could eat.
We set up this kitchen space in detail, and before we started the scene, I asked her to begin her soliloquy one minute before she went to the kitchen:
- (in soliloquy, one minute before): I’m sad, alone, and afraid of what will happen tomorrow (referring to a serious problem in the company).
T.: Okay. Now, continue the soliloquy, but go to the kitchen until the “crazy fat person” appears.
- (in soliloquy): I want to sleep, switch off, and not think about tomorrow. At this moment, she stops and says to T.: The “crazy fat person” begins to open the refrigerator.
T.: Very good! Freeze a little and choose a mask with which to be this “crazy fat person.”
- goes to the wall where the masks are hanging and carefully takes down a chubby face with red cheeks and a feather on top of the head and says: This is the one, without a doubt!
T.: Wear it for a while and imagine this scene: V. is alone, worried, and sad. She goes to the refrigerator (T puts down a cushion to mark the role of the client), and then you show up, enter the scene, and talk with V.
- (with the mask, in the role of crazy fat person): I came to help you, dear (in an exaggerated way). I’m your dear friend. I always fill you up with something and make you sleep. Come, and I’ll sing you a lullaby.
T.: Change places for a while. Take off the mask (T. puts the mask on the pillow, and V. assumes her proper place at the refrigerator door).
- (as V., towards the “crazy fat person”): Get away from me. You don’t help me. I need to lose weight to change my life, and you don’t let me. I’m still fat and alone. Go away. I hate you!
After a few more role reversals to deepen the characteristics of V.’s split aspects, T. asks V. to leave the scene and watch while he sets two pillows—one with the mask and one without—and quickly repeats the dialogue quickly (so that the client does not get “cold”).
Then, he says: “These two parts are yours, V. One brings you to therapy, and the other offers you the addiction. We need to know them better, and we will do so from now on.”
- EXECUTING DOUBLES OF THE ADDICTED SIDE
It is very useful to run doubles of the addicted side, especially emphasizing the paradoxical nature of this side of the personality.
Crazy fat person: Bring me your pain, and I’ll give you relief.
T., as a double (of V., in the role of the crazy fat person): Bring me your pain, and I will give you the illusion of relief.
Crazy fat person: I shall set you free.
T., as a double (of V., in the role of the crazy fat person): I will be your only boss.
Crazy fat person: Spend some time with me. You can trust me. You can trust no one else.
T., as double (of V., in the role of the crazy fat person): Spend some time with me, and I’ll teach you not to trust anyone.
Crazy fat person: I’ll teach you a way to not face your problems.
T., as double (of V., in the role of the crazy fat person): You will get rid of the problems for a short time, but they will not go away.
Over time, T. may propose that the client takes on the double role of the addicted side herself, in order to internalize a type of reasoning that is less influenced by the addicted logic.
C) WRITING LETTERS
Writing letters is a good way of discriminating parts—those of the writer and the reader. It is my favorite strategic resource for maintaining the link between sessions. In the case of addiction, we suggest that the letters be written in several directions:
- From the addicted side to the self
- From the self to the addicted side
- From the body to the addicted side
- From the object of addiction to the self
- From various members of the social atom to the self
- From the addicted side to the most intimate family relationships, etc.
- D) BUILDING METAPHORS FOR THE ADDICTED PART
W., a 42-year-old, highly successful homosexual professional, has a partner with whom he has lived for 20 years. He’s a “sex addict,” with possible compulsions to leave at daybreak and have sexual intercourse with strangers without using protective measures.
“Like a vampire hunting for blood,” he says spontaneously, referring to this ego-dystonic part of his personality. I asked him to forget himself and to play the vampire role and to tell me his story, with a beginning, middle, and an end.
“I was a handsome young man,” he says, “when one night, walking casually down the street, I was attacked and bitten by a vampire. I lost the freedom to be who I wanted to be, and I transformed into a vampire. Being a vampire is not a choice. It is my destiny.”
I asked him to show, with his body, how he felt as a vampire. He folds into himself and says, “Ashamed.”
I get closer, put my hand on his back, and ask him, “When, before, have you felt so ashamed?”
“When my father beat me in front of everybody,” he says, referring to a scene that occurred when he was five years old. Often, throughout his psychotherapy, we worked on this scene to understand the vampire side of his personality.
As you can see, metaphors are great resources with which to bring out split worlds—parts not assumed of the life story and of the clients’ selves. They allow multiple therapeutic uses and can be brought forward spontaneously, as in the cited example, or built through the implementation of some behaviors, feelings, etc.
E) THE EMPTY CHAIR
The therapist places an empty chair in front of the client and urges him to imagine there are people sitting there, or parts of himself with whom he wishes to work. In the case of the addiction, the drug itself can be embodied there, as well as the partners of the addiction—the addicted side of the personality that dominates the self, metaphors, dreams, etc.
The role-playing is done with the client changing positions; i.e., the client plays a role, then he changes chairs with another person, and the other person starts role-playing. This is role-playing without dramatic action. This technique can be used as an initial warm-up, followed by open stage work, or as a single technique within a psychodramatic work.
I like to ask the client to talk to the drug, reverse the roles and, after some time, he/she becomes the double of this object or addictive practice in order to externalize the unsaid—the future consequence—and to finally be able to appropriate itself and not dissociate from the full experience. The therapist may play roles as well, if he wishes, or he can merely observe, interviewing both conflicting parties and presenting a point of view that was not addressed in the dialogue.
- (40 years old; smokes marijuana all day in the car, at work, at school, etc.) to the empty chair, where marijuana sits: I need you.
C., as marijuana to C.: Me too. We are an inseparable pair.
C., to marijuana: But I’m missing classes and may lose my job.
C., as marijuana to C.: Well, that’s what they say. We understand things better—more deeply.
C., to marijuana: No way. I do not even remember what I have to write today. I have to ask Luis.
C., as marijuana to C.: That idiot, C.D.F…
- asks C. to get up, places a cushion in place of C., and says, “Now I’ll be marijuana and you stay behind me, explaining what I—marijuana—am not saying.”
T., as marijuana to cushion representing C.: Luis is an idiot. He has a stupid face. He knows nothing.
C., as marijuana twofold: Stay only with me. I’m your only friend. Don’t study. Don’t date. Only with me will you be happy.
C., as C. to T.: It is just like my mom, who does not like any girlfriend of mine. It seems to want hold on to me.
- then asks C. to construct a recent scene in which his mother displayed this domineering aspect, and the session continues with a classic psychodrama, using typical psychodrama techniques.
In fact, there are many ways to promote the discrimination of these parties that are in conflict, and I find it extremely useful to spend some time of the therapy session processing this division.
ENTERING INTO THE PSYCHODYNAMICS OF THE CLIENT – WORKING WITH THE REGRESSIVE SCENE (Cukier, 1998: 67)
The intrapsychic psychodrama (Pitzele, 1992) with regressive or infantile scenes is a powerful resource for working with addictions. Its basic goal is to reframe issues related to self-esteem, discriminate infant pain defenses, and evaluate the function of current addictive behaviors within the context of the client’s life story.
In my book, Emotional Survival, I describe in detail the management of drama with regressive scenes. Figure 4 schematically shows the steps that need to be covered in this paper, and Figure 5 provides a roadmap to interviewing the client in his role as a child.
FIG. 4- WORK SCHEME WITH CHILDHOOD SCENE
FIG. 5 – SCHEME OF INTERVIEW WITH THE CLIENT IN THEIR ROLE AS A CHILD
Many sessions take place in order to process the material obtained in a traumatic childhood scene. We seek the communication of the adult part of the personality with the child part in order to make a sort of negotiation and “redecision.” The client’s adult part needs to understand this inner child’s concrete thinking and negotiate with it in order to obtain alternatives that do not compromise health and happiness.
A drama with the regressive scene runs out only when the client:
- Relives the pain of the childhood scene
- Gains the ability to understand what he did to survive
- Understands the current problems caused by his childhood defenses
- Exercises new forms of appropriate adult actions by modifying his current conduct
It is evident that a session of only 50-60 minutes cannot account for all these aspects. I have worked for about three months on a scene to understand the most part of the connections. This work represents the center of the hurricane. It is the most important bullet shot with our trigger, and we should not spend it in vain by going too fast.
There are many ways to finish a session in the middle of this work, leaving some links open in order to reignite the patient’s and continue the following week. With this aim in mind, certain strategic tasks, like homework, are given. These include:
- Write in detail and bring in for the next session what happened in this scene. If you have a picture from that time, bring it as well.
- Write a letter to yourself as a child. Take care to write in child language, because the person who will read it is a child under eight years of age.
- Make a collage or find a picture on the Internet of the character that carries your childhood protection.
- Take a picture of this scene in an imaginary Polaroid and continue with it next week.
- Write a letter to each of the characters in this scene (father, mother, brother, etc.) What would you say to them today about what happened in that childhood scene?
- Imagine if the world’s best lawyer could defend this child. What would his argument be?
- What would the child who you once were ask you for, if he could?
Sometimes the client does not want to continue the work the following week because they have something more urgent to work on or because they do not feel prepared to enter into the old anguish. The task is then deferred to when he can resume it. Sometimes the client does not complete the task. He forgets about it or does not want to do it alone. We can help the client implement the work during the next session or let him bring it for the next time. It is always good to discuss why the task was not done because it is representative of an agreement with the therapist that was signed and broken.
Let me describe an example where I used this technique with a shopping addict client:
A., a 35-year-old compulsive shopper spends money he does not have, buying things he often does not use. In a particular session, he says he wants to work on the “urge to go to a certain store in São Paulo, known for its sophisticated, international, and extremely expensive products.”
- to A.: Go around the room, stretch your body, and start thinking of when you felt this urge most recently.
A.: Yesterday, after walking in the morning.
T.: Where were you?
A.: When the urge started?
A.: I was combing my hair after my bath.
T.: We will set up your bathroom—the mirror … Where is the door of this room?
- Patiently provides the locations of all the bathroom parts—the cabinet, mirror, etc.
T.: Begin to comb, and start a soliloquy.
A .: Today I am well. I should fit into those leather pants … I need to buy them. If I go to the store, I can pay in ten installments. I can even wear them tonight to C’s party.
T.: Take a deep breath, close your eyes, and enter yourself. Look for what you feel in your body when you start to think about it.
A.: My hands shake and sweat. I get excited
T.: Let this excitement take care of your whole body. Starts jumping higher and higher. He laughs.
T.: Very good. Higher. Jump higher … What does this joy remind you of?
- (Immediately): My father coming for me every two weeks. I was waiting at the door. We were going to the restaurant, bowling, or shopping. He bought everything I wanted. He had more money than my mother. My mother even told me to ask him for things.
T.: One day in particular?
A.: Many similar days. I had a father every two weeks.
T.: We will set up one of those days here … Remember a moment from one of those days.
A.: Buying a car game ( an expensive motor car race) . It was a big toy store there at the top of Lapa (it is a district in S.Paulo)… We had already gone there on another week … We went in the morning—on Saturday. Then, we set it up at his house. We set it up all afternoon. He and I were very happy.
T.: A., take a deep breath and close your eyes. Picture this scene inside you, and especially look at your face, your body, and your age. What are your emotions right now?
A.: Joy. Joy!
T.: What did you need at this point in your life?
A.: I needed this time not to end and for it not to be so rare (he cries) … He died when I was 12, and the two weeks were over.
T .: Take a deep breath and go back to the scene within you … What are you learning at this time in your life that you will never forget?
A.: I like my father, even though my mother did not (crying). He is good to me. He likes playing with me (more crying).
- (Going to the corner where he minimized the bathroom scene and the shopping urge): Look at this 35-year-old man here … He needs to go to this store to buy this expensive object … Do you have something to talk to him about—your nine-year-old self—this very minute?
A.: Your father is not there, you idiot (crying) … You will only get in trouble.
T .: Go back to your adult role, A. In front of the mirror … Look for a minute at this boy (points to the childhood scene in which the cushions mark the roles) … Do you think you could get in touch with him during the week—write him a short letter? I feel that you need to talk. It seems that there is some relationship between your father and the car game , the urge, the leather pants, and the chic shop … Think about it, and we will continue in the next session.
In the next session, warmed up by the note that the client, in his adult role, wrote to his boy self, we resume his father’s death scene. The patient, age 12, is in front of his father’s coffin, sad and angry, because his mother and the new father’s wife have created a tense atmosphere at the funeral.
T., for A.: What do you need at this point in your life?
A.: For my mother to stop thinking only about herself and think of me and keep me.
T.: What do you learn by not having what you needed?
A.: I have to be on my own from now. Nobody will care for me.
T.: What does this mean for a 12-year-old boy?
A.: That I have to look for a way to make money so I get all I want.
A., to T. (out of the child role and speaking as an adult): Buying all I want is a way to do this, isn’t it?
T.: It seems so. Buying all you want is to have a father within, and this is what we need to change.
4- End of psychotherapy – setting new behaviors and new sociometry
The addictive behavior is a safe behavioral and predictable mode of preservation, but it is dysfunctional and uncreative. Psychodrama can do much to develop the spontaneity of the patient to help him train new behaviors and build risk in new sociometries.
Techniques such as role-playing, dramatization of feared scenes, and dramatic games help to reveal fears an individual might not otherwise be aware of, behaviors not developed, and roles not played. I like setting up my office as a privileged and magical laboratory, where pigeons and colorful scarves come out of a black top hat and are later transformed into new dreams, future projects, and new relationships.
FINAL WORD – RELAPSES
Relapses in addiction are normal. The therapist should inform the client that he is already expecting this and that he will certainly never stop helping him. There is a tendency, almost generalized, for patients to end the therapeutic process following relapse. This is because in addition to being disappointed with the therapy, their self-esteem is very low. They have catastrophic thoughts of personal ruin, which in turn lead back to the cycle of the addiction.
Therapists need to pay attention to relapse situations because they are often repeated and because we can predict them if we watch for some indicators. These are some signs the client may show of a possible relapse: skipping therapy, showing remorse and shame, starting to blame others for their problems, self-victimizing, staying slow and repetitive, etc.
Those who relapse do not restart from zero, because they have already made some progress and need only to resume control. Making a prognosis of relapses early in the treatment and paying attention to life situations that may encourage them can shorten the resumption of control process.
Returning to AA is also very difficult the second time, especially for the group shame it brings and because it discredits the therapeutic capacity of the meetings. Individual therapy needs to focus on improving this process of resuming group meetings.
It is desirable for the therapist to share his own mistakes because it can act as a model for the patient. “If my doctor or therapist makes mistakes, apologizes and starts all over again, I can too.” Errors do not demolish a person. The best thing is to admit them promptly and fix them as soon as possible so that the denials and lies do not accumulate.
To recover from an addiction is to break the dependence of the internal addictive ritual and discover a new way of living—one that is more vulnerable to fears, conflicts, and relationships.
Changing the self-image is one of the most difficult aspects of the therapeutic process, and the shame for actions committed in the past can ruin recovery. The therapist must help the client transform shame into guilt, which will naturally generate remedial action.
Learning to admit mistakes is one of the goals of therapy. I often reframe what clients mean by human nature telling them that to be “human” is to make mistakes and to seek to get it right the next time. Moreover, our admitted vulnerability generates a secondary benefit, which is to encourage empathy from other people and bring them closer to us.
Omnipotent people who know everything and do not need help from anyone else, in general, are lonely. We connect with other humans through our very human faults.
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-  This article is mainly based upon the book “The addictive Personality”(1996) from Twerski, J. A, that I deeply recommend readers to read.
- . Psychologist, Psychotherapist, Psychodramatist ,by S O P S P (Psychodrama Society of S. Paulo) and by Jacob Levy Moreno Institute of São Paulo.
-  Obsessions and compulsions are related and, in general, accompany each other. Both involve people becoming consumed by something irrational. An obsession refers to an irrational idea and compulsion (an irrational act). Obsessions and compulsions are like post-hypnotic suggestions. There is an irresistible urge attached to them. Some authors argue that compulsive behaviors are actions whose sole purpose is to keep the individual busy so they do not experience feelings of anxiety, boredom, depression, and anguish. They become occupied with something beyond themselves in order to flee from their troubles.
-  Most obese individuals, bulimics, and people who eat compulsively eat at night and hide themselves away from everyone else’s sight.
-  A stressful situation refers to any situation that leads the individual to a state of despair, either due to a battle to preserve his own life or the life of someone who is important to him.
-  All patient names are fictitious, and the client descriptions themselves are mixtures of many cases. I will use T. and the initial letter of the client’s fictitious name to differentiate between the therapist and the client in the cited examples.
-  Procrastination: the habit of leaving tasks that should be done now till later
- Bulimia nervosa is essentially characterized by the presentation of binge eating and inappropriate compensatory methods to prevent weight gain (purging, fasting, or exaggerated exercise). Furthermore, the self-assessment of individuals with bulimia nervosa is excessively influenced by body shape and weight.
-  I always ask at the beginning of the sessions what the patients want to work on in that session. I believe this simple question encourages client autonomy and responsibility during the time we spend together.
-  Soliloquy = this psychodramatic technique consists of asking the client to “think out loud”, as if there were a loudspeaker in his head.
-  Role Reversal = in this technique the therapist ask the client to take the other’s place, playing the role of somebody whom he has been talking about – rather than just talking about this person. Using the interview technique the therapist helps the client to compose this character and empathize, little by little, with its perceptions, emotions, and opinions.
-  The double’s aim is to get in touch with the client’s non-verbalized, sometimes even unconscious, emotions in order to help him express them. The more the therapist is identified with the client, the better double he will be able to play. I normally say to the client that, for a brief moment, I will stop being me and I will take his place. Through short but precise talks, I try to show him what I have observed. Finally, I let him know I am back to my role as director.
-  I always start the scene setup by the entrance door of the place where it occurred. It helps me define the space and warms the client up because he realizes I really know where the furniture, window, etc. are.