Lena Volkova, Lena Burtseva, Tigran and Anya - huge gratitude. Inner emptiness. These words are often used when talking about the peculiarities of the mental world of chemically dependent patients, in particular drug addicts. What does this mean? What is the manifestation of this phenomenon? I want to immediately make a reservation that I will be talking about my own emotional and professional experience at work, so these considerations do not at all pretend to be absolutely accurate or scientific. What prompted me to write this article was the desire to share my experience and feelings, and the fact that it often arises after working with these patients. The desire to tell someone what’s wrong with me now, when the meeting with the patient is over, the desire to be heard, to be together... I’ll start with what remains after work (this is especially typical for working with drug addicts): fatigue, surprise, and also quite often a mixture of irritation, despair, fear, sometimes hope - all that is called powerlessness. Powerlessness in the face of a disease that destroys their health, relationships, lives, in front of the fear that accompanies them every day, in front of the stress that at any moment can drive them back to drug use, in front of the pain that only they can cope with and that no one can alleviate .And, of course, my own powerlessness. Your anger, your disappointment, your sadness and your hope. And each time it starts anew: to help you live only today, to see in yourself the destructive effect of the disease and to find the courage to admit it in order to remain “pure”, to turn to the values ​​that already exist now, to accept the weakness and limitations of your strength in front of their dependence , let go, say goodbye and move on with your life, marveling at your freedom. This work requires a lot of effort with very little return. The percentage of those who recover is small, and the patients themselves, due to their personal characteristics, tend to devalue the help of other people; their ability to express gratitude develops slowly, as the patient gradually “grows up.” By the way, regarding gratitude. It seems to me that in real therapy no therapist can be “free” from his own sensitivity to such a manifestation of the client as a feeling of gratitude, as well as to its absence. This is the kind of “countertransference” from which it’s just great to “not be free”, unless, of course, we treat our activities as something more than simply manipulating the client’s feelings (that is, our own too). I will not now go into a discussion of the intricacies of transference relations, I just want to say that no amount of money (again, for my taste) will pay for the mental labor invested in working with chemically dependent patients, without which your contact with the patient will not take place at all , or it will not become so new for him that the patient will at least notice that there is someone else next to him, except for those who are chemically dependent like him. Precisely due to the fact that even the highest rates do not fully compensate for disappointments and patience, the therapist turns out to be more sensitive to the manifestations of gratitude from patients; it somehow “balances”, or, conversely, “swings”, the interpersonal “exchange of energy” between the patient and therapist. In working with drug addicts, I noted one more feature: in order to establish a therapeutic contact and for the patient’s cooperation, the therapist’s honesty and openness are necessary. The idea seems to be not new, however, in this work the therapist’s honesty is of particular importance. I will say more about the therapeutic position a little later, now I want to draw attention to the fact that the therapist achieves success only by remaining alive and interested, patients instantly perceive falsehood, boredom and indifference addressed to them and react with aggression in one form or another: devaluation, rudeness , ignoring, sabotaging tasks, emotional unavailability. And in this they are very similar to “difficult” teenagers, with their spontaneity, difficulties in controlling theirbehavior and emotions, with special sensitivity, vulnerability, and exactingness associated with the chronic dissatisfaction of the basic needs of each person - safety and intimacy. So working with chemically dependent patients “without getting involved” is both difficult and ineffective, and it can simply “fail” "therapeutic process. And this is understandable. The main deficit in the life of a recovering drug addict is associated with a lack of trust in the world and, as a result, in oneself. Moreover, in this case, trust means the simplest “things”: predictability and adequacy of the reactions of others to one’s behavior and feelings, clarity and stability of people’s positions in relationships with the patient, their ability to empathize and attentive interest in what is happening in the patient’s life. In addition, what is “particularly successful” in another person is the ability to control their feelings, remain sensitive, interested, involved in what is happening around them, experience both joy and sadness - the whole range of feelings and at the same time not be absorbed by emotions, not become a slave to them so much. to put your life at risk of destruction and uncontrollability. Of particular importance is the ability of another to experience such strong and potentially destructive feelings as anger, fear, resentment, sadness, therefore, every time the therapist allows himself to live, that is, to feel, in the presence of the patient, he gives him the opportunity for hope and provides great support by showing , how you can experience this without causing unnecessary damage to yourself or others. And now it makes sense to think about what can be called success in working with chemically dependent patients, what is generally within our power, what we can influence and what we can teach. A drug addict is borderline personality, the features of which are diffuse identity, primitive defense mechanisms, impairments in reality testing, in addition, they have nonspecific signs of ego weakness: low ability for sublimation, low tolerance to anxiety, rapid regression of behavior to an earlier stage of development in a stressful situation. Psychotherapy is the process of “growing up” the patient from the moment when substance use has practically stopped his emotional development. By stopping the use of consciousness-altering substances, a person seems to find himself at the point of his psychological development from which the use began, and here we see instability of self-esteem, lack of self-esteem, inability to tolerate stress, anxiety, that is, the inability to take care of oneself, first of all, their psychological well-being, distrust of the world, experiencing it as dangerous and often hostile, and themselves as helpless, vulnerable, useless and uninteresting. The experience of the danger of the outside world is also connected with the fact that the patient does not very well understand where his possibilities of influence on the environment begin and end, what he can do in general and what they can do in relation to him, that is, the recovering drug addict poorly distinguishes between his boundaries and boundaries others and often has difficulty constructing and naming them. The designation by others of their boundaries can be perceived by him as aggression towards him simply because it somehow limits his momentary, impulsive desires. The use of a chemical substance always performs a protective function, protecting the psyche from the “overloads” that a person faces in his life , however, the price of such protection turns out to be extremely high - the loss of this reality itself and oneself, both in the literal and figurative sense. Drug addiction is a fatal disease, drug addicts die, are maimed, end up in prison, and go crazy. At the same time, you can often hear from drug addicts themselves that they “don’t care what happens to them,” “a drug addict is not afraid of death.” This is both true and untrue. The truth is that these people are really poorly aware of what is happening to them, are not able to plan their actions and foresee their consequences, to think about theirfuture, sense danger signals in time, seek help, that is, they experience great difficulty in taking care of themselves. The untruth is that we are not talking about the absence of fear of death, but about the lack of value of one’s own life, a lack of understanding of why they should live, who they are, what they can do, how to avoid unbearable pain, fear, loneliness and make their own life enjoyable. Every addict is alone in the whole world, and if there is one thing he knows for sure, it is that there is no other salvation from this loneliness except a substance that will simply destroy everything that causes anxiety. And when I talk about the “inner emptiness” of a drug addict, I mean this set of traits: a devaluing attitude towards oneself and towards life in general, the lack of reliable supports, be it significant connections with other people, interests or activities, the chaos of life itself, loneliness, fear , the inability to take care of himself, the constant need for someone or something to fill him from the outside and organize his life. I do not mean at all that any drug addict, especially one who has begun to recover and has already stopped constant drug use, is a “degraded type”, without social connections, relatives or work. It’s amazing how easily and inevitably all this is exchanged for the possibility of instant relief that the drug gives, how little the mortal risk of going “back” is significant, how few “internal clues”, unexchanged values ​​remain during use. The disease is closely intertwined with personality. This is manifested, first of all, in the fact that psychological personal defense mechanisms are used by a person to justify and support his use, that is, introducing into the body a chemical substance that is alien to him, which changes the biological functioning of the body itself. The main manipulation of the addict is shifting responsibility for his use from oneself to surrounding circumstances, that is, the presentation of convincing facts confirming the compulsion to use substances, as a result of which a person takes a completely passive and helpless position, the position of a victim who is not in control of either the situation or his life. Any effective rehabilitation program begins with the person accepting responsibility for his life and recovery, that is, from the recognition of the fact that only he himself makes the decision to continue to use substances or not to use them. Rehabilitation programs, which are based on the 12-step model, involve recognition and acceptance by the addicted person of his powerlessness over the substance, that is his complete inability to control the process of use, its very fact, as well as the amount of substance used, to predict the consequences of his use, which gradually destroy his life and personality. Accepting your powerlessness means that any contact with a substance will lead to the resumption of systematic use, further destruction of life, that is, a complete loss in competition with the substance, and the only way to save yourself and your life is to abandon the obviously losing fight, that is, completely eliminate the substance from your life. Accepting your powerlessness, which means completely giving up the substance, is often a long and difficult process. Abandonment of a substance involves a change in a person’s entire life, his social connections, a restructuring of the personality, which learns to rely on its own resources and the help of other people in solving its problems, the development of new defense mechanisms and insecurity from all those emotional experiences and crises, losses, separations, successes and joys that fill the life of every person. Accepting powerlessness also means rejecting the idea of ​​the existence of an “ultimate savior” who will always solve and solve for a person his “insoluble, unbearable” problems and can make him happy once and for all, generously bestowing that warmth and security that is so painfully lacking. Awareness and experience of one’s powerlessness in front of a substance that destroys life andchanges consciousness and becomes the basis for further personal growth also because (in addition to social rehabilitation and restoration of human connections) that the patient for the first time is faced with the limitations of any human strength, with the need to accept what surrounds him, no matter how painful and undesirable it may be , goes through experiences of anger, disappointment, despair and survives, becoming more confident, stronger, gradually developing what in psychotherapy is called self-reliance. This sense of support becomes a resource for survival in subsequent crises, strengthening sobriety and personal development. Responsibility for oneself is something that you can talk about for a long time and beautifully, something you can be proud of, giving examples of your own choices, but what is most difficult to implement, especially in acute life situations situations where significant relationships and well-being depend on one’s own actions and decisions. An addicted person has a universal way of avoiding responsibility - using a substance that changes the state, not the situation - and he will not give it up just like that, the person will defend the disease that has become a “crutch” for him. The main “technique” of resisting the disease at the early stage of rehabilitation is manipulation of the very experience of powerlessness. A person who wants to stop using, but constantly “breaks down”, explains this by the inability to cope with cravings, that is, his powerlessness, and every time, turning to others for help and sympathy, he actually multiplies for himself evidence of the impossibility of stopping use, the lack of effective help. At the same time, the addict himself does nothing or almost nothing to avoid contact with the substance, that is, he continues to remain in a “competitive” relationship with it. Any drawing of his attention to his own actions is perceived as aggression, causes resentment “for the already unfortunate victim,” allowing him to continue using “out of grief,” which is more typical of alcoholics, or “out of revenge,” which drug addicts often do, which causes another a surge of despair or anger from the addict’s loved ones. (In the language of Gestalt therapy, the addict breaks off contact with himself and others through the projection of aggression or rejection, being unable to withstand the tension associated with the development of the contact cycle; in psychoanalysis, this interaction can be described as projective identification). Thus, formally and easily recognized powerlessness becomes a tool of manipulation. (It is clear that true acceptance of powerlessness in the event of continued use would mean refusal of further help and a responsible choice of one’s further death from drugs. Well, since nothing can be done...). If a person is really “ripe” for conscious cessation of use and is ready make efforts to maintain sobriety, one can discover a paradoxical situation at first glance: the very powerlessness that was easily accepted in use is now rejected. An addicted person avoids in every possible way confronting his feelings and actions associated with the manifestation of his powerlessness, remembers “good days”, ignores help, assures himself and others that he can cope with his problems on his own, that he is not a drug addict like everyone else, who need to “digging” into themselves. Thus, external competition with the substance (use) becomes internal, without essentially changing - the basic ideas about one’s own exclusivity, the possibility of ever controlled, safe use remain the same. Now accepting one’s powerlessness over the substance becomes psychologically unprofitable, that is, it interferes with use. Now accepting powerlessness means recognizing the fact that any “contact” with a substance ends in its “victory” and puts the patient before the need for a conscious and responsible choice: to live with or without the drug, to deal with the consequences of his actions, to manage his own life. Admitting your defeat in this “struggle” with the substance opens the way tosalvation. Stopping use means a completely different way of life, forgotten or almost unfamiliar: tension, systematic activity, reasonable and necessary self-restraints, discovery of a huge world next to you, filled with other people's desires, as persistent as your own. This is difficult if life remains empty and is experienced from a position of helplessness, a “victim of circumstances.” This is possible if a person “invests” all his strength in searching for new ways of existence and does not lose hope. Therefore, the restoration of the individual from the consequences of drug use begins with the restoration of the main human values ​​- safety, one’s own life, relationships, one’s work. Features of chemically dependent people can be difficult to understand, it is even more difficult to accept, this gives rise to that same powerlessness, already of the therapist himself working with these patients, which forces him to “work for wear,” experience acute disappointment, get tired, steals personal time, mental strength, hope, if it is not recognized in time and is accepted as an expression of the real limitations of one’s capabilities in helping drug addicts. Just as it is difficult for patients themselves to admit their powerlessness over a substance and accept it, so it can be difficult for a therapist to come to terms with the impossibility of “saving”, “getting out” everyone he wants . For the therapist, this may mean his incompetence, weakness, as well as fear and humiliation, “losing.” And here it is very important to notice how patients draw the therapist into “their game,” where victories and defeats are counted, where there is fierce competition both for the substance and with the substance, which means survival or death. One of the typical “traps” that a therapist falls into is the experience of his own omnipotence in front of the “victim” of the drug. And patients are excellent at using this “technique”, taking the position of a “victim”, provoking the therapist to “save” them and thereby shifting responsibility for their recovery to the therapist, who may or may not “cope”. At the same time, they “empower” the therapist to be “omnipotent” in the simplest and most effective way - by providing a huge “credit of trust” to their “savior”. Of course, I want to justify such “trust”. And the therapist finds himself in a hopeless situation: he, being as powerless over the substance as his patients, begins to behave as if he can cope with the patient’s addiction, that is, in fact, control his life, defeat the drug. The competition between the substance and the patient becomes a competition between the substance and the therapist. Often the patient himself enters into competition with the therapist on the side of the drug, trying with his behavior to put the therapist in a situation of powerlessness. In this case, the patient forces the therapist to experience what he himself feels about his addiction. And here it is very important to show another way of experiencing powerlessness, to “give up” in this competition, to recognize the limitations of one’s abilities to influence the life and use of another person. With all the anger, disappointment, regret, pain, sadness, but step aside, leaving the patient alone to “enjoy” his “victory” and the dubious gain that he receives. It often happens that this gain is exactly what the patient sought - use, alienation, pseudo-independence, an illusory world instead of the real one. And this is the reality of a therapist working with chemically dependent people. And now I can say a few more words about the therapist’s position in relationships with dependent patients. There are two self-destructive ways out of a state of powerlessness: rescue or self-abasement. In the case of “rescue,” I choose a position of omnipotence, when I continue to do what I cannot do, ignore my capabilities and lose energy, deceive myself and the patient, and find myself in a “vicious circle” of fatigue and tension. In the latter case, I become either a “victim” or a “tyrant” towards myself (and this repeats what patients do to themselves)..2003