This article is a case report of a patient with drug addiction and borderline personality disorder, whose system of values was seen and worked on from a pathological accommodation perspective. The patient underwent relational psychotherapy with element of Mentalization Based Therapy, in a fixed, empathic and sustaining setting. The desired results have been reached and the patient ended the treatment after 2, 5 year of weekly psychotherapeutic sessions.
Adam is 28 years old when he starts psychotherapy; he is an immigrant of Polish origin. He is the middle of 3 brothers. His father died due to alcohol abuse when he was 4. He grew up with his mother, step-father, grandfather with alcohol use disorder and 2 brothers. He took the role of the defender of the mother and the younger brother. At the age of 15 he ended up in a juvenile detention center due to aggressive behavior and minor offences. He finished a vocational school and earned living trafficking drugs. He now runs an illegal house rent for tourists. His friendships were very scarce and conflictive when I met him, mixing what was a friendship with business. He was in a 3-year relationship when he started therapy.
His chief complaint was the feeling of emptiness and lost values.
Adam comes from a very precarious background, where conflicts were solved by aggression and the stronger you were the better chances you had to be respected and survive. Adam perceived life dichotomously, everything was either black or white and his strong beliefs in values like brotherhood, courage, strength and fidelity helped him survive in the cruel world of drug trafficking that he belonged to as a child. His values were his shelter, the only one that protected him from lack of affect, recognition and emotional attunement with his caregivers. These values were, however, unreal, as the real world is neither black nor white, and when Adam started functioning in the world outside his gang, due to a forced immigration, he started feeling depressed, confused and lost. In his new world things were not solved by physical aggression and money was a normal means of exchange. When he shared a flat and could not pay for it, he was asked to leave and he could not understand what happened to the brotherhood. He started by dismissing all the people that let down his values until he realized he was completely alone. Would he not dismiss somebody for letting down his values, he would feel like letting himself down. There seemed to be no solution. Adam was becoming more and more depressed.
He started abusing drugs, the substances being the only way he could find to cope with the explosive mixture of feelings. He had difficulty controlling himself; he would end up in fights and risk his life at least on a weekly basis. He did not know how to control his emotions. He felt lost because he was not sure who he was and what he was capable of. His unstable sense of self and unstable emotions contributed to the feeling of emptiness.
I diagnosed Adam with a Substance Use Disorder (305.60 Cocaine mild; 304.40 Amphetamine moderate, 305.20 Cannabis mild) and a Borderline Personality Disorder 301.83, according to DSM-V . The drug use started at the age of 15 and lasted intermittently until I met him, at the age of 28. The last episode lasted for 6 months before therapy.
The psychoanalytic relational psychotherapy was provided for 2, 5 years, once a week, in a private setting.
The first and very important element of his therapy was providing him with a fixed setting that would establish rigid frames and be a secure, foreseeable and clear space within which we would move, fulfilling a container function [2,3]. It is crucial in borderline patients and in patients with addictions whose sense of self is unstable and who have difficulty setting their own limits and respecting the limits of the others. The fixed setting consisted of regular weekly sessions that would be his secure space but a space that Adam would have to take responsibility for and learn to respect. At the beginning of his therapy and due to drug abuse he would miss many sessions but he would pay for them, as it was part of the contract. He learned to respect that and even to appreciate the foreseeable and clear rules of our space that he soon started applying in his life, slowly putting more order into his chaos.
Secondly, each session was a corrective emotional experience [4,5] for Adam. My aim was to repair the damages caused in his childhood in order to treat his current deficits that resulted in his pathological behavior. What Adam needed was someone who would listen to him without judging, who would understand his emotions and motivations and help him understand himself, who would make sense of who he was while his self was unstable, who would sustain his vices and cultivate his virtues. He needed emotional attunement  and empathy to be able to be himself and through being himself in this facilitating setting discover who he was and accept himself. In order for this process to work, it required a great deal of the psychotherapist´s emotional implication but within limits of the setting. He needed to feel that I really cared for him and that what we were doing was real. Patients with borderline personality disorder are traumatized patients especially prone to detecting lack of real affect and interest.
Moreover, besides the emotional part of the therapy, each session was also a Mentalization  broadening experience. We would talk about his past and his everyday life trying to give every experience a new perspective and a new understanding. The aim was for Adam to learn to understand the mind of his own but without losing the perspective of the others. The lack of the ability to mentalize, being one of the elements of the borderline personality disorder, causes that we assume that our interpretations are true and we act as if they were. Mentalization requires practice in an empathic atmosphere and we intended to provide Adam with such experience during every session of his 2, 5-year therapy.
Using the strategies of mentalization (Mentalization Based Therapy)  that help understand our mind and the mind of the others; and the assumptions of the relational psychoanalytic psychotherapy , based on the analysis and practice of the interaction, we worked on regulating Adam´s emotions, providing him with different tools than idealized values or aggression. During the psychotherapeutic process he changed the attitude he had towards life. His mind was becoming more and more flexible. He came to realize that his childhood values of either being the strongest or being nothing were no longer adaptive to his adult reality. He was starting to develop new values and coping tools, more flexible and adaptive, that step by step would let him abandon the old ones. With the help of psychotherapy, he was feeling less confused, he would understand himself, his motivations, his background and his emotional reactions better and his anxiety would diminish. After 2 years in therapy and various ups and downs, he was finally in control of his addiction. The last stage of therapy, maintenance took place for 6 more months.
He came to therapy to find his lost values and faith in people and therapy helped him realize that he needed to abandon those strict values and accept himself the way he was, imperfect. Paradoxically, by accepting his imperfections and being able to share them and look at them from a different angle, he managed to find himself and find his happiness.
We could base the understanding of Adam’s case on the concept of pathological accommodation. It is a concept introduced by Brandshaft [10,11], which makes reference to a situation when an individual adapts to a traumatic or pathological situation by finding a system of coping that brings him or her an immediate solution to a problem or a relief but causes problems in a long run. It is an attempt of surviving in extreme emotional situation when the individual has no access to better forms of coping, either because of the limitations of the environment or because of lack of better resources (e.g. a little child of traumatized parents that was never taught how to regulate his or her emotional states). The concept of pathological accommodation is the relational way of looking at symptoms. A symptom is not a problem itself but is an effect of an inadequate adaptation to a problematic situation. A patient with addiction may think that his or her real problem is his inability to control his impulses. However, addictions are only symptoms that indicate of a problem. If we dig more deeply we may realize that these patients use substances in order to calm the anxiety that they never learned to control in a more adaptive way. We assume that when they were little, something emotionally difficult, maybe traumatic, took place or was taking place repetitively (e.g. parents living together but apart) that caused emotional distress. The caregivers were too busy or too traumatized themselves, that they were unable to offer a soothing response to their children (e.g. it’s ok to be sad if you see us quarreling), so they had to find a solution themselves that immediately calmed them down (substance use, rigid application of values). No wonder once they discover the soothing power of such mechanisms, they apply it to all stressful situations, which results in a detention in their emotional maturation. When they grow up and when the life circumstances overwhelm them, they tend to resort to such soothing behaviors that now may cause much more serious consequences. They have pathologically accommodated to a traumatic situation and they never learned how to cope differently. Now they do not realize that their symptom is their way of coping. How do we invert a pathologically accommodated system? What therapy aims to do is help them find new, more adaptive ways of dealing with problems and the old ways gradually disappear.
During his psychotherapeutic process Adam was starting to realize that he had idealized certain groups and friends and the feeling of being deceived was growing in him. Something that helped him survive as a child and adolescent was no longer useful in his adult life and he was obliged to adapt to this new situation and adapt his system of values. This task overwhelmed him and he was alone. He then resorted to his other soothing and maladaptive mechanism, substance abuse. Psychotherapy helped him find more adaptive ways of regulating his emotional states and dealing with lack of self-esteem.
This paper intends to demonstrate that relational psychotherapy is an efficient treatment in patients with addictions and borderline personality disorders.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, DSM-5. 2013.
- Modell AH. The psychoanalytic setting as a container of multiple levels of reality: A perspective on the theory of psychoanalytic treatment. Psychoanalytic Inquiry. 1989; 9: 67-87.
- Quinodoz D. The psychoanalytic setting as the instrument of the container function. The International journal of psycho-analysis. 1992; 73: 627.
- Alexander, F. Analysis of the therapeutic factors in psychoanalytic treatment. The psychoanalytic quarterly. 1950; 19: 482-500.
- Bernier A, Dozier M. The client-counselor match and the corrective emotional experience: Evidence from interpersonal and attachment research. Psychotherapy: Theory, Research, Practice, Training. 2002; 39: 32.
- Gallese V. Mirror neurons, embodied simulation, and the neural basis of social identification. Psychoanalytic Dialogues. 2009; 19: 519-536.
- Gergely G, Fonagy P, Jurist E, Target M. Affect regulation, mentalization, and the development of the self. New York: Other Press. 2002.
- Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. American Journal of Psychiatry. 2008; 165: 631-638.
- Mitchell SA. Attachment theory and the psychoanalytic tradition: Reflections on human relationality. Psychoanalytic Dialogues. 1998; 9: 85-107.
- Brandchaft B, Doctors S, Sorter D. Toward an emancipatory psychoanalysis: Brandchaft’s intersubjective vision. Routledge. 2013.
- Brandchaft B. Systems of pathological accommodation and change in analysis. Psychoanalytic Psychology. 2007; 24: 667.