Treating a drug addict involves an interplay of five elements that must continually be brought into action:

• the diagnosis of the subject of the addiction;
• the family and its interactional mechanisms;
• the values of the addictive culture and of the civilization that shaped and engendered it;
• the clinical picture of the drug’s intensity in its phases of use, abuse and addiction;
• the type of treatment indicated, among which we favor the professional therapeutic community, to set ourselves apart from so-called voluntarist and/or religious communities.

The diagnosis of the subject of the addiction

The drug does not interest us only as a chemical power generating a greater or lesser physical and/or psychological dependence, which will call for a specific type of detoxification; it also interests us for the way it is articulated with the subject’s imaginary, for the place of “plug-object” it occupies in the history of a deprived being.

Designating the drug addict as a deprived being goes beyond the singular contributions of Spitz and Bowlby, who point to the state of affective deprivation as the seed of schizoid disorders and of conduct disorders with drug addiction and delinquency. The reference cited at the outset encompasses the one I have just described. It also includes the pathologies that point to the social, economic and ethical abandonment of large sectors of the population, which can be surveyed with a sociological map.

Something unites all these categorizations: anguish, haste, voracity, fullness, oral and motor impulsiveness. In other words, fullness, filling oneself to the brim. Emptiness in the face of filling to the brim. Up to the limit of the overdose; excess; immoderation, that is to say perversion (pouring something out in excess without regard for measure).

This deprivation, which is ontological, anthropological and psychic in every human being, and which is the foundation of sublimatory enjoyment and of all the creations in which the desire born of this lack, in the arms of the law, becomes love, child, signifier, that is to say culture, is in the drug addict a fissure, a crack, no longer in a side wall but in a foundation; it acknowledges a history that is social, ethical and psychological. That is why a therapist of today must travel through this fascinating space where illness is the history of a postponement and where the symptom is the cry of a subject who was unable to grow up.

Two premises: abstinence and consent

Two premises underpin the possible treatment of an addiction: abstinence and voluntary consent.

As regards abstinence, the setting seeks to underline the limit placed on enjoyment as a way of speaking about something; otherwise the ecstasy of the drug makes it possible to mock a therapeutic scheme founded on the lack of the object, a lack that will lead to being able to speak, that is to say to being able to render absent.

Whether abstinence is possible or not will lead to different therapeutic measures, from outpatient consultation to detoxification treatment, by way of the various models of the professional therapeutic community.

Voluntary consent marks another important step, in which the professional is not an employee of the family but works with it in order to introduce the patient, usually young, into a scene that is hard for him to accept, since the drug is forbidden within the therapeutic encounter.

The place of the recovered addict

The role of the recovered drug addict and of the relatives of recovered addicts is important at this point. We must ask ourselves why. In the professional therapeutic community model, we advocate the inclusion of recovered addicts, treated by psychotherapeutic methods, and of the family, both at the moment of crisis and in the aftercare of the addiction. On this point, we follow the same criterion as with all the professionals working in the professional therapeutic community. The explanations are obvious: since Freud, the best guarantee for treating madness is to know and treat our own madness; all the more so since the poorly recovered addict tends to turn into a Manichaean fanatic against drugs, and his description reminds us very much of the one the brilliant Kurt Schneider gave of fanatical psychopaths in his book Psychopathic Personalities.

The recovered addict brings to the therapeutic scheme the possibility of tuning in to a common code with the addict to be treated. We live in a highly compartmentalized world; the drug addict is an outsider of a culture that he unconsciously caricatures through his illness.

Outsiders have their own code, in which the professional is part of a persecutory world, of an ignorant and ignored adult world. The professional himself has his prejudices toward these patients, whom he tends to stigmatize in various ways, usually through pessimistic psychiatric diagnoses.

The scientific is always a discovery, and the professional himself must strip away his ideological prejudices. In my daily work, I have seen two opposite and extreme medical models. On one side, the professional who identifies with the patient and ends up saying that the drug is not the problem, tolerating use, abuse and even intoxication.

We later learned that he too, in certain cases, had used and was still using. Therapist and patient daily foreclose a reality; they believe they are treating a production of the unconscious when in fact, during the session, the patient is intoxicated. They are companions in mockery. At the other extreme, the rigid therapist sees in the symptom an offense to his wounded narcissism and deploys the most varied means to calm the “beast.”

Mechanical restraints, brutal sedation. The professional who takes charge of drug addicts must struggle against these two temptations of ignorance; in one, he will live in the placidity of perversion; in the other, in a directed paranoia. The addict knows these stories from his relationship with the professional world; one of these two models has already treated him, not to mention the modern Messiahs who, from the non-professional world, made of him a sinner, a man without faith. He has fallen into the hands of those who turn religion, which is a transcendent value, into cheap goods.

As we can see, our poor addict finds himself checkmated by various interests, professional or sectarian.

The recovered addict, included in a professional team, tends to generate a common code with the addict to be recovered, beyond the ideologizations that would marginalize him even further, and above all by keeping him away from this knowledge: his symptom is a cry of the unconscious in the folds of a history to be listened to.

Nosology: the drug as object

Diagnosis passes through two moments: nosological and nosographic.

The nosological moment attempts to grasp the different inflections that the drug, as object, has introduced into the subject’s relationship to the Law and to pleasure over the course of his history.

The nosographic moment runs through the different spaces in which reality and unreality are configured, from the adolescent identity disorder and psychotic or pre-psychotic pathologies to the modern alterations produced by the social abandonment of young people, which form part of what are called psychosocial illnesses, linked to the violence of the discourse of civilization.

In its nosology, we observe:

• an object that captures the drive;
• an object that denounces the non-loss of the object;
• an object which, not being lost, appears majestic, demanding, domineering.

A passionate circuit is established with the drug-object: “cocaine is my girlfriend,” many addicts say; a relationship, consequently, that is independent, idealized, made of fascination, fear and suffering.

In the history of these subjects there are real abandonments; an abandonment which, in the first moments of the baby’s life, leads to the impossibility of hallucinating the object, a hallucination that would allow the discharge to be postponed; hence motor subjects, incapable of tolerating everyday disagreements, that is to say the frustration between, for example, hallucination and perception, the search for and the finding of the object, what is one’s own and what is foreign.

Failures in the symbolic fabric that would make it possible to mediate disagreements through a paternal function that has failed in its representatives, from the perverting absence of the father to the sometimes symbiotic abandonment of the mother. No intermediation is possible.

Piera Aulagnier teaches us: “the more necessary the object of pleasure, the more its power to cause suffering intensifies each time it refuses its presence or rejects the investment that the ego asks it to share.” This is what founds the alienation of the subject, who commits himself even further, now on the biological level, through neurochemical receptors, generating an imperious search now founded on intoxication and on a neuro-hormonal imbalance.

The fracture of the addicted ego, comparable to Olievenstein’s formulation of the “broken mirror” (the image of an ego fractured in its very mythical constitution), engenders a genuine identity problem that attempts to crystallize pathologically through the drug, which operates as a genuine superglue on this break; a break which, being originary, is alienated in the supposedly ideal identity conquered: being a drug addict. This identity is articulated with a fixation on the mockery of the Law, which manifests itself in various cynical forms.

The static ecstasy in pleasure, which fails both on the biological level, through the role played by neurochemical receptors, and on the properly psychological level, since a pleasure that is not limited by castration leads to immoderation and to the encounter with real death.

The pleasure the addict brings us in his flash, a non-communicable pleasure, comparable only to that of the delirious person who cannot recount his delusion; he feels himself God in a narcissistic image; a God who is pure drive. “I am what I want to be,” said an old philosophical definition of God, which announces in modernism the Ego as idol, the Ego as God. This being-God, since he hears nothing of the other, this feeling sacred in the profane paradoxically brings him, who feels immortal, closer to real death (see my book Abordaje psicoterapéutico de la psicosis, Paidós).

Pleasure, from narcissism, logically becomes endogamous and autoerotic.

The injection and the act of injecting oneself configure the perverse ceremony, which follows these stages: a) annulment of discourse (everything is and must be… right now); b) ritual ceremony (he is a modern priest, since the syringe, the “mana” power of the drug, the sharing of the body in a mythical groupality through blood, the illusory and magical power of the syringe configure a genuine cult); c) sequestration (something must remain hidden); d) excess: a key phenomenon for understanding the perverse act, which reaches its height in the Dionysian orgy and the overdose; e) supplementary legality (another legality must always be created to justify the one that has been subverted). The mockery of the Law leads him to the continual defiance of death. It is a very particular suicide: the feeling of always being able to start over. A continuous attempt to defy death (for further details on these points, see the book Los adictos, las comunidades terapéuticas y sus familias, Trieb).

Nosography: from the least to the most serious

On the nosographic level, addiction runs through a wide range of diagnostic aspects.

The most usual, from the least to the most serious, are:

These pathologies are inflected by the social and family diagnosis, which will mark the possible limits of therapeutic action and the most indicated types of treatment.

The family

We observe the following elements when considering the family groups of drug addicts; they may present together or, in some families, some of them may prevail.

Addiction stabilizes the family.

Addiction is a paradoxical protest, and therefore one with no way out, insofar as the mechanisms for symbolizing reality fail in the face of a dysfunctional family problem.

In the families of drug addicts, undefined generational boundaries are observed: weak monogenerational alliances, strong heterogenerational alliances (for example mother-son, which mask difficulties in the couple relationship). The identified patient has thus found himself exposed very early to the possibility of incest, of promiscuity and of everything that betrays an insufficiency of the paternal Law through the failure of its representatives.

It is common, in the addict’s family, to encounter the parents’ various addictions: to alcohol and to work. In alcohol-dependent parents, we find that they function as poorly structured children and that, more than parents, they are rival sibling-children.

In those dependent on work, we find the absence of dialogue, the discord with the symbolic (which, for the author of these lines, is the heart of family life). This deficiency in the symbolic generates a great deal of defenselessness and abandonment. We might think that, more important than whatever is traumatic in living, there is the fact of having someone to talk to in order to suture the wounds that any life in common entails.

Let us not forget that the word addict comes from addictum: the unsaid, what remains to be said. It is a pathology of family dialogue, of generational dialogue.

The symptom is the only way the family has of coming together.

The symptom, by betraying the absence of the referents of the law (failure of the maternal and paternal other as the place of language), engenders a pathology in which what is lacking in the symbolic is sought in the real; the search takes the form of fanatical enjoyment and goes through social representatives that are acts of vengeance and refuges (the judge, the police). A vengeance that is crime, insofar as the place where one learns to live the law (the family) has been fractured.

A Law which, according to the Ancients, is: “a path for growing.”

In the symptom, the patient is depositary and sentinel. As a character, he is the chosen depositary of a genuine historical family drama. This depends on his place in the family, on the desire that the different characters have brought into play, on the Oedipal problematic of the parents and grandparents. “De-depositing” is a genuinely traumatic and conflictual place. This is where treatment can founder, which depends greatly not only on the family pathology but also on the technical skill and personal maturity of the therapist. The patient, as sentinel, controls and prevents the psychiatric outbreak of one of the parents or siblings.

The addicted patient is subjected to a family myth: the language of three generations or more, which come to fruition in him. From this myth, his illness acquires a virtuality, and he himself becomes part of the myth. The myth is part of the family discourse; it is a genuine code and intercode. It teaches how to see reality. Each family myth is genuinely selective of a geographical, historical, neighborhood sector, corresponding to an era, in which each generational stratum has displaced its conflicts onto the next. Language, genuinely liberating, functions as a catalyst for signifying structures frozen and coagulated in historical strata without dialectic, and therefore narcissistic, in which the parental diachrony is fixed.

In these myths there are multigenerational settlings of accounts (Boszormenyi-Nagy) that people attempt to settle on the patient, and pathological loyalties that find their maximal expression in him. The therapist must listen to a family language: that is his function.

The patient caricatures a social and family way of life. His truth is a negative.

The young person of today confronts his neurotic, perverse or psychotic conflicts and in this way takes part in a trade, the fruit of a market ethic in which his illness is necessary to the maintenance of the world. The family lays bare, in all its problematic, a great deficiency in which the paternal and maternal functions, which structure subjectivity, fail. The family too emerges damaged and deteriorated from this market ethic.