At the beginning of treatment Parker B. lived with two male musician
roommates, and living frugally was able to survive off the earnings of his
band. The band had a strong local following, playing a lot of club dates both
at home and in neighboring towns. Two years before, based on the strength of
his songs, local fan base and sales from a self-produced EP, the band
successfully landed a major record deal. When their CD was released it got
minimal promotion from the label, despite a national tour during which they
opened for a name act. The CD received good but not great support from
critics, and sold respectfully. The label dropped the band the next year. At
the time, Parker said he'd been cynical all along and wasn't surprised that it
came down that way. Of note, however, was the fact that his consumption of
alcohol and experimentation with amphetamine increased soon thereafter. 
 Parker reported that his mood had worsened over the preceding six months. He
felt hopeless and unmotivated, his sleeping was disturbed, and he'd lost
weight .Although he'd had some suicidal thoughts, he denied any intent or plan
and had no history of gestures. Upon closer examination as he'd originally
disavowed any feelings pertaining to this, it became clearer that a
predisposing factor was the breakup of a relationship with a woman he'd been
dating for the last year. She had expressed her unhappiness with his seeming
lack of caring as she wanted more of a commitment in the relationship, and
more recently she had been worried about his use of alcohol and drugs.
Similarly, other friends had told him that he was becoming harder to be
around, that he seemed impatient and reactive. He said he felt surprised by
this. He said he did feel guilty about missing so many band practices and knew
that his performance was starting to slip at gigs. My diagnoses on Axis I
were: Major Depressive Episode and Amphetamine and Alcohol Abuse.
 The beginning of the therapy was characterized by Parker's superficial
compliance to attending the weekly individual sessions. He frequently missed
sessions without calling despite his understanding that he'd be charged for
the time. When called by me, he agreed to make the next meeting and reported
no particular feelings about missing the session or about consciously
intending to skip the session either. He initially minimized the extent of his
drinking and speed use, but did agree not to come to the sessions having used
or drank past midnight the night before. As far as I could tell, he did comply
with this part of our slow to build alliance. The frequency of his absences
declined over the first few months and a clearer picture of his behaviors and
history emerged.

 The goals of the initial phase of Parker B.'s psychotherapy were to develop a
working therapeutic alliance , to clarify and treat his active substance abuse
and to tease this out from the depression. Although the onset of Parker's
depression seemed clearly related to recent (although largely disavowed)
losses - those of his girlfriend's departure six months before and his record
contract the year before- the acceleration of his alcohol and drug use to
substance abuse status complicated the clinical picture and needed immediate
attention. My technical focus during this phase would best be characterized as
cognitive-behavioral although I was aware of important self-object
transferences beginning to develop in the context of my sustained empathic
stance.

 Parker's substance consumption in the preceding year had escalated from
social drinking on the weekends, about two to three beers in a night, and
occasional pot if someone offered him some during the week, to snorting speed
on the weekends with subsequent alcohol binges as he was coming down. As he
settled into our weekly meetings, he began to acknowledge the negative
consequences to him of these binges. He said that he first started using speed
from time to time with friends after his record deal fell apart and it seemed
to help his mood with no associated problems. He thought it had a good impact
on his playing as well. 

 During this phase of the treatment, I provided education as to the
progressive nature of addiction and the depressant effects of alcohol and
stimulants. I explained the counterproductive cycle he'd established in his
attempts to feel less depressed and advocated that he commit himself to
complete abstinence from all mind-altering substances while we were trying to
work on his problems. He seemed to find comfort in the idea that
antidepressant medications could be tried if his depression didn't lighten up
with some clean and sober time. I strongly encouraged Parker to check out some
AA/NA meetings and as (luckily) he had a musician friend who was working a
12-Step recovery program, he eventually attended some meetings. By the end of
the first six months of treatment, Parker agreed that he should completely
abstain from using substances and was able to do that in the next two months,
after several brief "slips" on alcohol. He didn't fully agree that he had a
problem with drinking in the absence of the speed, was clearly not committed
to lifelong abstinence, but agreed to quit in the short-run to see if that
helped his mood. 

 Ongoing aspects of the treatment over time involved my attention to Parker's
difficulty identifying and expressing his internal states , including feelings
and wants, his denial of his dependency needs often resulting in angry
outbursts and then painful isolation, and his perfectionistic and self-
critical internal dialogues or "self-talk". The theoretical frame of the
therapy would best be described as a blend of psychoanalytic self-psychology
and cognitive-behavioral principles. In the context of a consistent and
predictable therapeutic structure , a "good enough" empathic stance with my
active mirroring of his feeling states and his abstinence from drugs and
alcohol, the relationship between us deepened. When I failed to accurately
understand and mirror him, these breaches were explored and repaired. I
challenged his self-defeating behaviors and cognitions and helped him to
explore alternative strategies to feel better and get his needs met to the
extent that he could begin to know what those were. He reported feeling less
depressed, had regained his weight, resumed full participation with his band ,
began dating someone new and even began writing new songs.

As the therapeutic alliance strengthened in the second year of treatment, the
meaning of Parker's family history was more fully revealed and he began to
share my curiosity in trying to understand the origins and emotional functions
of his self-defeating patterns. Parker had warm but vague memories of his
mother as she died in a car accident when he was nine years old. When he was
eleven and his sister was eight, his father remarried. Parker's stepmother was
highly narcissistic and critical of both he and his father. Parker's father
was a kind but depressed man who was not emotionally available and never lived
up to his own father's considerable material success. His wife angrily and
regularly expressed her disappointment about her husband's limited ambitions
and status. In addition her drinking progressed over time to alcoholic
proportions and became the proverbial "pink elephant in the living room", in
that it was never discussed, just felt. Parker recalls feeling embarrassed on
his father's behalf as a fifteen year-old, that his father didn't ever seem to
stand up for himself or fight back. Of note during that period is that Parker
started to play guitar and had a very positive if somewhat idealized
relationship lasting for several years with his guitar teacher, an
enthusiastic and funny twenty-five year old man. Music became an important
avenue for Parker to feel that he fit in somewhere and to comfort himself. In
the sessions he was able to begin to experience feelings of anger, shame and
sadness in relation to these earlier aspects of his life. 
His initial expectations in the transference revolved around fears that I was
privately feeling contemptuous of him despite my exterior support, and that if
he allowed himself to feel close to me, or need anything from me, that I would
shame and reject him. Over time he was able to risk these feeling states in
the session and trust that I was not going to re-enact his early relationship
with his stepmother in this way. Similarly he began to share his excitement
about songs he'd completed and eventually brought me tapes to hear. He acted
casually at first, denying that he cared much about my reaction. Later he
acknowledged that he needed me to consider them "brilliant" to make up for his
doubts about their worth. Generally his self-concept alternated between breezy
grandiosity and harsh feelings of worthlessness in a classic example of "all
or nothing" thinking. He came to see that either of these extreme positions
kept him from experiencing the mixture of emotions that reflected his internal
experience in real time.

The extent of Parker's hypervigilance to my reactions came further into view
with time. He seemed to become particularly anxious when feeling genuinely
expansive and hopeful. It became clear that he feared his achievement would
somehow make me feel less competent, as though there was only a limited
quantity of good feelings. He could not enjoy sharing his success fully as he
would feel guilty, protective of me, and then resentful. We began to
understand his ambivalence about success and recognition in the context of
pathogenic fears that he would humiliate and devastate his father with greater
success. As he worked these fears out with me in the sessions, he decided to
share some of his thoughts and feelings with his father with whom he'd
reestablished contact. This contact had been built on Parker's previous
decision not to visit when his stepmother had been drinking. The meeting was
difficult; his father listened, but Parker did not feel understood.
Nonetheless, he was better able to see himself as separate from his father's
life choices.

After about a year of complete sobriety Parker decided to see if he could
drink socially. He understood the concept of cross addiction and seemed
appropriately cautious in his thinking. His plan was to limit his drinking to
the weekends and quantity to two beers a night. We agreed that he'd experiment
with "controlled drinking" for six months to a year and see what happened. In
addition to the control question, a second consideration was, of course,
whether social drinking would negatively affect his mood and overall progress.
In that he had no (biological) family history of alcoholism and he'd had an
abuse rather than dependence diagnosis, I was moderately optimistic. We also
agreed that if he was not able to stick to his plan over time, or if his mood
worsened, he would get serious about AA and resume abstinence.

 By the beginning of the last year of treatment, Parker's band was beginning
to do short tours. He'd successfully sold two songs to well-established acts
and he was receiving royalties. His traveling for two to four week periods
during the next four months necessitated a change in the frame of the therapy
and we scheduled thirty minute phone sessions once a week from the road.
Despite the obvious temptations and pressures on the road, such as hanging out
in bars for hours, boredom, separation from his girlfriend, graveyard shift-
type hours and so on, he was able to stay on course with his drinking goals.
In sharp contrast to his initial presentation, Parker was able to acknowledge
and express his feelings of frustration and sadness being separated from his
steady girlfriend. On one occasion he let me know that he even missed me. In
consciously experiencing his current emotions, he became aware of the depth of
his sadness over the loss of his mother as a child and his disappointment and
feelings of abandonment with his father. He began to understand how he'd shut
down his trust and hopeful expectations of others, and was able to share these
feelings with his girlfriend which helped soothe him. At the same time, his
relationship with his little sister became closer. It seemed that Parker's
therapy coincided with his sister's growing awareness of the impact of growing
up with an alcoholic stepmother and she had been starting to read the adult
children of alcoholic (ACOA) literature. For the first time Parker felt he had
a family apart from his music.

On the surface of things, Parker B.'s departure from psychotherapy was a by-
product of his decision to relocate from San Francisco to Los Angeles to
pursue the song writing aspects of his career. His band and girlfriend went
with him. After our three years together I didn't really argue much about his
leaving the therapy. We both knew that he was ready. He was not depressed, had
developed his capacity for connection with others, had reclaimed his full
range of feelings, understood his limits with substances, and his writing and
playing was stronger than ever. He seemed to have rediscovered his dream and
for the first time as an adult was able to feel good about having one. 

 References
Beck, Aaron T.(1976) Cognitive Therapy and the Emotional Disorders. Meridian
Books, New York.
Beck, Aaron T., Wright, Fred D., Newman, Cory F., Liese, Bruce S. (1993)
Cognitive Therapy of Substance Abuse. The Guilford Press, Inc.
Brown, Stephanie.(1995). Treating Alcoholism. Jossey-Bass Publishing, San
Francisco. 
Kohut, Heinz. (1977). The Restoration of the Self. International Universities
Press, Inc.
Kohut, Heinz. (1984). How Does Analysis Cure? The University of Chicago Press.
Stolorow, Robert D., Brandchaft, Bernard, Atwood, George E.(1987).
Psychoanalytic Treatment:An Intersubjective Approach. The Analytic Press.