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PTSD and addiction are a marriage made in the avoidance of unbearable affect; an avoidance that is costly in the resulting traumatic reenactments experienced by patients whose attempts to escape the past keep them evermore tightly bound to it. Rather than "difficult patients" a more dynamic and intersubjective conceptualization emphasizes the notion of a "difficult treatment dyad." Vicarious traumatization, unconscious affects about addiction, and pressures within the treatment surround conspire to pull the therapist out of connection with the patient at critical points, and toward sadistic abandonment or collusive indulgence. The concomitant desires to rescue and desert patients create forces for action in the therapist, precisely when what is needed most is the ability to tolerate and contain one's own and the patient's affective experience. The pull for action is also felt by treatment systems, eager for "action" that can be measured in "behavioral observables." Support for the therapist in the form of process supervision can assist the therapist to contain, identify, and acknowledge his/her affective responses evoked in treatment. The therapist is called upon to "grow one's own heart" through a confrontation with the undeveloped parts of self that are vulnerable to the dynamics of the treatment.

Under the Influence of Unconscious Process: Countertransference in the Treatment of PTSD and Substance Abuse in Women