Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Research Article, J Addict Behav Ther Rehabil Vol: 3 Issue: 2

Through the Mirror� Considerations Concerning the Pertinence of Structural Diagnosis for Young Drug Addicts

L Schiltz*
Head of Research Unit in Clinical Psychology (PCSA), Hôpital Kirchberg, Luxembourg
Corresponding author : L. Schiltz
Laboratoire de Psychologie clinique, Hôpital Kirchberg, 9, Rue Edward Steichen L-2540, Luxembourg
Tel: 00352 433668
E-mail: [email protected]
Received: August 03, 2013 Accepted: February 19, 2014 Published: February 24, 2014
Citation: L Schiltz (2014) Through the Mirror…Considerations Concerning the Pertinence of Structural Diagnosis for Young Drug Addicts. J Addict Behav Ther Rehabil 3:2. doi:10.4172/2324-9005.1000118

Abstract

Through the Mirror… Considerations Concerning the Pertinence of Structural Diagnosis for Young Drug Addicts

What is the object of the desperate quest of drug addicts? Olievenstein (1983) distinguishes the “real drug addict” from the one who has become a regular user by fortuitous events. According to the author, the “real drug addict’s” split traces back to the stage of the mirror where he had the opportunity to grasp a unified reflexion of himself; afterwards, the mirror broke. Later, the person desperately tries to gain back this feeling of a full existence, and it is the drug, which allows him to temporarily close this hole. Olievenstein’s conception is analysed through the description of four young drug addicts’ evolution, and the theoretical question of the significance of the drug for the drug addict is discussed. The discussion is also fed with some data taken from a retrospective study based on drug-dependent prisoners’ records. By means of a correlational and multidimensional analysis, the possibility to distinguish two profiles of functioning, based on the metaphorical versus the metonymic prevalence in the TAT, is tested. Consequences for psychotherapy are drawn from these considerations.

Keywords: adolescence; break; delinquency; drug addiction; narcissism; stage of the mirror; substitute object

Keywords

Adolescence; Break; Delinquency; Drug addiction; Narcissism; Stage of the mirror; Substitute object

Introduction

The current clinical conception seems to no longer maintain the old opposition between “impulsive drug addicts” who have an irrepressible need of immediate satisfaction and “compulsive drug addicts” who battle their addiction and play a subtle game of temptation and guilt [1]. However, the psychotherapists who take care of adolescents who are in touch with drugs often mention that the dangers emanating from the exposure to this environment are not the same for everybody [2] and that the desire to explore new sensations [3] does not necessarily lead to the condition of a drug addict [4].
Does Olievenstein [5] have a point when describing the figure of the “real drug addict” who is different from the one who has become a user by fortuitous events? According to the author, the “real drug addict” is someone who, in the sensitive stage of the mirror, had the opportunity to grasp a reflexion of his face in a mirror; afterwards, the mirror broke. During his whole life, the person remembers the nostalgia of the unified reflexion that she grasped, and it is only the drug experience that gives her this feeling of living a full life that she is missing. Therefore, the “real drug addict” cannot quit the drugs. He is ready to pay whatever price is asked for these few moments when he feels like really being alive.

Drug Addiction and Identity Issues

International literature shows that, in order to explain the phenomenon of drug addiction, the complex interaction of factors belonging to different levels has to be taken into consideration [6-9]. A schema similar to the one presented by Garner et al. [10] in order to explain the genesis of eating disorders could be put forward. The author indeed distinguishes the predisposition factors, the facilitation factors and the chronification factors.
In the case of drug addiction, the predisposition factors concern the personal vulnerability prior to encountering the drug, a vulnerability resulting from an interaction between genetic factors and precocious traumata [11], the facilitation factors are the period of the quest for identity of adolescence, the ideologies glorifying drugs, the friends’ incitements, the break of the relationship with the parents, while the chronification factors correspond to the effects of the substance on the situation of absence [12,13], but also to the dynamics of the social relationships that are established in the drug environment [8] and to the effects of belonging to a marginalised group [14-16].
From cause …
Many authors emphasise the need to take into consideration the split of the mental functioning that exists prior to the drug addiction [1,17,18]. According to Jeammet et al. [2], these subjects’ usual functioning modalities are the expression of a deficiency of the process of internalisation and elaboration, accompanied by a depletion of the libidinal investment, by the prevalence of everything attached to the realm of the Ideal Self over the one of the superego as well as by the floating of the identity. According to Therrat et al. [19], the predisposition factors are located either on the part of impulsiveness or on the part of narcissistic deficiency. On the other hand, a type of insecure or disorganised attachment [20] can be a risk factor as it is often associated with a deficiency of emotional control and with an impairment of the mentalisation capacities that predispose the subject to heightened psychological stress during his day-to-day social interactions [21]. Recent research has shown that this problem is often transgenerational [22-24].
On the part of categorial psychopathology, international researchpapers quote the borderline and narcissistic personalities among the risk factors [25-27]. On the other hand, the relationship between antisocial personality and drug addiction are about to be better known [28,29]. These persons’ heightened vulnerability seems to be linked to their weak tolerance level with regard to frustration. On the other hand, current research has explored the complex interactions between the use of cannabis and schizophrenia [30,31]. The drug can be used for self-medication purposes by those presenting a latent psychosis; however, the effect is two-way. The positive symptoms of schizophrenia (delusion, hallucinations) can be quickened while the negative symptoms (social inhibition, cognitive deficiency, anhedonia) can be improved according to the patients’ appreciation [32,33], but not according to recent controlled research [34].
… To effect
On the other hand, the young drug addict quickly develops selfsabotage behaviours of his motivational and volitional potentialities [35-38] and risks getting roped into a vicious circle, not only because of the reduction of the social relationships, but also because of the effects of the drug on his personality and his cognitive capacities. Let us recall that one has to distinguish the short-term effects, hallucinogenic, euphorigenic, relaxing or anaesthetic, from the long-term effects: heightened irritability, instability, dysphoria, motivational deficiency, disturbances of judgment and of memory [31,39,40], hence changes that, on their part, have a negative effect on the quality of interpersonal relationships.
A recent field of study in cognitive psychology deals with the interactions between subjective experiences linked to the use of drugs and the personal cognitions that are associated with them [40]. The latter are partially linked to the neurophysiological effects of the substances themselves and partially to the beliefs and preconceptions imparted within a given culture [41] and, particularly, within youth culture: “Heroin appeases and is euphorigenic, cannabis increases sociability and facilitates communication, cocaine allows an increased power of concentration, etc”. If research has not yet made generalising conclusions regarding the impact of the personal cognitions on the users’ behaviours, interesting implications for psychotherapeutic treatment could emerge. The cognitive-behavioural approach becomes more efficient if a metacognitive approach is added, which is aimed at showing to the young users that the emotions and cognitions that they impute to the effects of the drug do not correspond to reality but are the result of their own interpretations. This alienation allows them to feel less submissive to their desires and needs and favours the development of the mentalization capacities [20,42].
Can one find typical profiles and/or developments among drug addicts?
In order to verify Olievenstein’s conception [5], we will start by presenting the development of four adolescent users of illicit substances that were treated during a more or less long period of time in the context of psychology services for adolescents. We have chosen four extreme examples, leaving aside any personal characteristics and only maintaining the typical traits. The chosen examples are representative of a large number of individual developments. According to clinical and epidemiological literature, there is a subgroup of subjects on whom the therapies seem to have almost no effect [15]. Do they correspond to Olievenstein’s “real drug addict”?
The pernicious evolution towards chronic drug addiction leads, for some regular users, to a stay in a penitentiary setting, as chronic drug use can be associated with drug dealing and antisocial behaviours that are liable to prosecution (breaking and entering, armed robbery, violence against people, etc.), even if the causal connection between drugs and crime can be two-way [43]. In order to answer the question whether structural differences are still recognizable in confirmed drug addicts, we will present some results of a retrospective study based on records. The data were collected during judiciary expertise of drug addicts.. The analysis of the TAT protocols can give hints at the young drug-dependent prisoners’ structural functioning as well as at the developed compensatory defence mechanisms.

Drugs and Quest for Identity

Four differential developments
Myriam: Myriam first used heroin at the age of 13 years. Her sporadic use continued in the form of inhalation. Luckily for her, she was afraid of intravenously injecting herself with the drug. Around the age of 17 years, she succeeded in discontinuing the drug use without ever getting a withdrawal treatment. She received regular psychotherapeutic support in the context of the psychology services of her school. Simultaneously, she was treated by a general practitioner.
Despite the fact that at certain times she stole money from family members in order to purchase the drug, she has never been marginalised and her social contacts were not confined to the drug environment. She did not at all identify with this environment, but fought to find her own way by availing herself, for instance, of dramatics. In an amateur dramatic society she played the role of Cinderella’s stepmother. The identification with this negative part allowed her to confront the destructive tendencies that she felt governing over herself. She talked a lot about this in her psychotherapy sessions and made an effort to carve out the symbolical significance of her fascination with this dark part of her being.
The therapeutic relationship allowed her to rely on the sane parts of her personality and to accompany her efforts to subdue the appeal of heroin that she qualified as a “diabolical substance providing an ineffable well-being”. She could not say more about it. She availed herself of painting and writing a diary in order to facilitate her quest for identity and to reinforce her aspiration of controlling herself. The analysis of this spontaneous output facilitated the symbolical elaboration of her experiences in the course of the psychotherapy sessions.
In the long run, her condition did not aggravate. She still gave in sporadically, but the life instinct prevailed in the long run. She was successful in her studies and started a professional career to her liking.
Fred: Fred was a brilliant student until 4th grade. He seemed to be an adolescent without any problems. But, at the age of 16 years, he completely self-destructed within a few months. A friend of the family that he had admired for his artistic temperament familiarised him with the use of cannabis by glorifying the effects of the drug on the level of the expansion of the mind. Rapidly a double addiction took place, a relational dependency on “his guide” accompanied by the mental need to obtain hallucinogenic substances.
At the end of one single experiment with hallucinogenic mushrooms of the psilocybin species, he did not resemble anymore the person he used to be. It was as if his former Self had been driven apart completely. His condition was evocative of the vulnerable subjects described in the clinical literature of the 1970s [44] who became irretrievably psychotic after just one single massive dose of LSD.
We faced a human being that was completely destroyed, perambulating with a lowered head, uttering only insulting and foul statements, undergoing excessively annihilating delusions. Rorschach and TAT showed that his pulsional and emotional functioning was completely marked by the absence of the secondary process and that primary violence was expressed in a completely detached form. Similarly, his cognitive and mnesic functioning was deeply affected while beforehand he had given much evidence of his outstanding intelligence.
The recommended psychotherapeutic and psycho pedagogical measures seemed to have no effect at all on him and his parents took him out of school in order to have him admitted to a specialised institution. At the end of several unsuccessful commitments, he joined a protected occupational workshop. Several years later his condition remained unchanged.
In the current state of research, we can only speculate about the long-term neurotoxic effects of hallucinogenic substances [39,45]. In this context, one has to worry about the fact that the cannabis that is currently dealt in on the narcotics market stems from transgenic mutations and contains a THC rate of 26%, i.e. 4 to 5 times more than natural cannabis that was used in the 1970s. For vulnerable subjects suffering from low level borderline functioning [17] or latent psychosis there is a double risk: on the one hand, they become more quickly mentally addicted, on the other hand, the danger of psychotic decompensation is bigger. In this context, one has also to mention the risk of developing paranoia following the use of cocaine or crack [46], a risk that seems to increase with a predisposition factor.
Jacques: Jacques represents a case of pseudo-healing; but his later evolution shows that there was no change on the level of the deep structure of his personality, so that his past finally caught up with him.
Jacques had been treated during two years by psychology services on request from a juvenile court judge. At the age of 17 years, he had been arrested for dealing in heroin and he had undergone a jail sentence following a withdrawal treatment in a clinical environment. Upon his return to high school, the mission of the psychology services consisted in accompanying his reintegration. Contrary to other adolescents addicted to illicit drugs, he cooperates and does not deny his problems at all; he does not deal anymore, but he sporadically uses cannabis during his Saturday night outings. On Christmas Eve, he relapses once by injecting himself with heroin, without becoming addicted.
The psychological investigation shows the formation of a False Self. What is noticeable about the adolescent is his anhedonia, his irritability, his fantasmatic deficiency and his hypochondriac anxieties that hide behind a superficial adaptive behaviour. He has upheld a superficial relationship with his parents. He complains about not being able to build a lasting love relationship with a young girl.
Despite cognitive-psychodynamic psychotherapy his mentalisation capacities develop only a little. On the other hand, the psycho pedagogical measures prove efficient: he learns to focus more and his endurance improves. He finishes high school and has a stable employment during ten years.
In the long run however, he becomes alcohol-addicted and he dies at the age of 30 years of a trivial infectious disease, his poly-addictive behaviour having weakened his immune system in the long run.
Tania: Since the age of 14 years, Tania, who had an extremely easy-going education, has only been doing whatever she wants. During one of her outings, an older friend makes her use LSD. She says that the experience was extremely unpleasant and that she wanted to kill herself by slitting her wrists. A friend “heals” her by slapping her in the face.
Despite the appearance of pseudo-maturity, which impresses many of her male companions, the psychological test exposes her lack of self-assurance and her affective infantilism; she feels a great need of enhancing her status, she is always looking for acceptance and easily mistakes the imaginary world for reality, by availing herself of lies that she partially lets herself be fooled by. Her tendencies to mythomania cloud the depressive setting of her personality. Her parents had encouraged her to contact ambulatory counselling services dependent on a hospital, but she refused going back there. Changing their educational attitude completely, they threaten to place her in a very severe boarding school. It is under this threat that she agrees to be treated by the school psychology services. Quickly, a relationship of trust is built.
Tania becomes aware of her instability, but does not succeed in changing her ways. She has short and superficial relationships with many boys and smokes a lot, despite a heart condition that she does not care about. She openly expresses her rancour towards her parents whom she accuses of leaving her alone and of not understanding her, and whom she despises because of their inconsistency. The projective tests however expose feelings towards them that are much more ambivalent. At the end of several months, she becomes nervous and anorexic, loses a lot of weight, admits to secretly taking her mother’s tranquillizers, but denies any use of illicit substances. One day she comes into the psychologist’s office in tears. She claims that she has started smoking cannabis on a regular basis and that she has just used some in the school lavatories, but that she wants to give up this habit.
The psychologist suggests to her to participate in the supervised study of the high school in order to develop her learning capacities, and this suggestion seems to be fruitful. But the next year, she goes again through a critical period, during which she is extremely anxious and irritable. She admits to having restarted smoking cannabis and to having injected herself several times with a substance that she does not know the name of but that turns out to be LSD. She describes the experiences that were extremely unpleasant, during which she had the impression of becoming insane. The dimensions of all the objects seemed to have changed and she was afraid of bursting. After having had a disquieting “flashback” experience, she decides to not use that substance again.
Little by little, she reduces her use of cannabis and tobacco and seems to become emotionally more stable. Her school grades improve. At the age of 16 years, she switches schools and orientates herself towards technical education. From time to time she sends her regards to the psychology services’ team telling them that she is well.
Tania took much bigger risks than other adolescents, but right from the start her capacities of imaginary and of symbolical elaboration were better developed. Particularly, she was conscious of the unmet affective needs hidden behind her confabulations and pseudo-hysterical manifestations.
Her preferred means of expression was poetry. She continuously wrote poems that she brought to the counselling sessions and that corresponded to the flowery or burlesque expression of the typical preoccupations of middle adolescence. The content of her poetry indicated that the matter of her quest is rather focused on objectal than on narcissistic needs.
The significance of the drug at adolescence
We have seen above that, according to Olivenstein’s conception [5], the particularly vulnerable personalities are the ones that have a split on the level of primary narcissism. A comparison can be made with Bergeret’s “essential depression” [47]. If one is based upon Kohut’s theorisation [48] who admits two separate developmental lines, namely a narcissistic line and a developmental line, one can assume that the issue of the “real drug addict” is located on the narcissistic line, where the drug can assume the role of a “narcissistic prosthesis” [19]. The link between dissociative experiences, linked to precocious traumata, and addiction to cannabis that seems to temporarily give back to the users a feeling of unity and fullness [31,49], can be interpreted similarly.
For the adolescents that are less vulnerable, the drug seems to primarily contribute towards reinforcing the social link with the peer group and allow the youth in quest for emancipation to distinguish themselves from the adult group [15]. Even if the risk to develop a psychic or even physical addiction is less heavy in these cases, it can nevertheless not be excluded completely [8,9].

Retrospective Study Based on Records Conducted in a Penitentiary Environment

A study in a penitentiary environment has to allow us answering our question whether, at the end of a drug-dependent life of several years, differences as to structural pathology can still be distinguished within the group of users, despite the levelling effect of the substances themselves and despite the long exposure to the drug environment.
In the case of a structural specificity of the “real drug addicts”, we can admit that, in the projective tests of a sub-group of confirmed drug addicts, the expression of narcissistic suffering should exceed the expression of the nostalgia of love. On the other hand, the weakness of the mentalisation capacities should be reflected on the level of the formal characteristics and of the contents of the protocols [50], and especially the metaphorical versus metonymical level of expression and elaboration.
Methodology
Our experimental sample is composed of 15 subjects (Table 1) corresponding to the following criteria:
• Regular use of at least 5 years
• Drug dealing leading to a customer’s death or linked to other offences liable to prosecution by the criminal division, such as breaking and entering or violence against another person.
Table 1: Descriptive Presentation of the sample (N=15).
The subjects had all had several in-depth clinical interviews as well as psychometric and projective tests. Interviews were also conducted with family members. The evaluation was based on an integrated quantitative and qualitative approach. In order to answer the question mentioned above, we will present a correlational and multidimensional study of the TAT protocols.
The analysis of the protocols is made by means of a rating scale established in a phenomenological and structural perspective that allows going from qualitative analysis to quantification and to the use of inferential and non-parametric multidimensional statistics [51]. Former studies have shown that the fantasmatic deficiency that is reflected in the absence of metaphorical themes in the TAT (mundane or descriptive contents) could be a differential diagnostic dimension between different types of functioning that are defined according to structural psychopathology [50,52].
Results of the correlational analysis
The links between the different variables of the rating scale have been explored by means of rank correlations (Spearman’s rho).
In our sample of N=15 detained persons, the absence of metaphorical aspects in the TAT protocols, susceptible to indicate a weakness of the mentalisation capacity significantly correlated with the absence of personalised moral feelings (rho=.71; p<.01), with a lack of autonomy in social relationships (rho=.56; p<.05), with the absence of intrinsic motivation (rho=.52; p<.05) and with the presence of an exclusive egocentric position that could be corresponding to a narcissistic split (rho=.64; p<.05).
The links between the deficiency of the process of mentalisation and personality pathology could hence be interpreted as defined by our hypothesis.
Results of the multidimensional analysis
The application of optimal scaling (HOMALS procedure) to the rank correlation matrix has also shown the importance of the capacity of imaginary and symbolical elaboration. The inspection of the matrix of the measures of discrimination has led to a denomination proposal that is psychologically plausible for a solution with three dimensions, whereof each one is characterised by a very satisfying internal consistency (Cronbach’s α between .93 and .88):
Dimension 1: reflexivity and projection into the future
Dimension 2: expression of non-elaborated destructive tendencies
Dimension 3: banal content and absence of formal application
These dimensions appear compatible with the structural conception of psychopathology, the first one being able to allude to the neurotic functioning, the second one to the borderline functioning [47] and the third one to the defensive or factual functioning [53].
Some stories chosen among those lying at the barycentre of the distributions will allow us to illustrate the psychological meaning of the different dimensions.
Typical example dimension 1: “The boy and his Violin”: “Paul is a little boy who is similar to all the children of his age. Is this really true?
No, it is not. He would absolutely like to learn to play the violin. He owns a violin, he has scores, but he sometimes lacks courage because he does not know how to shape up. But he would like to learn himself, in order to be able to be proud of himself, later, when he will know how to play.
In the evening, when he is sitting in his room, he thinks about later and dreams about being a famous musician. Then he takes his violin and starts playing. When he produces a wrong note, he starts all over again, he tells himself that he is able to make progress and that his music will become more and more beautiful. In the end, he puts his violin down and escapes his narrow room, forgets the noises of the cars, imagines being on a stage, in the middle of a big orchestra, playing Beethoven, Strauss, Chopin and Mozart. The conductor smiles at him and the audience is applauding.
He starts practicing again and does never give up. He is sure that one can learn from one’s mistakes, provided that one is not constantly blamed for them” (TAT, plate 1).
Typical example dimension 2:The Devil”: The devil proclaims: “Again, I wield power over a human being. If it goes on like this, I will be the only Master of Death. It is easier to commit evil acts than to do good acts. One day the world will disappear. At this moment, all the human beings will bow to me” (TAT, plate 15).
Typical example dimension 3:This picture reminds me of a football match. The first player scored a goal, the second one congratulates him. Thanks to this goal, the team won this important tournament” (TAT, plate 10).
The first story illustrates the capacity to dream and to use one’s imagination in order to maintain one’s motivation, to rise above one’s limitations and to reach a distant goal, whereas the second one expresses the fascination by the yearnings for power and the third one remains at the purely descriptive level of the rationalizing defence.
Metaphorical prevalence versus metonymic prevalence
According to the differential criteria carved out above, we can suggest a provisional typology that opposes a primary to a more differentiated functioning, based on the level of mentalization (Table 2).
This possibility of combination, presented solely as an indication, given the restricted size of our sample, could back Olievenstein’s conception of the “real drug addict” [5], but also the old conception opposing the “impulsive drug addicts” or psychopathic ones [54] to the “compulsive drug addicts” or anxious ones, provided that it is interpreted in terms of structure [47]. An interesting field of study could consist in exploring more in depth the links between the metonymic prevalence in the TAT stories and certain sub-groups of drug addicts, namely those having an antisocial personality [28], a low-level borderline functioning [30], respectively a heboidophrenia combined with drug addiction [55].
Table 2: Level of Mentalization in the Stories of the TAT.

Psychotherapeutic Consequences

From the considerations mentioned above it results that the choice of the psychotherapeutic method for the young drug addicts should take into consideration their structural diagnosis.
The difficulties inherent to the treatment of confirmed drug addicts have often been described [15,56-58]. One hence has to insist on the necessity of tertiary prevention, i.e. one has to take intensive care of the beginning drug users, especially those having identity disorders, in order to prevent serious psychopathological and antisocial evolutions.
If a therapeutic offer can take place within the school, its effectiveness can be heightened as it can be combined with a psycho pedagogical approach destined for preventing academic failure and dropping out from school [8]. On the other hand, the impact of leisure activities and the circle of friends is crucial. In a school environment, these factors can more easily be taken into consideration. For all the treatment measures taken by ambulatory services, the parents’ collaboration is crucial [59].
For the young occasional users in search of unknown sensations or lacking autonomy vis-à-vis consumption habits prevailing in the peer group, the offer of a support psychotherapy accompanied by psycho pedagogical measures can seem to be sufficient. For the adolescents suffering from a narcissistic wound, the psychotherapeutic approach should be the same as for low-level borderline functioning in general [17]. Given the danger of a rapid deterioration of the situation [60], an eclectic approach focussed on mentalisation, of the cognitivepsychodynamic type, should be preferred to classical psychoanalysis [61-63]. On the other hand, the use of artistic mediation, combined with verbal psychotherapy, can be appropriate [52,64,65]. This combined approach could contribute to increasing the capacities of symbolization in an indirect and unintrusive manner. This is a largely unexplored field of study.
In prison, the confirmed drug addicts’ psychotherapy encounters specific difficulties [38], namely weakness of the personalised sense of guilt and the massive presence of archaic guilt, abstinence that was imposed from the outside, promiscuousness with companions that have not been chosen, the therapist’s ambiguous status, by both representing the Law and supporting the detainee’s efforts to take his life into his own hands. In the penitentiary context, the therapeutic offer should also take into consideration the subjects’ structural specificities by preferring methods that are aimed at the reflection capacity [66,67]. As is the case for the school context, the use of artistic mediation can be appropriate for the people presenting a less mentalized functioning that is characterized by metonymic prevalence in the projective tests.

Conclusion

One can wonder whether the mirror that was broken during the first year of one’s life can be repaired.
According to Kohut et al. [48] and also according to McArthur et al. [68] who has a long experience in the psychotherapeutic treatment of adolescents and young adults suffering from serious structural deficiencies, the pieces of the mirror can be stuck together again, but it will always remain cracked. One has to make do with developing compensatory structures that allow using in the best possible manner the subject’s emotional, cognitive and volitional resources. One also has to take into consideration the long-term neurotoxic effects of the drug [69,70].
Why can the means of an artistic mediation be particularly appropriate for those that correspond to the profile of the “real drug addict”? As the capacities of imaginary and symbolical elaboration are often reduced and as their verbal expressions are poor, the created object can be a visible, tangible and possibly audible medium for mentalisation. In metaphorical terms: Even if the broken mirror can never be completely repaired, one can hope to create a substitute mirror, which is less clear and less bright than the original mirror, but which is nevertheless providing a vague reflexion of what the person could be.

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