Img: The Dead Mother, Edvard Munch (1899 - 1900)

Children's Minds in the Line of Fire COCAP Blog

There's a hole in daddy's arm
Author: Ben Fife

Amalia, a working class Latina mother who came into treatment with me because of the stress of parenting a child with special needs messages me ahead of an appointment to tell me she is running late. She is agitated when she arrives. The first thing she tells me is that her brother is in jail.  This, his second lockup in 6 months, is and is not a shock. The previous arrest happened when he drove high on oxycontin on expired plates to try to score more pain pills in another town. 

This arrest is more infuriating because Amalia feels implicated. Her brother’s wife (a semi-retired nurse who she is close with and who provides her family with child care when she and her husband are at  work) let her know that Amalia’s brother hit her. Amalia advised his wife  to make a police report. The report lead to the brother’s arrest. 

The close knit family is furious with the brother’s wife and is pressuring Amalia to post her brother’s bail. She is refusing and wracked with a feeling of “wrongness,” for having the thought that this arrest may be what her brother needs to get his act together. She laments that there is no one in the family who could readily take her brother in should someone post bail. She feels guilty for seeing her brother’s signs of untreated severe mental illness for many years and never successfully getting him help. She is also furious with her own mother, nieces and nephews who are claiming that the brother’s wife is responsible for the violence. Amalia is especially worried about how her own and her brother’s wife’s distress and distraction have left them emotionally absent when interacting with Amalia’s children.

This is an example from my practice of an opioid adjacent case. It is not unusual. It is a snapshot of a patient facing a family crisis with themes that reverberate in the transference. The themes, pressured presences, confusing absences, confusions between loving and hating, caring and hurting, come up over and over again in work with patients impacted by the opioid epidemic.  

In my own practice 1 out of three of my clinical hours involve work with patients whose difficulties I have come to think of as “opioid-adjacent.” I see children who have lost parents to fentanyl overdoses, children with parents in recovery from opioids, young adults who have lost siblings to overdoses, teenagers anxious about who will be carrying Narcan if they go out dancing with friends, parents struggling to manage relationships with extended family members in the throws of addiction and parents struggling to reduce dependency on opioid pain medications themselves. 

Staying in contact with  patients' experiences of the opioid epidemic has been helped by developing ways of thinking about absence both at the intrapsychic level and at the level of larger social forces. Take for example the social and psychological experiences that leave children vulnerable to loss in working class families where there is an opiate using father. Case and Deaton (2020), propose that opiate use and other factors contributing to the increase in “deaths of despair,” are tied to new absences in the social contract. Working class white and Latino men without college educations face an absence of jobs that pay enough to support families. In many instances these men are for the first time in generations making less than the generation of their parents, and are encountering an absence of the life they expected to live and to provide. In turn they are increasingly unlikely to be seen or to see themselves as economically viable partners and they become more likely to be absent from family life and to be more stressed when they are part of it. If they turn to opiate or alcohol abuse they become psychologically absent if they are high at home and are more likely to be physically absent longer than they expect or intend if they use outside of the home. The experiences of absence become clinically important phenomena not only if and when these fathers come in for treatment, but also in the experiences that children and other family members have of these vulnerable adults.  

In 1982 Andre Green proposed two different tracks along which the unconscious can develop.  The first he says following Freud, is a vertical model. A present caregiver is wanted body and soul by an infant. The infant develops a sense that what he or she wants is too much and could harm or change the caregiver. The infant feels guilt in relation to his or her desire. This conflict between desire and guilt (primary process) is covered over by conscious thought (secondary process) that denies or obscures the presence of the desire. The awareness of some communication from below, in the form of symptoms, slips of the tongue, dreams, forms a bridge between the unconscious guilt and desire and conscious thought and action. This constitutes a tertiary process by which the unconscious can come to be, to some degree, known.  

Green’s second model, the horizontal one, occurs when early development is characterized by the absence of an available other. There are the wishes to have the (absent) object and there is the infant’s need to prematurely accommodate a reality where the object can’t be reached. These psychic states of need on the one hand and lack on the other, exist side by side, in fragments that seem to be incommunicado with one another. What is unconscious here is not the conflict, but the fact of the split between these states of being. It is as if each thought a person has about what is happening is made up of different pieces that don’t fit together as a whole. What is split here are feelings towards the object of love and hate, which are by the work of the unconscious kept separate. Importantly there is no tertiary process available for communication between these different sides of psychological experience. The analyst or analytic therapist is called upon to use his or her own capacity to communicate between conscious and unconscious thought in service of the treatment.  In short Green says, in situations where early experience is dominated by the absence of an available other, unconscious dynamics will be dominated by splitting and confusion around love and hate.  

This model has helped me in my work with people impacted by the opioid epidemic. It offers a way of thinking about the early, often intergenerationally echoed modes of relating in families, while also offering a way, in the here and now, to understand the psychological impact of the encounter between need and absence. In the imaginary play, for example, of a child whose father died from a fentanyl overdose, figures that occupy the position of a paternal role, enforcers of rules and order, are often bureaucratized, punitive, and distant. If in the play I am assigned the role of a father or other holder of order (teacher, police officer, doctor, railway conductor) I can expect to be kept at a distance, either given set of scripted roles meting out harsh punishment for minor infractions, or put in different disguises and assigned to watch the child’s character secretly. Should I express concern in the play in the form of discomfort at the idea of meting out a harsh punishment or attempt to make contact with a feeling, there will be a great crash or disaster, I will be found guilty of causing it, and I will find my character hated for any act of care or concern - punished violently and severely, possibly for the remainder of the hour.  

Containment in therapy is always partial. When our opioid-adjacent patients bring forward their own needs for recognition in the world and  encounter absences in the capacity of those they depend on (within and outside of families) to hold their experiences, further splitting and confusion around contact, care, love, and hatred emerge. Sometimes there are explicit  needs for dynamic psychotherapists and psychoanalysts to consult with  other people in a child’s world in ways that protect the privacy of therapy while opening up some space within the other for increased understanding of the child. However, given the scale of the issues at hand here, I believe our field needs to find ways to reduce the splitting that is so prevalent in our contemporary social world when encountering those impacted by the opioid epidemic. 

For Green, the encounter between need and absence that mattered most was a very early one that would lay the groundwork for unconscious dynamics that remain with the subject for the rest of his or her life. I have no sense of certainty about whether what creates these dynamics is primarily an infantile relationship that repeats or whether splitting dynamics are the product of societal processes where basic needs for contact and care are being denied on a mass scale.  I’m not convinced that for clinical practice a precise etiology of the symptoms we encounter matters all that much. I think that what matters here is the psychic reality of our patients, which is that needs that encounter nothing but an absence of contact create splits and confusion. That can happen early, creating a lens on future experience, and that can happen later. That can also be re-enacted in our offices, and outside our offices.  

The generation of analysts and analytic psychotherapists I belong to has made what many are calling a “turn to the social,’’ pushing training institutions to consider a social unconscious as a shaping force in psychic life. This turn reflects, I believe, a wish for greater involvement of psychoanalysis in the world. One, perhaps undervalued, way that we as analytic communities can be more involved in the world is to try to bring our non-analytic colleagues, physicians, teachers, politicians, paraprofessional caregivers and parents, into safe contact with the emotional landscapes of children whose lives are shaped by loss and absence. These diverse adults are also coming into contact with more of the fragmenting pain and distress caused by large-scale traumas like the opioid epidemic, and need ways to understand the complicated feelings evoked by this contact, including the confusional mixes of love and hate. I think that this can take many forms - consultation, teaching, writing op-eds, and getting involved in political projects that impact policy in useful ways. If we as an analytic community, with what we know about the short and long term impacts of loss, cannot be present and attempt to help those in need understand these experiences, we risk becoming one more absent object in a time of need. 

*From John Prine’s 1971 song,  Sam Stone 


Case, A., & Deaton, A. (2017). Mortality and Morbidity in the 21st Century. Brookings Papers on Economic Activity, 397–443.

Case, A., & Deaton, A. (2020). Deaths of despair and the future of capitalism. Princeton University Press.

Green, A. (1986) Psychoanalysis and ordinary modes of thought. In On Private Madness. (pp 17-29) Karnac. 

Winnicott, D. W. (1965) The Aims of Psycho-Analytical Treatment (1962). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development 64:166-170

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