Psychotherapy Volume 35/Fall 1998/Number 3 TREATING SUBSTANCE-ABUSE PATIENTS WITH HISTORIES OF VIOLENCE: REACTIONS, PERSPECTIVES, AND INTERVENTIONS SCOTT KELLOGG The Rockefeller University One of the more troubling experiences that occurs in the psychotherapy of addicted persons is when they relate stories concerning their involvements with past acts of violence. Whether these events are regretted or not, they often arouse strong feelings in therapists and can present both patients and clinicians with questions about how to proceed. Attribution theory can be a useful tool for understanding the feelings and countertransference that arises, and a combination of insights from the fields of posttraumatic stress disorder (PTSD) treatment and existential therapy, along with a focus on the question of character, are a potential foundation for the development of therapeutic interventions. The relationship between substance abuse and violence, the importance of treatment context, and the interdependence of identity and action are explored here. Introduction This article attempts to address a difficult and challenging therapeutic situation: that of working The authors express their thanks to Robert Hoffnung for his thoughtful criticism. This work was supported in part by NIDA grants P50 DA09241, 5K12 DA06963, DA05130, and DA00049. Correspondence regarding this article should be addressed to Scott Kellogg, Laboratory on the Biology of Addictive Diseases, The Rockefeller University, 1230 York Avenue, New York, NY 10021-8574. Electronic mail may be sent to kellogs@rockvax.rockefeller.edu. ELISA TRIFFLEMAN Yale University with an adult substance-abuse patient who relates his or her past commission of or involvement with acts of serious violence, including crimes or acts of aggression that were unreported and unprose- cuted and which are now ego-dystonic or difficult to accept. These revelations may concern: (a) crimes against the general public to support a drug habit or actions taken in drug-dealer "turf wars"; (b) acts committed in the course of self-defense, during personal disputes, out of revenge, and dur- ing family quarrels; (c) car accidents while high or intoxicated; or (d) gang initiations or disputes with other gangs. Stories of this nature may be encountered in both clinical and research settings-as these au- thors discovered during a treatment research study on PTSD and substance abuse (Baker & Triffle- man, 1998; Triffleman, Carroll, & Kellogg, in press). At the time that these stories were pre- sented, it had been some 10 or 20 years since the acts occurred, and there was no issue of imminent danger to the therapist or to anyone else. As with standard trauma victimization histories, accounts often emerged when patients or subjects were asked explicitly, directly, and specifically about them (Krinsley et al., 1994), or in the context of discussions concerning activities undertaken to support substance habits. Many patients said they had not discussed these experiences during prior treatment because no one had directly inquired about them; a situation that may indicate a reluc- tance by both treatment providers and patients to deal with such histories. Several studies, however, have indicated a con- nection between violence and substance abuse. In a comprehensive review of the literature on violence, homicide, and psychiatric disorders, Asnis, Kaplan, Hundorfean, and Saeed (1997) found that alcohol and drug abuse and antisocial personality disorder were associated with violent acts. Kermani and Castaneda (1996), in another 405