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Psychodynamic therapy focuses on unconscious processes as they are manifested in the client's present behavior. The goals of psychodynamic therapy are client self-awareness and understanding of the influence of the past on present behavior. In its brief form, a psychodynamic approach enables the client to examine unresolved conflicts and symptoms that arise from past dysfunctional relationships and manifest themselves in the need and desire to abuse substances.
Several different approaches to brief psychodynamic psychotherapy have evolved from psychoanalytic theory and have been clinically applied to a wide range of psychological disorders. A growing body of research supports the efficacy of these approaches (Crits-Christoph, 1992; Messer and Warren, 1995).
Short-term psychodynamic therapies can contribute to the armamentarium of treatments for substance abuse disorders. Brief psychodynamic therapies probably have the best chance to be effective when they are integrated into a relatively comprehensive substance abuse treatment program that includes drug-focused interventions such as regular urinalysis, drug counseling, and, for opioid-dependents, methadone maintenance pharmacotherapy. Brief psychodynamic therapies are perhaps more helpful after abstinence is well established. They may be more beneficial for clients with no greater than moderate severity of substance abuse. It is also important that the psychodynamic therapist know about the pharmacology of abused drugs, the subculture of substance abuse, and 12-Step programs.
Psychodynamic therapy is the oldest of the modern therapies. As such, it is based in a highly developed and multifaceted theory of human development and interaction. This chapter demonstrates how rich it is for adaptation and further evolution by contemporary therapists for specific purposes. The material presented in this chapter provides a quick glance at the usefulness and the complex nature of this type of therapy.
The theory supporting psychodynamic therapy originated in and is informed by psychoanalytic theory. There are four major schools of psychoanalytic theory, each of which has influenced psychodynamic therapy. The four schools are: Freudian, Ego Psychology, Object Relations, and Self Psychology.
Freudian psychology is based on the theories first formulated by Sigmund Freud in the early part of this century and is sometimes referred to as the drive or structural model. The essence of Freud's theory is that sexual and aggressive energies originating in the id (or unconscious) are modulated by the ego, which is a set of functions that moderates between the id and external reality. Defense mechanisms are constructions of the ego that operate to minimize pain and to maintain psychic equilibrium. The superego, formed during latency (between age 5 and puberty), operates to control id drives through guilt (Messer and Warren, 1995).
Ego Psychology derives from Freudian psychology. Its proponents focus their work on enhancing and maintaining ego function in accordance with the demands of reality. Ego Psychology stresses the individual's capacity for defense, adaptation, and reality testing (Pine, 1990).
Object Relations psychology was first articulated by several British analysts, among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and Harry Guntrip. According to this theory, human beings are always shaped in relation to the significant others surrounding them. Our struggles and goals in life focus on maintaining relations with others, while at the same time differentiating ourselves from others. The internal representations of self and others acquired in childhood are later played out in adult relations. Individuals repeat old object relationships in an effort to master them and become freed from them (Messer and Warren, 1995).
Self Psychology was founded by Heinz Kohut, M.D., in Chicago during the 1950s. Kohut observed that the self refers to a person's perception of his experience of his self, including the presence or lack of a sense of self-esteem. The self is perceived in relation to the establishment of boundaries and the differentiations of self from others (or the lack of boundaries and differentiations). "The explanatory power of the new psychology of the self is nowhere as evident as with regard to the addictions" (Blaine and Julius, 1977, p. vii). Kohut postulated that persons suffering from substance abuse disorders also suffer from a weakness in the core of their personalities--a defect in the formation of the "self." Substances appear to the user to be capable of curing the central defect in the self.
[T]he ingestion of the drug provides him with the self-esteem which he does not possess. Through the incorporation of the drug, he supplies for himself the feeling of being accepted and thus of being self-confident; or he creates the experience of being merged with the source of power that gives him the feeling of being strong and worthwhile (Blaine and Julius, 1977, pp. vii-viii).
Each of the four schools of psychoanalytic theory presents discrete theories of personality formation, psychopathology formation, and change; techniques by which to conduct therapy; and indications and contraindications for therapy. Psychodynamic therapy is distinguished from psychoanalysis in several particulars, including the fact that psychodynamic therapy need not include all analytic techniques and is not conducted by psychoanalytically trained analysts. Psychodynamic therapy is also conducted over a shorter period of time and with less frequency than psychoanalysis.
Several of the brief forms of psychodynamic therapy are considered less appropriate for use with persons with substance abuse disorders, partly because their altered perceptions make it difficult to achieve insight and problem resolution. However, many psychodynamic therapists work with substance-abusing clients, in conjunction with traditional drug and alcohol treatment programs or as the sole therapist for clients with coexisting disorders, using forms of brief psychodynamic therapy described in more detail below.
Psychodynamic Psychotherapy for Substance Abuse
Supportive-expressive (SE) psychotherapy (Luborsky, 1984) is one brief psychodynamic approach that has been adapted for use with people with substance abuse disorders. It has been modified for use with opiate dependence in conjunction with methadone maintenance treatment (Luborsky et al., 1977) and for cocaine use disorders (Mark and Faude, 1995; Mark and Luborsky, 1992). There have been many studies of the use of SE therapy for substance abuse disorders, resulting in a significant body of empirical data on its effectiveness in treating these problems (see below).
Mark and Faude asserted that although their therapeutic approach was devised specifically for cocaine-dependent clients, these people often have multiple dependencies, and this approach can be used to treat a variety of substance abuse disorders. However, clients should be reasonably stable in terms of their substance abuse before beginning this type of therapy (Mark and Faude, 1995).
Mark and Faude theorized that substances of abuse substitute a "chemical reaction" in place of experiences and that these chemically induced experiences can block the impact of other external events. The person with a substance abuse disorder will therefore have a "tremendously impoverished and impaired capacity to experience," and traditional psychotherapy might have to be augmented with techniques that focus on increasing a client's ability to experience (Mark and Faude, 1995, p. 297).
Effective SE therapy depends on appropriate use of what is termed the core conflictual relationship theme (CCRT), a concept first introduced by Lester Luborsky. According to Luborsky, a CCRT is at the center of a person's problems. The CCRT develops from early childhood experiences, but the client is unaware of it and how it developed. It is assumed that the client will have better control over behavior if he knows more about what he is doing on an unconscious level. This knowledge is acquired by better understanding of childhood experiences (Bohart and Todd, 1988). The CCRT develops out of a core response from others (RO), which represents a person's predominant expectations or experiences of others' internal and external reactions to herself, and a core response of the self (RS), which refers to a more or less coherent combination of somatic experiences, affects, actions, cognitive style, self-esteem, and self-representations.
Most people with substance abuse disorders have particularly negative expectations of others' attitudes toward them (that is, the RO), although it remains unclear which came first--this response or the substance abuse disorder. Either way, the two become mutually reinforcing. Following are examples of statements that reflect the core RO of a person with a substance abuse disorder:
"Everybody hates me."
"I am just being used."
"People laugh at me."
"No one understands how I feel."
"Everybody wants me to be something I'm not."
"They're just waiting for me to make a fool of myself."
For many people with substance abuse disorders, alcohol or drug use is a way of self-medicating against feelings of low self-worth and low self-esteem that reflect the client's RS. A negative RO reinforces a negative RS and can lead to the deceptive and manipulative behavior that is sometimes observed in this population. The client's RS is based on the individual's somatic experiences, actions, and perceived needs. Following are examples of statements that could reflect a client's core RS:
"I'm so stupid and gullible."
"I can't do anything right."
"If I didn't use drugs, I would lose my mind."
"I can't help myself."
"I'm not a very nice or honest person."
A third component of CCRT is a person's wish; it reflects what the client yearns for, wishes for, or desires. The client's "wish" is largely based on individual personality style. Those with substance abuse disorders often have a wish to continue using the substance without having to endure the consequences. Put another way, they would like to be accepted (or loved or appreciated) as they are, without having to give up the pleasure they get from their use (Levenson et al., 1997). Many people who have substance abuse disorders have much invested in denying that they really have a problem, in portraying themselves as helpless victims, and in disclaiming their role in the behavior that has brought them into treatment.
Once therapy has been initiated, the therapist and client can work together to put the client's goals into the CCRT framework and explore the meaning, function, and consequence of her substance abuse, looking in particular at how the RO and RS have contributed to the problem. The CCRT framework also can be used to identify potential obstacles in the recovery process as the therapist and client explore the client's anticipated responses from others and from herself and discuss how these perceptions will change when she stops abusing substances.
The CCRT concept also can help clients deal with relapse, which is regarded by virtually all experts in the field as an integral and natural part of recovery. Relapse offers the client and the SE therapist the opportunity to examine how the RO and RS can serve as triggers and to devise strategies to avoid these triggers in the future. Finally, SE therapy is conducive to client participation in a self-help group such as Alcoholics Anonymous, or it can be used as a mechanism to examine a client's unwillingness to participate in these groups.
Stella and Christopher: A Case Study
The case study in this section came from the NIDA Collaborative Cocaine Study (Mark and Faude, 1997; adapted with permission). SE is the therapeutic approach used.
While dependent and impulsive, Stella, a 28-year-old cocaine-dependent woman, would be seen under many circumstances as warm and open. She appears to be the kind of person who wears her heart on her sleeve, but it is a big heart nonetheless, capable of caring for others with loyalty and compassion. In addition, she has a tenacity of spirit; despite a horrific personal history she completed her training as a medical technician and has worked in that capacity for much of the last 4 years. Her therapist, Christopher, is a well-trained psychodynamically oriented therapist. He is an intelligent, serious, and measured person, whose well-meaning nature comes through under most circumstances despite his natural reserve.
Stella has a history of polysubstance abuse, including the abuse of prescription drugs, both anxiolytics and opioids. She worked as a medical technician until she injured her back 3 months ago. At the beginning of treatment, she told Christopher that she was going to request medication from her physician for her back pain. After her eighth session, with her reluctant agreement, Christopher informed the physician that she was in treatment for cocaine dependence. Christopher asked the physician to find a medication other than diazepam (Valium) for Stella's back pain.
Stella began the 19th session complaining that ever since the physician found out she was a drug user, he has treated her differently. "He thinks I'm a scumbag drug addict," she said. Christopher acted uncharacteristically: he offered some advice. He suggested that Stella consider telling her physician how she feels about his treatment. The intervention strikingly altered the mood and productivity of the session. After a brief expression of sympathy for her position, he focused on her extreme distress over the physician's treatment. He attempted to explain the intensity of her reaction in terms of projection: that she responded so strongly because of her negative view of herself.
Matters got worse as the session continued. Stella related a second negative incident when she described her treatment by the physician in a group therapy session. The group therapist responded, "Well, you manipulate doctors!" Stella had been furious.
Christopher encouraged her to say more. Stella became frustrated at Christopher's lack of understanding and explained that again, she felt she was being treated like a "scumbag," this time by the group therapist. Christopher suggested that Stella might tell both the physician and the group therapist how she felt. The tension in the session disappeared, and Stella remarked that she has always had trouble sticking up for herself.
In supervision, Christopher realized immediately that he was indirectly letting Stella know that he understood and agreed with her.
Diagnostically speaking, Stella has a borderline personality disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] (American Psychiatric Association, 1994). When she was between 6 and 8 years old, Stella's maternal grandfather sexually abused her. Her parents divorced when she was 10, and she lived with her mother, who was often drunk and physically abusive. Stella said she was closer to her father, whom she described as gentle. He appeared to others as weak and ineffectual.
At age 15, Stella ran off with a boyfriend who was also her pimp. After 2 weeks she returned home, was unable to leave her mother, and was diagnosed as having agoraphobia, for which she took chlordiazepoxide (Librium). Two years later she ran away with another man, a particularly sadistic pimp. For 5 years she was too terrified to leave him. It was during this period that she started using cocaine.
The cocaine both "disclaims action" and affirms her "badness." Her cocaine use enabled her to avoid examining why she stayed with her boyfriend and simultaneously affirmed her badness. So, she deserves her fate. She would use the cocaine to clear her painful feelings and feel "strong and independent," then "feel like a big baby for having to use the drugs." She thought of herself as a "big baby," for returning to her mother at age 15 and for being unable to leave her current boyfriend. Her reactions to cocaine are typical; a brief surge or a "high," followed by a crash. However, these typical reactions also fit her core theme: she wants to be loved and cared for but believes she will be thwarted and exploited by others because of this wish. Her response then is to use drugs, which makes her feel strong and independent for a brief time and also makes her see herself as deserving of being thwarted and exploited, which has happened repeatedly in interpersonal contexts in her life.
Stella's drug use became a part of the therapy in two ways. In the first session, Stella told Christopher that she had taken chlordiazepoxide for several days before their appointment, to relieve her anxiety. She pointed out that it had been prescribed by a doctor. Presumably, Christopher would have known the results of her drug screen, which was part of the program. She thus confessed before being confronted by drug screen results. Her claim that the prescription was legitimate facilitated her denial that she has anything to be concerned about.
Second, Stella announced her intention to ask her physician for diazepam, a commonly abused medication. By contacting her physician, Christopher replayed a common scenario in her life: she signals that someone should take control or care for her, then resents it when they do, feeling that she is being treated like a "scumbag drug addict." She can create the largely illusory sense of being cared for when someone treats her as a helpless incompetent. Was this how Christopher was treating her when he called her physician?
When Christopher suggested that she tell the physician and the group therapist how she felt about the way they had treated her, his words may have given advice, but his communication actually conveyed agreement with Stella's position that she had been unfairly treated.
Stella experienced Christopher's agreement and support through his intervention. However, what could have made this a more powerful therapeutic interaction would have been either for Christopher to directly acknowledge his misgivings about having taken charge and contacted the physician or to explore how Stella came to hear his initial obliqueness as giving her what she wanted--his care and support.
Research on the Efficacy of Supportive-Expressive Therapy
It is only since the 1980s that psychosocial components of the treatment of substance abuse disorders have become the subject of scientific investigation. Most research on the efficacy of psychotherapy for the treatment of substance abuse disorders has concluded that it can be an effective treatment modality (Woody et al., 1994). Comparisons among specific models of therapy have become the focus of much interest.
As mentioned above, SE psychotherapy has been modified for use with methadone-maintained opiate dependents and for cocaine dependents. In SE therapy, the client is helped to identify and talk about core relationship patterns and how they relate to substance abuse. One study compared SE therapy and cognitive-behavioral therapy with standard drug counseling for opiate dependents in a methadone maintenance program. Clients were offered once-weekly therapy for 6 months. Adding professional psychotherapies (either SE or cognitive-behavioral) to drug counseling benefited clients with higher levels of psychopathology more than using drug counseling alone. However, drug counseling alone was helpful for clients with lower levels of psychopathology (Woody et al., 1983). Another study involving three methadone programs was also positive regarding the efficacy of SE therapy (Woody et al., 1995). In this study, clients receiving SE therapy required less methadone than those who received only standard substance abuse counseling, and after 6 months of treatment these clients maintained their gains or showed continuing improvement. Gains tended to dissipate in those who received drug counseling only (Woody et al., 1995).
One study compared SE psychotherapy with structural family therapy for the treatment of cocaine dependence (Kang et al., 1991; Kleinman et al., 1990). Both types of therapy were offered once a week. The researchers found that once-weekly therapy, of either type, was not associated with significant progress. Dropout rates were high, and overall abstinence in both groups did not appear to differ from that expected from spontaneous remission. The main conclusions were that the lack of treatment effects may have resulted because these treatments did not offer enough frequency and intensity of contact to be effective for cocaine-dependent people in the initial stages of recovery. This study had at least two flaws, however. One was that the therapists were not well-trained in SE therapy; therefore, it is questionable whether or not the treatment they provided was actually SE therapy. The other was that the therapy was provided in a municipal office building where courts and social services were administered, thus this setting lacked many features of traditional substance abuse treatment settings.
More recently, a large multisite study of 487 persons receiving treatment compared SE therapy with cognitive therapy and drug counseling for cocaine dependence (Crits-Christoph et al., 1997). Each of the three conditions included, in addition to the individual treatment, a substance abuse counseling group. A fourth condition received group counseling without additional individual therapy. This study was a theoretical descendant of the methadone studies mentioned earlier. It was hypothesized that SE and cognitive therapy might be more effective than individual drug counseling for clients with higher levels of psychiatric severity. The results showed that each type of treatment was associated with significantly reduced cocaine use. However, for this population of outpatient cocaine-dependent clients, drug counseling was more successful at reducing substance use than SE or cognitive therapy (Crits-Christoph et al., 1999). One implication of this finding is that drug-focused interventions are perhaps the optimal approach for providing treatment for substance abuse disorders (Strean, 1994).
What this means for practitioners of psychodynamically oriented treatments is that in addition to providing the more dynamic interventions, it is important to also incorporate direct, drug-focused interventions. This can be accomplished by one therapist combining both models or, in a comprehensive treatment program for substance users, one therapist providing dynamic therapy and an alcohol and drug counselor providing direct, drug-focused counseling. It can be argued that this is why SE therapy was so helpful in the methadone studies. In those studies, psychodynamic therapy was well integrated into a comprehensive methadone maintenance program. In other words, in addition to the dynamic therapy, clients received substance abuse disorder counseling along with methadone (Woody et al, 1998).
One study conducted a small, controlled trial comparing SE therapy to a brief (one-session) intervention for marijuana dependence. The SE approach was adapted for use in treatment of cannabis dependence (Grenyer et al., 1995) and was offered once a week for 16 weeks. Results showed that both interventions were helpful but SE therapy produced significantly larger reductions in cannabis use, depression, and anxiety, and increases in psychological health (Grenyer et al., 1996). The authors concluded that SE therapy could be an effective treatment for cannabis dependence.
Clients Most Suitable for Psychodynamic Therapy
Brief psychodynamic therapy is more appropriate for some types of clients with substance abuse disorders than others. For some, psychodynamic therapy is best undertaken when they are well along in recovery and receptive to a higher level of self-knowledge.
Although there is some disagreement in the details, this type of brief therapy is generally thought more suitable for the following types of clients:
Those who have coexisting psychopathology with their substance abuse disorder
Those who do not need or who have completed inpatient hospitalization or detoxification
Those whose recovery is stable
Those who do not have organic brain damage or other limitations due to their mental capacity
Psychodynamic Concepts Useful in Substance Abuse Treatment
Psychodynamic theories endeavor to provide coherent explanations for intrapsychic and interpersonal workings. Because of the importance of this approach in the development of modern therapy, the techniques that stem from these theories are inevitably used in any type of psychotherapy, whether or not it is identified as "psychodynamic." For example, people who have worked with those who have substance abuse disorders are familiar with "denial," even if they are not aware that this process is one of the psychodynamic defense mechanisms. Counselors whose clients have an immediate and strong negative reaction to them often benefit from an understanding of the concept of "transference." It also is helpful for an alcohol and drug counselor who is left feeling hopeless and confused after a session to understand how "countertransference" could be at work. Therefore, counselors who treat clients with substance abuse disorders can benefit from understanding the basic concepts of general psychodynamic theory discussed in this section, even if they do not use a strictly psychodynamic intervention.
The Therapeutic Alliance
The alliance that develops between therapist and client is a very important factor in successful therapeutic outcomes (Luborsky, 1985). This is true regardless of the modality of therapy. The psychodynamic model has always viewed the therapist-client relationship as central and the vehicle through which change occurs. Of all the brief psychotherapies, psychodynamic approaches place the most emphasis on the therapeutic relationship and provide the most explicit and comprehensive explanations of how to use this relationship effectively. Luborsky and colleagues are among those who have documented the profound effect that the therapist-client relationship has on the success of treatment, however brief (Luborsky et al., 1985).
The psychodynamic model offers a systematic explanation of how the therapeutic relationship works and guidelines for how to use it for positive change and growth. In all psychodynamic therapies, the first goal is to establish a "therapeutic alliance" between therapist and client. In most cases, the development of a therapeutic alliance is partially a process of the passage of time. The more severe the client's disorder, the more time it will take. The capabilities of the therapist to be honest and empathic and of the client to be trusting are also factors. A therapeutic alliance requires intimate self-disclosure on the part of the client and an empathic and appropriate response on the part of the therapist. However, in brief psychodynamic therapy this alliance must be established as soon as possible, and therapists conducting this sort of therapy must be able to establish a trusting relationship with their clients in a short time.
One study of the therapeutic alliance and its relationship to alcoholism treatment found that for alcoholic outpatients, ratings of the therapeutic alliance by the patient or therapist were significant predictors of treatment participation and of drinking behavior during treatment and at 12-month followup, though the amount of variance explained was small (Connors et al., 1997). Among cocaine-dependent patients, another study found that patients' ratings of the therapeutic alliance predicted the level of current drug use at 1 month but not at 6 months (Barber et al., 1999). The alliance at 1 month, however, predicted improvement in depressive symptoms at 6 months. These findings suggest that the therapeutic alliance exerts a moderate but significant influence on outcome in the treatment of substance abuse disorders. The specific outcomes measured vary from study to study but include length of participation in treatment, reduction in drug use, and reduction in depressive symptoms.
Psychodynamic theory emphasizes that the client's level of functioning should determine the nature of any intervention. In Freudian psychoanalytic theory, substance abuse is considered a symptom associated with the oral or most primitive stage of development and represents an attempt to establish a need-gratifying symbiotic state (Leeds and Morgenstern, 1996). Analytic theorists within the Object Relations school hold that substances stand in for the functions usually attributed to the primary maternal (or care-giving) object. As a result, the substance abuser relates to the substance based on the disturbed pattern of relating that he experienced with the maternal object (Krystal, 1977). This would be considered a variant of borderline psychopathology, which is viewed as a fairly severe disturbance of ego functioning and object relations. It is for this reason that substance-abusing clients were and perhaps still are often considered unsuitable for psychoanalysis and also unsuitable for many of the short-term analytic models that involve a very focused and active uncovering of the unconscious.
Contemporary analytic theorists who concern themselves with substance abuse disorders typically do not focus on the idea that addiction is linked to a developmentally primitive level of ego functioning, although they may endorse it. One reason is that this idea leads to a rather pessimistic belief regarding the outcome of analytic treatments for substance abuse disorders. Another reason is that it does not contribute helpful information to the therapeutic approach, and it can impede the development of an empathic and respectful therapeutic alliance. Furthermore, there is increasing empirical evidence for the idea that severe substance abuse is largely driven by biobehavioral forces and that individual psychological factors are of lesser importance (Babor, 1991). Although analytic theories have tended to ignore this (Leeds and Morgenstern, 1996), it has become increasingly a part of the knowledge base in understanding substance abuse disorders.
Another critical underlying concept of psychodynamic theory--and one that can be of great benefit to all therapists--is the concept of insight. Psychodynamic approaches regard insight as a particular kind of self-realization or self-knowledge, especially regarding the connections of experiences and conflicts in the past with present perceptions and behavior and the recognition of feelings or motivations that have been repressed. Insight can come through a sudden flash of understanding or from gradual acquisition of self-knowledge. So, for example, a client who feels depressed and angry and subsequently drinks comes to realize that his feelings toward his father are stimulated by an emotionally abusive supervisor at work. This type of realization gives the client new options.
These options include learning to separate his reactions to the supervisor from his feelings about his father, working through his feelings about his father (of which he may not have been previously aware), actively choosing alternative behaviors to drinking when he feels bad (e.g., attending a 12-Step meeting), and accepting greater responsibility for his feelings and behaviors.
A broader definition of insight, also promoted by brief psychodynamic therapies, is simply any realization about oneself, one's inner workings, or one's behavior. For example, a client who says, "the only emotion I really feel is anger," has opened the door to understanding the effect others have on her, and vice versa. She can then begin to develop alternative behaviors to those that previously followed automatically from her anger (such as drinking), as well as to understand why her emotional repertoire is so limited.
Insight involves both thoughts and feelings. A purely intellectual exercise will not lead to behavior change. True insight involves a powerful emotional experience as well as a cognitive component and leads to a greater acceptance of responsibility for feelings and behavior. In treating substance abuse disorders, it is important to recognize that insight alone is often not sufficient to create change. Substances of abuse are powerful behavioral reinforcers and the therapist needs to help the client counter the strong compulsive desire for them. Thus, in addition to insight, it could be helpful to offer psychoeducation and make behavioral interventions, which might include encouraging attendance and participation in self-help programs and requiring regular testing by urinalysis and/or Breathalyzer™. Many therapists who conduct substance abuse treatment from a psychodynamic perspective are comfortable combining insight-oriented therapy with concrete, behavioral interventions.
Defense Mechanisms And Resistance
In psychoanalytic theory, defense mechanisms bolster the individual's ego or self. Under the pressure of the excessive anxiety produced by an individual's experience of his environment, the ego is forced to relieve the anxiety by defending itself. The measures it takes to do this are referred to as "defense mechanisms." All defense mechanisms have two characteristics in common: they deny, distort, or falsify reality, and they operate unconsciously. Some defense mechanisms are adaptive and support the mature functioning of the individual, while others are maladaptive and hinder the individual's growth. Generally the defenses hamper the process of exploration in therapy, and for this reason they are often confronted in the more expressive models of analytic therapy. However, in more supportive types of therapy, adaptive defenses are supported, and even the maladaptive defenses may not be confronted until the therapist has enabled the client to replace them with a more constructive means of coping.
In the treatment of substance abuse disorders, defenses are seen as a means of resisting change--changes that inevitably involve eliminating or at least reducing drug use. Mark and colleagues noted that two defenses frequently seen in those with substance abuse disorders are denial and grandiosity (Mark and Luborsky, 1992). Particularly with this group of clients, handling defenses can degenerate into an adversarial interaction, laden with accusations; for example, when a therapist admonishes the client by saying, "You are in denial" (Mark and Luborsky, 1992). They recommend avoiding ineffective adversarial interactions around the client's use of defenses by using the following strategies:
Working with the client's perceptions of reality rather than arguing
Sidestepping rather than confronting defenses
Demonstrating the denial defense while interacting with the client to show her how it works
Figure 7-1 defines the most common mechanisms clients use to defend themselves from painful feelings or to resist change.
Figure 7-1: Defense Mechanisms. Denial. Pretending that a threatening situation does not exist because the situation is too distressing to cope with. A child comes home, and no one is there. He says to himself, "They are here. I'll find them soon." (more...)
Effective use of the therapeutic relationship depends on an understanding of transference. Transference is the process of transferring prominent characteristics of unresolved conflicted relationships with significant others onto the therapist. For example, a client whose relationship with his father is deeply conflicted may find himself reacting to the therapist as if he were the client's father. The opening session in psychodynamic therapy usually involves the assessment of transference so that it may be incorporated into the treatment strategy. Strean found that, "all patients--regardless of the setting in which they are being treated, of the therapeutic modality, or the therapist's skills and years of experience--will respond to interventions in terms of the transference" (Strean, 1994, p. 110).
An initial goal of brief psychodynamic therapy is to foster transference by building the therapeutic relationship. Only then can the therapist help the client begin to understand her reasons for abusing substances and to consider alternative, more positive behavior. A longer term goal--necessitated by the brevity of the process--is to increase the client's motivation and participation in other modalities of treatment for substance abuse disorders.
Four contemporary analytic theorists have offered valuable psychodynamic perspectives on the etiology of substance abuse disorders.
Wurmser, a traditional drive theorist, suggests that those with substance abuse disorders suffer from overly harsh and destructive superegos that threaten to overwhelm the person with rage and fear. Abusing substances is an attempt to flee from such dangerous affects. These affects are the result of conflict between the ego and superego, brought about by the harshness of the superego. Given this understanding, Wurmser's main focus is the analysis of the superego. He believes that a moralistic stance toward the substance-abusing behavior is counterproductive and that substance abusers' problems consist of too much, rather than too little, superego. Wurmser recommends that the therapist provide a strong emotional presence and a warm, accepting, flexible attitude.
Khantzian theorizes that deficits, rather than conflicts, underlie the problems of those with substance abuse disorders. That is, weakness or inadequacies in the ego or self are at the root of the problem. Khantzian and colleagues developed Modified Dynamic Group Therapy (MDGT) to address these issues in a group therapy format, and this approach has some empirical support. Khantzian put forth the self-medication hypothesis, which essentially states that substance abusers will use substances in an attempt to medicate specific distressing psychiatric symptoms (Khantzian, 1985). It follows, then, that substance-dependent persons will express a strong preference for a particular drug of choice to medicate their particular set of symptoms. For example, those dependent on opioids are thought to be medicating intense anger and aggression that their egos are unable to contain. Cocaine-dependent people are believed to be seeking relief from intense depression or emotional lability (as in bipolar disorders) or attention deficit disorder. This continues to be a popular theory although most researchers and therapists now would say that this can offer only partial answers to the questions of how abusers develop drug preferences and what the meaning is of such preferences. It is important to consider the social and physical environmental context of substance abuse as well. That is, whatever drugs are most readily available in a person's community and what his peers and associates are using also have a strong influence on a user's drug preference.
Krystal offers two possible theories of the etiology of substance abuse disorders. One is based on an object-relations conceptualization. In this theory, the substance abuser experiences the substance as the primary maternal object.
The substance abuser relates to the substance in the same maladaptive relationship patterns that she experienced developmentally with the mother. The second theory focuses on the substance abuser's disturbed affective functions, known as alexithymia. It is thought that individuals with alexithymia do not recognize the cognitive aspects of feeling states. Instead, they experience an uncomfortable, global state of tension in response to all affective stimuli. Thus they seek to relieve this discomfort with substances.
McDougall views substance abuse as a psychosomatic disorder. It is a way of dealing with distress that involves externalizing and making physical what is essentially a psychological disturbance. Substance abuse then is the habitual use of an externalizing defense against painful or dangerous affects. McDougall suggests that these painful affects are the response to deep uncertainty about one's right to exist, one's right to a separate identity, and one's right to have control over one's body limits and behavior. The abuse of drugs is part of a "false self" that the individual creates to ward off these painful feelings.
Some critics have argued that a major limitation of those psychoanalytic theories is that they do not make allowances for the biological bases of substance abuse disorders (Babor, 1991). However, contemporary psychoanalytic theorists acknowledge that biology plays a role in behaviors related to substance abuse. But the unanswered question remains whether biological or psychological factors come first: Why does a person start using substances? Analytic concepts are useful here, in that they can be said to facilitate the resolution of problems that contribute to emotional distress and to help explore the connection among interpersonal patterns, emotions, and substance abuse.
Levenson and colleagues offer such a theory (Levenson et al., 1997). They describe a biopsychosocial conceptualization of substance abuse disorders that can, in part, be addressed by brief psychodynamic therapy. In this model, substance abuse disorders are particularly difficult to treat because, unlike other psychological disorders, there is a "primary urge" to abuse substances--an urge that can take precedence over every other aspect of life. Furthermore, the symptom (substance abuse) is often considered pleasurable by the client, in contrast to the symptoms of other psychological disorders (such as anxiety or depression). Thus, "[psychodynamic] therapy should be considered as part of an overall treatment plan that includes some kind of drug counseling and possibly other interventions as well, such as medications and family therapy" (Levenson et al., 1997, p. 125).
Integrating Psychodynamic Concepts Into Substance Abuse Treatment
Many of the concepts and principles used in psychodynamic therapy with clients who have substance abuse disorders are similar to those used with clients who have other psychiatric disorders. However, most therapists agree that people with substance abuse disorders comprise a special population--one that often requires more structure and a combined treatment approach if treatment is to be successful. To effectively treat these clients, it is important to combine skill in the provision of the model of therapy with knowledge of the general factors in the treatment of substance abuse disorders. These include knowledge of the pharmacology and the intoxication and withdrawal effects of drugs, familiarity with the subculture of substance abuse and with substance-dependent lifestyles, and knowledge of self-help programs. It also helps to feel comfortable working with substance abusers and for one's therapeutic style to express acceptance of and empathy for the client. In modifying SE psychotherapy for use with clients with substance abuse disorders, Luborsky and colleagues identified certain emphases that are particularly important (Luborsky et al., 1977, 1989). These emphases, listed below, are relevant for applying other types of psychotherapy to substance-dependent clients as well.
Much of the therapist's time and energy are required to introduce and engage the client in treatment.
The treatment goals must be formulated early and kept in sight.
The therapist must pay careful attention to developing a good therapeutic alliance and supporting the client.
The therapist must stay abreast of the client's compliance with the overall treatment program (if the client is involved in a comprehensive treatment program). This includes such things as the client's attendance at all facets of the program, submission to regular urinalysis, and use of any drugs.
If the client is receiving substitution therapy, such as methadone maintenance, attention should be given to the time of the client's daily dose and when, in relation to the dosing, the client feels therapy is best conducted.
Therapists whose orientations are not psychodynamic may still find these techniques and approaches useful. Therapists whose approaches are psychodynamic will be more successful if they also have a knowledge of the general factors in the treatment of substance abuse disorders and conduct psychotherapy in a way that complements the full range of services that clients with substance abuse disorders receive in a relatively comprehensive program.
Models of Brief Psychodynamic Therapy
Ten major approaches to short-term psychodynamic psychotherapy are briefly summarized in this section (for more detailed information, see Crits-Christoph and Barber, 1991). These approaches differ depending on the extent to which they use expressive or supportive techniques, focus on acute or chronic problems, have a goal of symptomatic change or personality change, and pay attention to intrapsychic or interpersonal dynamics.
Interpersonal psychotherapy is included because it is one of the important and better researched therapeutic approaches for treating substance abuse disorders. It is considered by some to be a psychodynamic model, but there are conflicting opinions on this. This list is not exhaustive; numerous other, perhaps less well known, approaches or modifications of these approaches are not mentioned. Many of these approaches have developed from clinical experience, and some are not well researched, if they are researched at all. Figure 7-2 summarizes the length of treatment, focus, and major techniques of various models of brief psychodynamic therapy.
Figure 7-2: Brief Psychodynamic Therapy.
Mann's Time-Limited Psychotherapy (TLP)
The goal of treatment in TLP is to diminish as much as possible the client's negative self-image through resolution of the central issue (Mann, 1991). Symptoms are reduced or eliminated as a byproduct of the process. TLP works via two main components of the treatment: the therapist's identification of the central issue and the setting of the termination date at the start of treatment. The central issue is always conceptualized in terms of the client's chronic and presently endured pain, resulting from painful life experiences. This pain is a privately held, affective statement about how the client feels about himself. Change comes about through the identification and exploration of the painful feelings about himself and through the feelings of loss surrounding termination. This model has a set treatment length of 12 sessions and promotes working through of termination issues.
Sifneos' Short-Term Anxiety-Provoking Psychotherapy (STAPP)
STAPP is a focal, goal-oriented psychotherapy that is usually practiced in 12 to 15 sessions and sometimes fewer (Nielsen and Barth, 1991). During the first session, the therapist and client agree on a clear psychodynamic focus, rather like a treatment contract. The foci that respond best to STAPP are unresolved Oedipal conflicts, but loss, separation issues, and grief may also be acceptable. Change comes about through the client's learning to resolve an emotional core problem, essentially problemsolving. Resolving the problem promotes a feeling of well-being and a corresponding positive change in attitude.
Davanloo's Intensive Short-Term Dynamic Psychotherapy (ISTDP)
In ISTDP, therapeutic techniques are used to provoke emotional experiences and, through this, to facilitate corrective emotional experiences or the positive reenactments, in therapy, of past conflictual relationships (Laikin et al., 1991). Change comes about by bringing to consciousness these past unresolved conflicts through intense emotional experiences, reexperiencing them in a more cognitive way, and linking them to current symptoms and problematic interpersonal patterns. Extensive use of analysis of the transference relationship also helps to bring the unresolved conflicts to the client's consciousness so that they can then be explored and resolved.
SE Psychoanalytic Psychotherapy
This model of dynamic therapy can be offered as an open-ended or a time-limited approach (Luborsky, 1984; Luborsky and Mark, 1991). The term "supportive" refers to the techniques aimed at directly maintaining the client's level of functioning--that is, "supporting" the client. The term "expressive" refers to techniques that intend to facilitate the client's expression of problems and conflicts and their understanding. Therapists using this approach will
Develop a good therapeutic alliance
Formulate and respond to central relationship patterns
Understand and respond to how the symptom fits into the central relationship pattern
Attend to and respond to concerns about separation (therapy termination)
Make interpretations that are appropriate to the client's level of awareness
Recognize the client's need to test the therapeutic relationship (in transference terms)
Frame the symptoms as problem-solving or coping attempts
Change comes about through three curative factors: a positive helping relationship, gains in self-understanding, and internalization of these gains.
The Vanderbilt Approach to Time-Limited Dynamic Psychotherapy (TLDP)
The primary goal of this therapy is to foster positive change in interpersonal functioning, which will then have beneficial effects on the more circumscribed symptoms (Binder and Strupp, 1991). Interpersonal problems are conceptualized in a specific format termed the "cyclical maladaptive pattern," which includes four categories of information:
Acts of the self toward others
Expectations about others' reactions
Acts of others toward the self
Acts of the self toward the self (introjection)
The theory of change is that therapy is a set of interpersonal transactions through which the client learns and is then able to change the maladaptive interpersonal patterns in her life. Analysis of the transference relationship and the therapeutic relationship as a model for healthier relationships are important components of the therapy.
Short-Term Dynamic Therapy of Stress Response Syndromes
This approach to brief dynamic therapy was developed for use with clients who are dealing with recent stressful events, such as traumatic experiences or the death of a loved one (Horowitz, 1991). The therapist establishes a working alliance with the client and then, using techniques appropriate to the client's state of mind and control processes, helps the client to integrate the life event and its meaning into his schema (a schema is one's way of understanding oneself in relation to others). The therapist fosters this process of integration and understanding by focusing attention, correcting distortions, making linkages, and counteracting defensive avoidance. For research, this model is offered as a 12-session therapy, but it can also be used as an open-ended therapy in clinical practice.
Brief Adaptive Psychotherapy (BAP)
BAP is a short-term analytic model developed to treat clients with personality disorders, although it is applicable to other groups of clients as well (Pollack et al., 1991). The theory of change is that through cognitive and affective understanding of the origins and operations of the maladaptive pattern, the client can change and construct more adaptive patterns. The techniques used include maintenance of a focus, much work on transference, and a high level of activity on the part of the therapist. The major maladaptive pattern is an interpersonal pattern, and it is explored in the present, in the past, and in the client-therapist relationship. These three areas are repeatedly linked to one another. The maximum number of sessions offered is 40, which Pollack and colleagues point out is more than some of the other brief models because of the higher level of psychopathology of the clients.
Dynamic Supportive Psychotherapy
Supportive therapy is widely practiced clinically but historically is defined mainly by the absence of expressive or interpretive components of psychoanalytic therapies (Pinsker et al., 1991). It evolved as the psychodynamically based therapy used for lower functioning or more fragile clients for whom the expressive work of therapy might be too distressing. The therapist has a cohesive psychodynamic formulation of the client but only shares parts of it in a manner intended to foster the client's adaptive functioning. The goals of supportive therapy are to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills, and ego function. Change comes about from learning and from identification with or introjection of an accepting therapist with whom the client has a good relationship. The techniques used include reducing anxiety, respecting defenses, clarification, limiting confrontation and interpretation, enhancing self-esteem, reframing, offering encouragement, advising, and modeling.
A Self-Psychological Approach
The essential aspects of the theory of Self Psychology (Baker, 1991) include the following:
The concept of the selfobject
The importance of the self in motivating behavior
The role of symptoms as the client's way of restoring self-cohesion
In this brief self-psychological therapy approach, one or two goals are established collaboratively in the initial sessions. The duration of treatment typically is 20 to 30 sessions, with fewer or more as needed. A selfobject is something or someone else that is experienced and used as if it were part of one's own self (Baker, 1991). For example, a child is dependent on the parent's love and praise to develop a sense of self-worth and self-esteem. In that way, the child internalizes a part of the parent as the selfobject. The theory of change is that understanding, followed by interpretation, leads to change. Success in therapy requires that dysfunctional intrapsychic structures be changed and/or that compensating new structures be added.
Interpersonal Psychotherapy (IPT)
IPT was developed initially as a time-limited, weekly psychotherapy for nonbipolar, nonpsychotic, depressed clients (Klerman et al., 1984). It has since been summarized in a manual for research and modified for treatment of other types of depression (dysthymia), other populations (adolescents and couples), and other problems (substance abuse disorders and bulimia). The goals of this approach are primarily symptom reduction and improvement in interpersonal functioning. The main techniques include the following:
The problem is explicitly diagnosed and the client is given the "sick" role.
The client is educated about the problem, its causes, and the treatments available.
The interpersonal context of the problem and its development are identified.
Strategies for dealing with the interpersonal context emerge and are tried by the client (problemsolving).
In addition to Supportive-Expressive psychotherapy, both IPT and MGDT have been studied as therapies for use in the treatment of substance abuse disorders.
IPT has been evaluated as an adjunctive treatment for a full-service methadone clinic (Rounsaville et al., 1983). This was a collaborative research project that paralleled a study by Woody and colleagues (Woody et al., 1983). Seventy-two methadone-maintained, opiate-dependent subjects who were diagnosed with a psychiatric disorder (e.g., depression) were randomly assigned to one of two treatment conditions, each lasting 6 months. The treatments were IPT offered once a week and low contact, consisting of one 20-minute meeting per month, when symptoms and social functioning were reviewed. Both groups also received treatment as usual in the methadone-maintenance program that included a weekly 90-minute session of group counseling. The main findings were that it was extremely difficult to recruit and retain clients in the program and that although both treatments were associated with significant clinical improvements during the 6-month period, there was essentially no advantage to IPT over low contact. This study was done in a program in which clients were suspended after 3 months if they continued to use illicit drugs, thus providing a potent behavioral intervention. For the control group, clients were forced to do well or leave the program.
A second study (Carroll et al., 1991) compared IPT with Relapse Prevention (RP), a cognitive-behavioral therapy (Marlatt and Gordon, 1985) for the treatment of ambulatory cocaine-using clients. This study evaluated the efficacy of 12 sessions of weekly individual psychotherapy, without adjunctive pharmacotherapy, as the sole treatment for 42 subjects who were randomly assigned to either IPT or RP. Rates of attrition were significantly higher for IPT than for RP, with only 38 percent of those in IPT compared to 66 percent of those in RP completing the 12-week course of treatment (Rounsaville and Carroll, 1993). On most outcome measures there were no significant differences between the two treatment conditions; both were associated with favorable outcomes. However, for clients with more severe psychiatric symptoms or more severe drug use, those who received RP were more likely to become abstinent than those who received IPT. Clients with more severe substance abuse disorders may require the greater structure and direction offered by the relapse prevention approach (Rounsaville and Carroll, 1993). This is entirely consistent with the observation that substance-focused interventions are perhaps the optimal approach for treating substance abuse disorders (Strain, 1999). Based on the rather modest empirical support, Rounsaville and Carroll suggested that the role of IPT in the treatment of substance abuse disorders might be the following:
To introduce clients into treatment
To treat clients with lower levels of substance abuse
To treat clients who did not benefit from other modalities
To complement other ongoing treatment modalities
To help clients maintain and solidify gains following the establishment of stable abstinence
Khantzian and colleagues developed MGDT to address the characterological underpinnings of substance abuse disorders (Khantzian et al., 1990). The group has four main goals:
The development of affect tolerance
The building of self-esteem
The discussion and improvement of interpersonal relationships
The development of appropriate self-care strategies
This approach has shown efficacy for abuse in research, but the research was not comparative, so it is not known how effective this approach is in contrast to other approaches.