Psychodynamic Therapy for Substance Abuse

Brief Psychodynamic Therapy

• Psychodynamic therapy focuses on unconscious processes manifested in present behavior.

• Goals: client self-awareness and understanding of the past's influence on present behavior.

• Brief form: examines unresolved conflicts and symptoms from past dysfunctional relationships that manifest as substance abuse.

• Effective when integrated into a comprehensive substance abuse treatment program (urinalysis, drug counseling, methadone for opioid-dependents).

• More helpful after abstinence is established and for clients with moderate substance abuse severity.

• Therapist should know about drug pharmacology, substance abuse subculture, and 12-Step programs.

Background

• Based on psychoanalytic theory with four major schools:

  • Freudian

  • Ego Psychology

  • Object Relations

  • Self Psychology

Freudian Psychology (Drive or Structural Model)

• Sigmund Freud's theories: sexual and aggressive energies from the id (unconscious) are modulated by the ego.

• Ego: moderates between the id and external reality.

• Defense mechanisms: ego constructions that minimize pain and maintain psychic equilibrium.

• Superego: formed during latency (5 to puberty), controls id drives through guilt.

Ego Psychology

• Derives from Freudian psychology.

• Focuses on enhancing and maintaining ego function in accordance with reality demands.

• Stresses individual's capacity for defense, adaptation, and reality testing.

Object Relations Psychology

• Pioneered by British analysts (Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, Harry Guntrip).

• Human beings are shaped in relation to significant others.

• Struggles and goals focus on maintaining relationships while differentiating from others.

• Internal representations of self and others acquired in childhood recur in adult relations.

• Individuals repeat old object relationships to master them.

Self-Psychology

• Founded by Heinz Kohut in the 1950s.

• Self: a person's perception of their experience of self, including self-esteem.

• Self is perceived in relation to boundaries and differentiation from others.

• Addictions stem from a weakness in the core of their personalities - a defect in the formation of the \"self.\"

• Substances seem capable of curing the central defect in the self, providing self-esteem and a feeling of being accepted.

• Each school presents discrete theories of:

  • Personality formation

  • Psychopathology formation

  • Change Techniques

  • Indications and contraindications for therapy

• Psychodynamic therapy differs from psychoanalysis:

  • It need not include all analytic techniques.

  • It is not necessarily conducted by psychoanalytically trained analysts.

  • Conducted over a shorter time and with less frequency than psychoanalysis.

• Brief forms may be less appropriate for substance abusers due to altered perceptions hindering insight and problem resolution.

• Many therapists work with substance-abusing clients alongside traditional treatment programs or as sole therapist for coexisting disorders.

Introduction to Brief Psychodynamic Therapy

• Long-term psychodynamic therapy typically requires at least 2 years to change identity or integrate missed developmental learning.

• Brief psychodynamic therapy believes changes can happen more rapidly or that short intervention will start an ongoing change process.

• Central concept: one major focus rather than free association.

• Central focus is developed during the initial evaluation process (first session or two) and must be agreed upon by client and therapist.

• Singles out the most important issues, creating structure and identifying goals.

• Therapist is active in keeping sessions focused.

• Interpretation is possible in a shorter time by addressing a circumscribed problem area.

• For substance abuse disorders, the central focus will always be the substance abuse in association with the core conflict within an interpersonal framework.

• Number of sessions: typically no more than 25 (Bauer and Kobos, 1987), but some models allow up to 40 (Crits-Christoph and Barber, 1991).

• Length of therapy often related to ambitiousness of therapy goals.

• Most therapists are flexible, depending on client characteristics, goals, and central issues.

Psychodynamic Psychotherapy for Substance Abuse

• Supportive-expressive (SE) psychotherapy (Luborsky, 1984) adapted for substance abuse disorders.

• Modified for opiate dependence with methadone maintenance (Luborsky et al., 1977) and cocaine use disorders (Mark and Faude, 1995; Mark and Luborsky, 1992).

• Studies support the effectiveness of SE therapy in treating substance abuse problems.

• Mark and Faude note applicability to multiple dependencies but clients should be reasonably stable before starting therapy.

• Substances of abuse substitute a \"chemical reaction\" in place of experiences, blocking the impact of external events, leading to an \"impoverished and impaired capacity to experience.\"

• Traditional psychotherapy may have to be augmented with techniques that focus on increasing a client's capacity to experience (Mark and Faude, 1995, p. 297).

• Effective SE therapy depends on appropriate use of the core conflictual relationship theme (CCRT).

• CCRT: central to a person's problems, develops from early childhood experiences. Clients are unaware of it and how it developed. Behavior is better controlled with better understanding of childhood experiences (Bohart and Todd, 1988).

Components of CCRT

• Core response from others (RO): person's predominant expectations/experiences of others' reactions to them.

• Core response of the self (RS): coherent combination of somatic experiences, affects, actions, cognitive style, self-esteem, and self-representations.

People with Substance Abuse Disorders

• Have particularly negative expectations of others' attitudes toward them (the RO).

• Unclear which comes first (negative expectations or substance abuse disorder).

• Examples of statements reflecting core RO:

  • \"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.\"

• 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.

• Negative RO reinforces a negative RS and can lead to deceptive and manipulative behaviour.

• The client's RS is based on the individual's somatic experiences, actions, and perceived needs.

• Examples of statements reflecting 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 person's wish: reflects what the client yearns for, often to continue using without consequences.

• People with substance abuse disorders often deny their problem, portray themselves as helpless victims, and disclaim their role in the behavior that brought them into treatment.

• Therapist and client work together to put client's goals into the CCRT framework and explore the meaning, function, and consequence of substance abuse, looking at how RO and RS have contributed to the problem.

• CCRT is used to identify potential obstacles in recovery as therapist and client explore the client's anticipated responses from others and from herself, discussing how these perceptions will change after stopping.

• The CCRT concept also helps clients deal with relapse, examining how the RO and RS can serve as triggers and devise strategies to avoid these triggers.

• SE therapy is conducive to client participation in self-help groups or can be used to examine a client’s unwillingness to participate in these groups.

Stella and Christopher: A Case Study

• Case study from the NIDA Collaborative Cocaine Study (Mark and Faude, 1997).

• Stella, a 28-year-old impulsive, cocaine-dependent woman, is seen as warm and open with a tenacious spirit, having worked as a medical technician for 4 years despite a horrific personal history.

• Christopher, her therapist, is a well-trained, serious, and measured psychodynamic therapist.

• Stella has a history of polysubstance abuse, including prescription drugs (anxiolytics and opioids), and injured her back 3 months prior to treatment.

• At the beginning of treatment, she told Christopher that she was going to request medication for her back pain from her physician.

• After her eighth session and with her reluctant agreement, Christopher informed the physician that she was in treatment for cocaine dependence and asked the physician to find a medication other than diazepam (Valium) for Stella's back pain.

• Stella complained that since her physician found out she was a drug user, he has treated her differently.

• Christopher gave Stella advice, suggesting she consider telling her physician how she feels about his treatment, altering the mood and productivity of the session.

• He attempted to explain the intensity of her reaction in terms of projection due to her negative view of herself.

• Matters got worse with Stella relating a second negative incident where she described her treatment by the physician in a group therapy session, to which the group therapist responded, \"Well, you manipulate doctors!\", making Stella furious.

• 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 that he was indirectly letting Stella know that he understood and agreed with her.

• Stella has a borderline personality disorder (DSM-IV).

• Between ages 6 and 8, 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 described her father as gentle.

• At age 15, Stella ran off with a boyfriend who was also her pimp, but returned home after 2 weeks.

• She was diagnosed as having agoraphobia and took chlordiazepoxide (Librium).

• Two years later, she ran away with another man, a particularly sadistic pimp, and stayed with him for 5 years, during which time she started using cocaine.

• The cocaine both \"disclaims action\" and affirms her \"badness,\" enabling her to avoid examining why she stayed with her boyfriend, while simultaneously affirming that she deserves her fate.

• She used 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, fitting 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 was a part of the therapy in two ways:

  • 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.

  • 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.

  • Christopher may have given advice, but his communication actually conveyed agreement with Stella's position that she had been unfairly treated.

• 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

• Since the 1980s, psychosocial components for the treatment of substance abuse disorders have become the subject of scientific investigation.

• Research has concluded that psychotherapy can be an effective treatment modality.

• 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-behavioural therapy with standard drug counselling for opiate dependents in a methadone maintenance program for 6 months. Adding professional psychotherapies to drug counselling benefited clients with higher levels of psychopathology more than using drug counselling alone (Woody et al., 1983).

• Drug counselling alone was helpful for clients with lower levels of psychopathology.

• 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 counselling.

• After 6 months of treatment, these clients maintained their gains or showed continuing improvement.

• Gains tended to dissipate in those who received drug counselling only.

• One study compared SE psychotherapy with structural family therapy for the treatment of cocaine dependence (Kang et al., 1991; Kleinman et al., 1990).

• Researchers found that once-weekly therapy, of either type, was not associated with significant progress and Dropout rates were high.

• 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.

• However, the study had at least two flaws:

  • Therapists were not well-trained in SE therapy, so it is questionable whether the treatment was actually SE therapy.

  • Therapy was provided in a municipal office building where courts and social services were administered, lacking many features of traditional substance abuse treatment settings.

• A large multisite study of 487 persons receiving treatment compared SE therapy with cognitive therapy and drug counselling for cocaine dependence (Crits-Christoph et al., 1997).

• Each of the three conditions included, in addition to the individual treatment, a substance abuse counselling group.

• A fourth condition received group counselling 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 counselling 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 counselling was more successful at reducing substance use than SE or cognitive therapy (Crits-Christoph et al., 1999).

• Drug-focused interventions are perhaps the optimal approach for providing treatment for substance abuse disorders (Strean, 1994).

• For practitioners of psychodynamically oriented treatments, 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 counsellor providing direct, drug-focused counselling.

• This is why SE therapy was so helpful in the methadone studies.

• Clients received substance abuse disorder counselling 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 (Grenyer et al., 1995), offered once a week for 16 weeks.
  Results: 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.

• 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.

• The techniques that stem from these theories are inevitably used in any type of psychotherapy, whether or not it is identified as \"psychodynamic.\"

• Those 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.

• Counsellors 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 counsellor who is left feeling hopeless and confused after a session to understand how \"countertransference\" could be at work.

• Counsellors who treat clients with substance abuse disorders can benefit from understanding the basic concepts of general psychodynamic theory, 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, regardless of the modality of therapy (Luborsky, 1985).

• 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.

• 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.

• 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 behaviour during treatment and at 12-month follow-up, though the amount of variance explained was small (Connors et al., 1997).

• Another study found that, among cocaine-dependent patients, 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.

• 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.

Developmental Level

• 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 (Krystal, 1977).

• The substance abuser relates to the substance based on the disturbed pattern of relating that he experienced with the maternal object.

• This would be considered a variant of borderline psychopathology, which is viewed as a fairly severe disturbance of ego functioning and object relations.

• 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.

• There is increasing empirical evidence for the idea that severe substance abuse is largely driven by biobehavioural 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.

Insight

• 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.

• 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, which 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 behaviours to drinking when he feels bad (e.g., attending a 12-Step meeting)

  • 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 behaviours 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.

• 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 TM.

• Many therapists who conduct substance abuse treatment from a psychodynamic perspective are comfortable combining insight-oriented therapy with concrete, behavioral interventions.

Defence Mechanisms and Resistance

• In psychoanalytic theory, defence 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 \"defence mechanisms.\"

• All defence mechanisms have two characteristics in common:

  • They deny, distort, or falsify reality.

  • They operate unconsciously.

• Some defence mechanisms are adaptive and support the mature functioning of the individual, while others are maladaptive and hinder the individual's growth.

• Generally the defences 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 defences are supported, and even the maladaptive defences 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, defences 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 defences 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 defences by using the following strategies:

  • Working with the client's perceptions of reality rather than arguing

  • Asking questions carefully

  • Sidestepping rather than confronting defences

  • Demonstrating the denial defence while interacting with the client to show her how it works

Common Defence Mechanisms

• Denial: Pretending that a threatening situation does not exist because the situation is too distressing to cope with.

  • Example: A child comes home, and no one is there. He says to himself,