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Psychodynamic Therapy

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.

Background

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.

Introduction to Brief Psychodynamic Therapy

The healing and change process envisioned in long-term psychodynamic therapy typically requires at least 2 years of sessions. This is because the goal of therapy is often to change an aspect of one's identity or personality or to integrate key developmental learning missed while the client was stuck at an earlier stage of emotional development.

Practitioners of brief psychodynamic therapy believe that some changes can happen through a more rapid process or that an initial short intervention will start an ongoing process of change that does not need the constant involvement of the therapist. A central concept in brief therapy is that there should be one major focus for the therapy rather than the more traditional psychoanalytic practice of allowing the client to associate freely and discuss unconnected issues (Malan, 1976). In brief therapy, the central focus is developed during the initial evaluation process, occurring during the first session or two. This focus must be agreed on by the client and therapist. The central focus singles out the most important issues and thus creates a structure and identifies a goal for the treatment. In brief therapy, the therapist is expected to be fairly active in keeping the session focused on the main issue. Having a clear focus makes it possible to do interpretive work in a relatively short time because the therapist only addresses the circumscribed problem area. When using brief psychodynamic approaches to therapy for the treatment of substance abuse disorders, the central focus will always be the substance abuse in association with the core conflict. Further, the substance abuse and the core conflict will always be conceptualized within an interpersonal framework.