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. 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.

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. 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 BreathalyzerTM. 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
Asking questions
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.

Transference

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.

Etiology

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.

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:

Empathy
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).

Other Research

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.
 
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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 34: Brief Interventions and Brief Therapies for Substance Abuse