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Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.)


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Psychodynamic therapy focuses on unconscious processes as they are manifested in theclient"s present behavior. The goals of psychodynamic therapy are clientself-awareness and understanding of the influence of the past on present behavior.In its brief form, a psychodynamic approach enables the client to examine unresolvedconflicts and symptoms that arise from past dysfunctional relationships and manifestthemselves in the need and desire to abuse substances.

Several different approaches to brief psychodynamic psychotherapy have evolved frompsychoanalytic theory and have been clinically applied to a wide range ofpsychological disorders. A growing body of research supports the efficacy of theseapproaches (Crits-Christoph, 1992; Messer and Warren, 1995).

Short-term psychodynamic therapies can contribute to the armamentarium of treatmentsfor substance abuse disorders. Brief psychodynamic therapies probably have the bestchance to be effective when they are integrated into a relatively comprehensivesubstance abuse treatment program that includes drug-focused interventions such asregular urinalysis, drug counseling, and, for opioid-dependents, methadonemaintenance pharmacotherapy. Brief psychodynamic therapies are perhaps more helpfulafter abstinence is well established. They may be more beneficial for clients withno greater than moderate severity of substance abuse. It is also important that thepsychodynamic therapist know about the pharmacology of abused drugs, the subcultureof substance abuse, and 12-Step programs.

Psychodynamic therapy is the oldest of the modern therapies. As such, it is based ina highly developed and multifaceted theory of human development and interaction.This chapter demonstrates how rich it is for adaptation and further evolution bycontemporary therapists for specific purposes. The material presented in thischapter provides a quick glance at the usefulness and the complex nature of thistype of therapy.


Background

The theory supporting psychodynamic therapy originated in and is informed bypsychoanalytic 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 inthe early part of this century and is sometimes referred to as the drive orstructural model. The essence of Freud"s theory is that sexual and aggressiveenergies originating in the id (or unconscious) are modulatedby the ego, which is a set of functions that moderates betweenthe id and external reality. Defense mechanisms are constructions of the egothat operate to minimize pain and to maintain psychic equilibrium. Thesuperego, formed during latency (between age 5 andpuberty), operates to control id drives through guilt (Messer and Warren, 1995).

Ego Psychology derives from Freudian psychology. Its proponents focus their workon enhancing and maintaining ego function in accordance with the demands ofreality. 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 thesignificant others surrounding them. Our struggles and goals in life focus onmaintaining relations with others, while at the same time differentiatingourselves from others. The internal representations of self and others acquiredin childhood are later played out in adult relations. Individuals repeat oldobject 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 experienceof his self, including the presence or lack of a sense of self-esteem. The selfis perceived in relation to the establishment of boundaries and thedifferentiations of self from others (or the lack of boundaries anddifferentiations). "The explanatory power of the new psychology of the self isnowhere as evident as with regard to the addictions" (Blaine and Julius, 1977, p. vii). Kohut postulated thatpersons suffering from substance abuse disorders also suffer from a weakness inthe 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 theself.

he ingestion of the drug provides him with the self-esteem which he does notpossess. Through the incorporation of the drug, he supplies for himself thefeeling of being accepted and thus of being self-confident; or he creates theexperience of being merged with the source of power that gives him the feelingof being strong and worthwhile (Blaine andJulius, 1977, pp. vii-viii).

Each of the four schools of psychoanalytic theory presents discrete theories ofpersonality formation, psychopathology formation, and change; techniques bywhich to conduct therapy; and indications and contraindications for therapy.Psychodynamic therapy is distinguished from psychoanalysis in severalparticulars, including the fact that psychodynamic therapy need not include allanalytic techniques and is not conducted by psychoanalytically trained analysts.Psychodynamic therapy is also conducted over a shorter period of time and withless frequency than psychoanalysis.

Several of the brief forms of psychodynamic therapy are considered lessappropriate for use with persons with substance abuse disorders, partly becausetheir altered perceptions make it difficult to achieve insight and problemresolution. However, many psychodynamic therapists work with substance-abusingclients, in conjunction with traditional drug and alcohol treatment programs oras the sole therapist for clients with coexisting disorders, using forms ofbrief psychodynamic therapy described in more detail below.


Introduction to Brief PsychodynamicTherapy

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

Practitioners of brief psychodynamic therapy believe that some changes can happenthrough a more rapid process or that an initial short intervention will start anongoing process of change that does not need the constant involvement of thetherapist. A central concept in brief therapy is that there should be one majorfocus for the therapy rather than the more traditional psychoanalytic practiceof allowing the client to associate freely and discuss unconnected issues (Malan, 1976). In brief therapy, thecentral focus is developed during the initial evaluation process, occurringduring the first session or two. This focus must be agreed on by the client andtherapist. The central focus singles out the most important issues and thuscreates 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 onthe main issue. Having a clear focus makes it possible to do interpretive workin a relatively short time because the therapist only addresses thecircumscribed problem area. When using brief psychodynamic approaches to therapyfor the treatment of substance abuse disorders, the central focus will always bethe substance abuse in association with the core conflict. Further, thesubstance abuse and the core conflict will always be conceptualized within aninterpersonal framework.

The number of sessions varies from one approach to another, but briefpsychodynamic therapy is typically considered to be no more than 25 sessions(Bauer and Kobos, 1987).Crits-Christoph and Barber included models allowing up to 40 sessions in theirreview of short-term dynamic psychotherapies because of the divergence in thescope of treatment and the types of goals addressed (Crits-Christoph and Barber, 1991). For example, somebrief psychodynamic models focus mainly on symptom reduction (Horowitz, 1991), while others target theresolution of the Oedipal conflict (Davanloo, as interpreted by Laikin et al., 1991). The length oftherapy is usually related to the ambitiousness of the therapy goals. Mosttherapists are flexible in terms of the number of sessions they recommend forclinical practice. Often the number of sessions depends on a client"scharacteristics, goals, and the issues deemed central by the therapist.


Psychodynamic Psychotherapy for Substance Abuse

Supportive-expressive (SE) psychotherapy (Luborsky, 1984) is one brief psychodynamic approach that has beenadapted for use with people with substance abuse disorders. It has been modifiedfor use with opiate dependence in conjunction with methadone maintenancetreatment (Luborsky et al., 1977) andfor cocaine use disorders (Mark and Faude,1995; Mark and Luborsky,1992). There have been many studies of the use of SE therapy forsubstance abuse disorders, resulting in a significant body of empirical data onits effectiveness in treating these problems (see below).

Mark and Faude asserted that although their therapeutic approach was devisedspecifically for cocaine-dependent clients, these people often have multipledependencies, and this approach can be used to treat a variety of substanceabuse disorders. However, clients should be reasonably stable in terms of theirsubstance abuse before beginning this type of therapy (Mark and Faude, 1995).

Mark and Faude theorized that substances of abuse substitute a "chemicalreaction" in place of experiences and that these chemically induced experiencescan block the impact of other external events. The person with a substance abusedisorder will therefore have a "tremendously impoverished and impaired capacityto experience," and traditional psychotherapy might have to be augmented withtechniques 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 thecore conflictual relationship theme (CCRT), a concept firstintroduced by Lester Luborsky. According to Luborsky, a CCRT is at the center ofa person"s problems. The CCRT develops from early childhood experiences, but theclient is unaware of it and how it developed. It is assumed that the client willhave better control over behavior if he knows more about what he is doing on anunconscious level. This knowledge is acquired by better understanding ofchildhood experiences (Bohart and Todd,1988). The CCRT develops out of a core response from others(RO), which represents a person"s predominant expectations orexperiences of others" internal and external reactions to herself, and acore response of the self (RS), which refers to a more orless coherent combination of somatic experiences, affects, actions, cognitivestyle, self-esteem, and self-representations.

Most people with substance abuse disorders have particularly negativeexpectations of others" attitudes toward them (that is, the RO), although itremains unclear which came first--this response or the substance abuse disorder.Either way, the two become mutually reinforcing. Following are examples ofstatements that reflect the core RO of a person with a substance abuse disorder:

A third component of CCRT is a person"s wish; it reflects whatthe client yearns for, wishes for, or desires. The client"s "wish" is largelybased on individual personality style. Those with substance abuse disordersoften have a wish to continue using the substance without having to endure theconsequences. Put another way, they would like to be accepted (or loved orappreciated) as they are, without having to give up the pleasure they get fromtheir use (Levenson et al., 1997).Many people who have substance abuse disorders have much invested in denyingthat they really have a problem, in portraying themselves as helpless victims,and in disclaiming their role in the behavior that has brought them intotreatment.

Once therapy has been initiated, the therapist and client can work together toput the client"s goals into the CCRT framework and explore the meaning,function, and consequence of her substance abuse, looking in particular at howthe RO and RS have contributed to the problem. The CCRT framework also can beused to identify potential obstacles in the recovery process as the therapistand client explore the client"s anticipated responses from others and fromherself and discuss how these perceptions will change when she stops abusingsubstances.

The CCRT concept also can help clients deal with relapse, which is regarded byvirtually 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 howthe RO and RS can serve as triggers and to devise strategies to avoid thesetriggers in the future. Finally, SE therapy is conducive to client participationin a self-help group such as Alcoholics Anonymous, or it can be used as amechanism 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; adaptedwith 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 bethe kind of person who wears her heart on her sleeve, but it is a big heartnonetheless, capable of caring for others with loyalty and compassion. Inaddition, she has a tenacity of spirit; despite a horrific personal historyshe completed her training as a medical technician and has worked in thatcapacity for much of the last 4 years. Her therapist, Christopher, is awell-trained psychodynamically oriented therapist. He is an intelligent,serious, and measured person, whose well-meaning nature comes through undermost circumstances despite his natural reserve.

Stella has a history of polysubstance abuse, including the abuse ofprescription drugs, both anxiolytics and opioids. She worked as a medicaltechnician until she injured her back 3 months ago. At the beginning oftreatment, she told Christopher that she was going to request medicationfrom her physician for her back pain. After her eighth session, with herreluctant agreement, Christopher informed the physician that she was intreatment for cocaine dependence. Christopher asked the physician to find amedication other than diazepam (Valium) for Stella"s back pain.

Stella began the 19th session complaining that ever since the physician foundout she was a drug user, he has treated her differently. "He thinks I"m ascumbag drug addict," she said. Christopher acted uncharacteristically: heoffered some advice. He suggested that Stella consider telling her physicianhow she feels about his treatment. The intervention strikingly altered themood and productivity of the session. After a brief expression of sympathyfor her position, he focused on her extreme distress over the physician"streatment. He attempted to explain the intensity of her reaction in terms ofprojection: that she responded so strongly because of her negative view ofherself.

Matters got worse as the session continued. Stella related a second negativeincident when she described her treatment by the physician in a grouptherapy session. The group therapist responded, "Well, you manipulatedoctors!" Stella had been furious.

Christopher encouraged her to say more. Stella became frustrated atChristopher"s lack of understanding and explained that again, she felt shewas being treated like a "scumbag," this time by the group therapist.Christopher suggested that Stella might tell both the physician and thegroup therapist how she felt. The tension in the session disappeared, andStella remarked that she has always had trouble sticking up for herself.

In supervision, Christopher realized immediately that he was indirectlyletting Stella know that he understood and agreed with her.

Diagnostically speaking, Stella has a borderline personality disorder asdefined by the Diagnostic and Statistical Manual of MentalDisorders, 4th Edition (American Psychiatric Association, 1994). When shewas between 6 and 8 years old, Stella"s maternal grandfather sexually abusedher. 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 toher father, whom she described as gentle. He appeared to others as weak andineffectual.

At age 15, Stella ran off with a boyfriend who was also her pimp. After 2weeks she returned home, was unable to leave her mother, and was diagnosedas having agoraphobia, for which she took chlordiazepoxide (Librium). Twoyears later she ran away with another man, a particularly sadistic pimp. For5 years she was too terrified to leave him. It was during this period thatshe started using cocaine.

The cocaine both "disclaims action" and affirms her "badness." Her cocaineuse enabled her to avoid examining why she stayed with her boyfriend andsimultaneously affirmed her badness. So, she deserves her fate. She woulduse the cocaine to clear her painful feelings and feel "strong andindependent," then "feel like a big baby for having to use the drugs." Shethought of herself as a "big baby," for returning to her mother at age 15and for being unable to leave her current boyfriend. Her reactions tococaine are typical; a brief surge or a "high," followed by a crash.However, these typical reactions also fit her core theme: she wants to beloved and cared for but believes she will be thwarted and exploited byothers because of this wish. Her response then is to use drugs, which makesher feel strong and independent for a brief time and also makes her seeherself as deserving of being thwarted and exploited, which has happenedrepeatedly in interpersonal contexts in her life.

Stella"s drug use became a part of the therapy in two ways. In the firstsession, Stella told Christopher that she had taken chlordiazepoxide forseveral days before their appointment, to relieve her anxiety. She pointedout that it had been prescribed by a doctor. Presumably, Christopher wouldhave known the results of her drug screen, which was part of the program.She thus confessed before being confronted by drug screen results. Her claimthat the prescription was legitimate facilitated her denial that she hasanything to be concerned about.

Second, Stella announced her intention to ask her physician for diazepam, acommonly abused medication. By contacting her physician, Christopherreplayed a common scenario in her life: she signals that someone should takecontrol or care for her, then resents it when they do, feeling that she isbeing treated like a "scumbag drug addict." She can create the largelyillusory sense of being cared for when someone treats her as a helplessincompetent. Was this how Christopher was treating her when he called herphysician?

When Christopher suggested that she tell the physician and the grouptherapist how she felt about the way they had treated her, his words mayhave given advice, but his communication actually conveyed agreement withStella"s position that she had been unfairly treated.

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Stella experienced Christopher"s agreement and support through hisintervention. However, what could have made this a more powerful therapeuticinteraction would have been either for Christopher to directly acknowledgehis misgivings about having taken charge and contacted the physician or toexplore how Stella came to hear his initial obliqueness as giving her whatshe wanted--his care and support.