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Center because that Substance Abuse Treatment. Quick Interventions and Brief Therapies for Substance Abuse. Rockville (MD): substance Abuse and also Mental wellness Services management (US); 1999. (Treatment innovation Protocol (TIP) Series, No. 34.)


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Psychodynamic therapy focuses on unconscious processes as lock are materialized in theclient"s current behavior. The objectives of psychodynamic therapy room clientself-awareness and understanding of the influence of the past on existing behavior.In its short form, a psychodynamic approach allows the client to study unresolvedconflicts and symptoms the arise from past dysfunctional relationships and manifestthemselves in the need and desire come abuse substances.

Several various approaches to brief psychodynamic psychotherapy have developed frompsychoanalytic theory and have to be clinically used to a wide selection ofpsychological disorders. A growing body of study supports the efficacy of theseapproaches (Crits-Christoph, 1992; Messer and Warren, 1995).

Short-term psychodynamic therapies can contribute to the armamentarium that treatmentsfor problem abuse disorders. Brief psychodynamic therapies probably have the bestchance to be effective when lock are integrated into a reasonably comprehensivesubstance abuse treatment regimen that includes drug-focused interventions together asregular urinalysis, drug counseling, and, because that opioid-dependents, methadonemaintenance pharmacotherapy. Short psychodynamic therapies room perhaps more helpfulafter abstinence is fine established. They might be much more beneficial for clients withno greater than moderate severity of substance abuse. That is also important that thepsychodynamic therapist know about the pharmacology the abused drugs, the subcultureof problem abuse, and 12-Step programs.

Psychodynamic treatment is the earliest of the modern-day therapies. Together such, it is based ina very developed and multifaceted theory of human advancement and interaction.This chapter demonstrates exactly how rich the is for adaptation and also further evolution bycontemporary therapists for certain purposes. The product presented in thischapter offers a fast glance in ~ the usefulness and also the facility nature of thistype the therapy.


Background

The theory supporting psychodynamic therapy originated in and is notified bypsychoanalytic theory. There are four significant schools of psychoanalytic theory,each that which has actually influenced psychodynamic therapy. The 4 schools are:Freudian, Ego Psychology, thing Relations, and Self Psychology.

Freudian psychology is based upon the theories first formulated by Sigmund Freud inthe early part of this century and is sometimes referred to together the drive orstructural model. The significance of Freud"s theory is the sexual and aggressiveenergies originating in the i would (or unconscious) space modulatedby the ego, i beg your pardon is a collection of functions that moderates betweenthe id and external reality. Defense mechanisms are constructions that the egothat run to minimize pain and to preserve psychic equilibrium. Thesuperego, formed throughout latency (between period 5 andpuberty), operates to control id drives through guilt (Messer and also Warren, 1995).

Ego Psychology derives native Freudian psychology. That is proponents emphasis their workon enhancing and maintaining ego role in accordance v the demands ofreality. Ego Psychology stress the individual"s volume for defense,adaptation, and also reality trial and error (Pine,1990).

Object relationships psychology was very first articulated by number of British analysts,among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and also Harry Guntrip.According to this theory, human beings are always shaped in relationship to thesignificant others surrounding them. Our struggles and goals in life focus onmaintaining relationships with others, while in ~ the very same time differentiatingourselves from others. The interior representations that self and also others acquiredin childhood are later played out in adult relations. People repeat oldobject relationships in an effort to master them and also become freed native them(Messer and Warren, 1995).

Self Psychology was started by Heinz Kohut, M.D., in Chicago throughout the 1950s.Kohut observed that the self refers to a person"s tardy of his experienceof his self, including the presence or absence of a sense of self-esteem. The selfis perceived in relation to the facility of boundaries and also thedifferentiations of me from others (or the lack of limits anddifferentiations). "The explanatory power of the new psychology the the me isnowhere as evident as v regard come the addictions" (Blaine and Julius, 1977, p. Vii). Kohut postulated thatpersons suffering from problem abuse disorders also suffer from a weakness inthe main point of their personalities--a defect in the development of the "self."Substances appear to the user to be qualified of curing the central defect in theself.

he sloop down of the drug gives him through the self-esteem which he does notpossess. Through the incorporation of the drug, he gives for himself thefeeling of gift accepted and thus of being self-confident; or he create theexperience the being linked with the resource of strength that offers him the feelingof being strong and worthwhile (Blaine andJulius, 1977, pp. Vii-viii).

Each of the 4 schools that psychoanalytic theory presents discrete theories ofpersonality formation, psychopathology formation, and change; techniques bywhich to conduct therapy; and indications and contraindications because that therapy.Psychodynamic therapy is differentiated from psychoanalysis in severalparticulars, consisting of the truth that psychodynamic therapy need not include allanalytic techniques and also is not carried out by psychoanalytically trained analysts.Psychodynamic therapy is additionally conducted end a shorter period of time and also withless frequency than psychoanalysis.

Several the the quick forms of psychodynamic treatment are taken into consideration lessappropriate for use with persons through substance abuse disorders, partially becausetheir transformed perceptions do it daunting to achieve insight and problemresolution. However, countless psychodynamic therapists occupational with substance-abusingclients, in connect with classic drug and also alcohol treatment programs oras the single therapist because that clients v coexisting disorders, using creates ofbrief psychodynamic therapy defined in an ext detail below.


Introduction to brief PsychodynamicTherapy

The healing and change procedure envisioned in irreversible psychodynamic therapytypically requires at least 2 year of sessions. This is since the score oftherapy is regularly to readjust an element of one"s identification or personality or tointegrate crucial developmental learning missed if the client was grounding at anearlier stage of emotionally development.

Practitioners of quick psychodynamic therapy believe that some transforms can happenthrough a more rapid process or that an initial quick intervention will begin anongoing process of change that walk not need the constant involvement that thetherapist. A central concept in brief therapy is that there must be one majorfocus because that the therapy quite than the much more traditional psychoanalytic practiceof permitting the client to combine freely and discuss unconnected issues (Malan, 1976). In quick therapy, thecentral emphasis is emerged during the initial review process, occurringduring the very first session or two. This emphasis must be agreed on through the client andtherapist. The central focus singles out the most crucial issues and also thuscreates a structure and also identifies a goal for the treatment. In brief therapy,the therapist is supposed to be reasonably active in maintaining the session focused onthe main issue. Having a clear emphasis makes it possible to do interpretive workin a reasonably short time due to the fact that the therapist just addresses thecircumscribed difficulty area. Once using short psychodynamic philosophies to therapyfor the therapy of substance abuse disorders, the central focus will always bethe substance abuse in association with the main point conflict. Further, thesubstance abuse and the core conflict will always be conceptualized within aninterpersonal framework.

The variety of sessions varies from one technique to another, but briefpsychodynamic treatment is frequently considered to it is in no much more than 25 sessions(Bauer and Kobos, 1987).Crits-Christoph and Barber had models permitting up to 40 sessions in theirreview of temporary dynamic psychotherapies because of the divergence in thescope that treatment and the varieties of goals addressed (Crits-Christoph and also Barber, 1991). For example, somebrief psychodynamic models emphasis mainly top top symptom reduction (Horowitz, 1991), while rather target theresolution that the Oedipal problem (Davanloo, as understood by Laikin et al., 1991). The size oftherapy is usually pertained to the ambitiousness of the treatment goals. Mosttherapists are flexible in regards to the variety of sessions they recommend forclinical practice. Frequently the number of sessions relies on a client"scharacteristics, goals, and also the issues deemed main by the therapist.


Psychodynamic Psychotherapy because that Substance Abuse

Supportive-expressive (SE) psychotherapy (Luborsky, 1984) is one short psychodynamic technique that has actually beenadapted for usage with people with substance abuse disorders. It has been modifiedfor use with opiate dependence in conjunction v methadone maintenancetreatment (Luborsky et al., 1977) andfor cocaine usage disorders (Mark and Faude,1995; Mark and also Luborsky,1992). There have been countless studies that the usage of SE treatment forsubstance abuse disorders, causing a far-reaching body of empirical data onits performance in treating these problems (see below).

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

Mark and also Faude theorized that substances the abuse instead of a "chemicalreaction" in place of experiences and also that this chemically induced experiencescan block the affect of other exterior events. The person with a problem abusedisorder will therefore have a "tremendously impoverished and also impaired capacityto experience," and also traditional psychotherapy might have to it is in augmented withtechniques that emphasis on boosting a client"s ability to experience (Mark and Faude, 1995, p. 297).

Effective SE therapy counts on appropriate use the what is termed thecore conflictual partnership theme (CCRT), a ide firstintroduced by Lester Luborsky. According to Luborsky, a CCRT is in ~ the center ofa person"s problems. The CCRT creates from beforehand childhood experiences, however theclient is unaware the it and also how the developed. That is assumed the the client willhave better control over behavior if the knows more about what that is act on anunconscious level. This expertise is gained by better understanding ofchildhood experience (Bohart and also Todd,1988). The CCRT develops out that a core an answer from others(RO), which to represent a person"s primary expectations orexperiences of others" internal and also external reactions to herself, and also acore response of the me (RS), which describes a more orless coherent mix of somatic experiences, affects, actions, cognitivestyle, self-esteem, and also self-representations.

Most human being with substance abuse disorders have an especially negativeexpectations that others" attitudes toward lock (that is, the RO), although itremains unclear which came first--this response or the problem abuse disorder.Either way, the two come to be mutually reinforcing. Complying with are examples ofstatements that reflect the main point RO of a person with a problem abuse disorder:

A third component that CCRT is a person"s wish; it shows whatthe customer yearns for, wishes for, or desires. The client"s "wish" is largelybased on separation, personal, instance personality style. Those with substance abuse disordersoften have a wish to proceed using the substance without having to endure theconsequences. Put another way, lock would favor to be accepted (or loved orappreciated) as they are, without having actually to give up the satisfied they acquire fromtheir use (Levenson et al., 1997).Many world who have actually substance abuse disorders have actually much invested in denyingthat castle really have actually a problem, in depicting themselves together helpless victims,and in disclaiming their function in the actions that has brought them intotreatment.

Once therapy has been initiated, the therapist and client can work together toput the client"s goals right into the CCRT framework and also explore the meaning,function, and an effect of she substance abuse, feather in particular at howthe RO and RS have contributed to the problem. The CCRT framework additionally can beused to recognize potential obstacles in the recovery process as the therapistand customer explore the client"s anticipated responses native others and fromherself and discuss just how these consciousness will change when she stop abusingsubstances.

The CCRT concept likewise can assist clients deal with relapse, which is pertained to byvirtually all specialists in the ar as one integral and natural part of recovery.Relapse supplies the customer and the SE therapist the chance to study howthe RO and RS can serve together triggers and also to devise techniques to stop thesetriggers in the future. Finally, SE treatment is conducive to customer participationin a self-help team such together Alcoholics Anonymous, or it have the right to be offered as amechanism to examine a client"s unwillingness to get involved in this groups.


Stella and also Christopher: A situation Study

The case study in this ar came from the NIDA collaborative Cocaine Study(Mark and also 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 countless circumstances together warm and also open. She shows up to bethe sort of human being who wears her heart on she sleeve, but it is a huge heartnonetheless, capable of caring because that others v loyalty and also compassion. Inaddition, she has actually a tenacity that spirit; regardless of a horrific personal historyshe completed she training as a medical technician and has operated in thatcapacity for much of the last 4 years. Her therapist, Christopher, is awell-trained psychodynamically oriented therapist. He is one intelligent,serious, and measured person, who well-meaning nature comes through undermost circumstances in spite of his organic reserve.

Stella has a history of polysubstance abuse, including the abuse ofprescription drugs, both anxiolytics and also opioids. She worked as a medicaltechnician until she injured her back 3 month ago. In ~ the start oftreatment, she told Christopher that she was going to inquiry medicationfrom her physician for her ago pain. After her eighth session, through herreluctant agreement, Christopher educated the medical professional that she to be intreatment because that cocaine dependence. Christopher request the physician to discover amedication other than diazepam (Valium) for Stella"s ago pain.

Stella started the 19th session complaining the ever due to the fact that the doctor foundout she to be a medicine user, he has actually treated her differently. "He think I"m ascumbag drug addict," she said. Christopher action uncharacteristically: heoffered part advice. He argued that Stella take into consideration telling her physicianhow she feels around his treatment. The treatment strikingly transformed themood and also productivity that the session. After a short expression that sympathyfor her position, he focused on her too much distress over the physician"streatment. The attempted to describe the soot of she reaction in state ofprojection: the she comment so strongly due to the fact that of her an adverse view ofherself.

Matters acquired worse together the conference continued. Stella related a 2nd negativeincident once she explained her treatment by the medical professional in a grouptherapy session. The group therapist responded, "Well, girlfriend manipulatedoctors!" Stella had been furious.

Christopher encouraged her come say more. Stella ended up being frustrated atChristopher"s lack of understanding and explained that again, she felt shewas being treated choose a "scumbag," this time by the group therapist.Christopher argued that Stella can tell both the physician and also thegroup therapist how she felt. The stress in the conference disappeared, andStella remarked the she has always had problem sticking up for herself.

In supervision, Christopher realized instantly that he to be indirectlyletting Stella understand that he understood and also agreed with her.

Diagnostically speaking, Stella has actually a borderline personality disorder asdefined by the Diagnostic and also Statistical hands-on of MentalDisorders, 4th Edition (American Psychiatric Association, 1994). As soon as shewas between 6 and also 8 years old, Stella"s maternal grandfather sexually abusedher. Her parents divorced once she was 10, and also she lived v her mother,who was regularly drunk and also physically abusive. Stella stated she was closer toher father, who she described as gentle. He appeared to others as weak andineffectual.

At age 15, Stella ran off through a boyfriend who was also her pimp. ~ 2weeks she reverted home, was unable to leave her mother, and also was diagnosedas having actually agoraphobia, for which she take it chlordiazepoxide (Librium). Twoyears later she ran away with an additional man, a an especially sadistic pimp. For5 year she was also terrified to leaving him. The was throughout this duration thatshe began using cocaine.

The cocaine both "disclaims action" and affirms she "badness." her cocaineuse enabled her to avoid examining why she stayed with her friend andsimultaneously affirmed she badness. So, she deserves she fate. She woulduse the cocaine come clear she painful feelings and also feel "strong andindependent," climate "feel favor a huge baby for having actually to usage the drugs." Shethought that herself together a "big baby," for returning come her mother at age 15and because that being unable to leaving her present boyfriend. Her reactions tococaine are typical; a quick surge or a "high," complied with by a crash.However, these common reactions additionally fit her main point theme: she desires to beloved and cared for however believes she will be thwarted and also exploited byothers because of this wish. Her an answer then is to usage drugs, i m sorry makesher feel solid and independent for a short time and also makes her seeherself as deserving of gift thwarted and also exploited, which has actually happenedrepeatedly in interpersonal contexts in her life.

Stella"s medicine use ended up being a component of the treatment in two ways. In the firstsession, Stella said Christopher that she had taken chlordiazepoxide forseveral days prior to their appointment, to relax her anxiety. She pointedout that it had actually been prescribed by a doctor. Presumably, Christopher wouldhave well-known the results of her drug screen, which was part of the program.She therefore confessed prior to being challenged by drug display screen results. Her claimthat the prescription was legitimate helped with her denial that she hasanything to be pertained to about.

Second, Stella announced she intention to ask her doctor for diazepam, acommonly abused medication. Through contacting her physician, Christopherreplayed a usual scenario in her life: she signals that someone must takecontrol or treatment for her, climate resents it when they do, emotion that she isbeing treated prefer a "scumbag medicine addict." She can develop the largelyillusory feeling of gift cared for when someone treats her as a helplessincompetent. Was this how Christopher was dealing with her once he dubbed herphysician?

When Christopher said that she phone call the physician and the grouptherapist exactly how she felt about the means they had treated her, his indigenous mayhave offered advice, however his communication actually conveyed commitment withStella"s position that she had been unfair treated.

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Stella skilled Christopher"s agreement and also support v hisintervention. However, what can have made this a an ext powerful therapeuticinteraction would have actually been either because that Christopher to straight acknowledgehis misgivings around having taken charge and also contacted the medical professional or toexplore just how Stella concerned hear his early stage obliqueness as providing her whatshe wanted--his care and also support.