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The main aim and focus in psychodynamic psychotherapy

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 Interventions and Brief Therapies for Substance Abuse.

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 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.

Psychodynamic psychotherapy

The superego, formed during latency between age 5 and pubertyoperates 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. 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. 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.

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. 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, 1977pp.

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.

  1. Major techniques used by psychodynamic therapists include free association , dream interpretation , recognizing resistance and transference , working through painful memories and difficult issues, and building a strong therapeutic alliance. 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.
  2. The person with a substance abuse disorder will therefore have a "tremendously impoverished and impaired capacity to experience," and traditional psychotherapy might have to be augmented with techniques that focus on increasing a client's ability to experience Mark and Faude, 1995 , p. 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.
  3. The more severe the client's disorder, the more time it will take. The results showed that each type of treatment was associated with significantly reduced cocaine use.

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 the main aim and focus in psychodynamic psychotherapy 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.

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Further, the substance abuse and the core conflict will always be conceptualized within an interpersonal framework. The number of sessions varies from one approach to another, but brief psychodynamic 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 their review of short-term dynamic psychotherapies because of the divergence in the scope of treatment and the types of goals addressed Crits-Christoph and Barber, 1991.

For example, some brief psychodynamic models focus mainly on symptom reduction Horowitz, 1991while others target the resolution of the Oedipal conflict Davanloo, as interpreted by Laikin et al. The length of therapy is usually related to the ambitiousness of the therapy goals. Most therapists are flexible in terms of the number of sessions they recommend for clinical practice.

Often the number of sessions depends on a client's characteristics, 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 been adapted for use with people with substance abuse disorders. It has been modified for use with opiate dependence in conjunction with methadone maintenance treatment Luborsky et al.

There have been many studies of the use of SE therapy for substance abuse disorders, resulting in a significant body of empirical data on its effectiveness in treating these problems see below. Mark and Faude asserted that although their therapeutic approach was devised specifically for cocaine-dependent clients, these people often have multiple dependencies, and this approach can be used to treat a variety of substance abuse disorders.

However, clients should be reasonably stable in terms of their substance abuse before beginning this type of therapy Mark and Faude, 1995. Mark and Faude theorized that substances of abuse the main aim and focus in psychodynamic psychotherapy a "chemical reaction" in place of experiences and that these chemically induced experiences can block the impact of other external events.

The person with a substance abuse disorder will therefore have a "tremendously impoverished and impaired capacity to experience," and traditional psychotherapy might have to be augmented with techniques that focus on increasing a client's ability to experience Mark and Faude, 1995p. Effective SE therapy depends on appropriate use of what is termed the core conflictual relationship theme CCRTa concept first introduced by Lester Luborsky.

  1. Pretending that a threatening situation does not exist because the situation is too distressing to cope with.
  2. The central focus singles out the most important issues and thus creates a structure and identifies a goal for the treatment.
  3. The goals of this approach are primarily symptom reduction and improvement in interpersonal functioning.

The CCRT develops from early childhood experiences, but the client is unaware of it and how it developed. It is assumed that the client will have better control over behavior if he knows more about what he is doing on an unconscious level. This knowledge is acquired by better understanding of childhood experiences Bohart and Todd, 1988.

The CCRT develops out of a core response from others ROwhich the main aim and focus in psychodynamic psychotherapy a person's predominant expectations or experiences of others' internal and external reactions to herself, and a core response of the self RSwhich refers to a more or less coherent combination of somatic experiences, affects, actions, cognitive style, self-esteem, and self-representations.

Most people with substance abuse disorders have particularly negative expectations of others' attitudes toward them that is, the ROalthough it remains unclear which came first--this response or the substance abuse disorder. Either way, the two become mutually reinforcing. Following are examples of statements that reflect the core RO of a person with a substance abuse disorder: A negative RO reinforces a negative RS and can lead to the deceptive and manipulative behavior that is sometimes observed in this population.

The client's RS is based on the individual's somatic experiences, actions, and perceived needs. Following are examples of statements that could reflect a client's core RS: The client's "wish" is largely based on individual personality style.

Those with substance abuse disorders often have a wish to continue using the substance without having to endure the consequences. Put another way, they would like to be accepted or loved or appreciated as they are, without having to give up the pleasure they get from their use Levenson et al.

Many people who have substance abuse disorders have much invested in denying that they really have a problem, in portraying themselves as helpless victims, and in disclaiming their role in the behavior that has brought them into treatment.

Once therapy has been initiated, the therapist and client can work together to put the client's goals into the CCRT framework and explore the meaning, function, and consequence of her substance abuse, looking in particular at how the RO and RS have contributed to the problem.

The CCRT framework also can be used to identify potential obstacles in the recovery process as the therapist and client explore the client's anticipated responses from others and from herself and discuss how these perceptions will change when she stops abusing substances. The CCRT concept also can help clients deal with relapse, which is regarded by virtually 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 how the RO and RS can serve as triggers and to devise strategies to avoid these triggers in the future.

Finally, SE therapy is conducive to client participation in a self-help group such as Alcoholics Anonymous, or it can be used as a mechanism to examine a client's unwillingness to participate in these groups. 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 be the kind of person who wears her heart on her sleeve, but it is a big heart nonetheless, capable of caring for others with loyalty and the main aim and focus in psychodynamic psychotherapy.

In addition, she has a tenacity of spirit; despite a horrific personal history she completed her training as a medical technician and has worked in that capacity for much of the last 4 years. Her therapist, Christopher, is a well-trained psychodynamically oriented therapist. He is an intelligent, serious, and measured person, whose well-meaning nature comes through under most circumstances despite his natural reserve.

Stella has a history of polysubstance abuse, including the abuse of prescription drugs, both anxiolytics and opioids. She worked as a medical technician until she injured her back 3 months ago.

At the beginning of treatment, she told Christopher that she was going to request medication from her physician for her back pain. After her eighth session, with her reluctant agreement, Christopher informed the physician that she was in treatment for cocaine dependence.

Christopher asked the physician to find a medication other than diazepam Valium for Stella's back pain. Stella began the 19th session complaining that ever since the physician found out she was a drug user, he has treated her differently. He suggested that Stella consider telling her physician how she feels about his treatment. The intervention strikingly altered the mood and productivity of the session. After a brief expression of sympathy for her position, he focused on her extreme distress over the physician's treatment.

He attempted to explain the intensity of her reaction in terms of projection: