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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 management (US); 1999. (Treatment development Protocol (TIP) Series, No. 34.)


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

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

Short-term psychodynamic therapies can add to the armamentarium that treatmentsfor substance abuse disorders. Quick psychodynamic therapies probably have actually the bestchance to be reliable when lock are combined into a fairly comprehensivesubstance abuse treatment regime that has drug-focused interventions such asregular urinalysis, drug counseling, and, because that opioid-dependents, methadonemaintenance pharmacotherapy. Quick psychodynamic therapies room perhaps much more helpfulafter abstinence is well established. They may be much more beneficial because that clients withno better than middle severity of problem abuse. That is also important the thepsychodynamic therapist know around the pharmacology that abused drugs, the subcultureof substance abuse, and 12-Step programs.

Psychodynamic therapy is the earliest of the modern therapies. Together such, that is based ina extremely developed and also multifaceted concept of human advance and interaction.This thing demonstrates how rich the is for adaptation and further development bycontemporary therapists for certain purposes. The product presented in thischapter gives a fast glance in ~ the usefulness and the complicated nature of thistype the therapy.


Background

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

Freudian psychology is based on the theories very first formulated by Sigmund Freud inthe early component of this century and is sometimes referred to together the drive orstructural model. The essence of Freud"s concept is that sexual and aggressiveenergies originating in the id (or unconscious) space modulatedby the ego, which is a set of features that moderates betweenthe id and external reality. Defense mechanisms room constructions of the egothat run to minimization pain and also to maintain psychic equilibrium. Thesuperego, formed during latency (between period 5 andpuberty), operates to regulate id drives with guilt (Messer and Warren, 1995).

Ego Psychology derives indigenous Freudian psychology. That proponents emphasis their workon enhancing and also maintaining ego duty in accordance through the requirements ofreality. Ego Psychology stress the individual"s capacity for defense,adaptation, and also reality experimentation (Pine,1990).

Object relationships psychology was very first articulated by numerous British analysts,among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and Harry Guntrip.According come this theory, human beings are constantly shaped in relation to thesignificant others neighboring them. Ours struggles and also goals in life emphasis onmaintaining relations with others, while at the very same time differentiatingourselves indigenous others. The internal representations of self and others acquiredin childhood are later played the end in adult relations. People repeat oldobject relationship in an effort to grasp them and also become freed native them(Messer and also Warren, 1995).

Self Psychology was founded by Heinz Kohut, M.D., in Chicago throughout the 1950s.Kohut observed the the self refers to a person"s late of his experienceof his self, including the presence or absence of a feeling of self-esteem. The selfis viewed in relationship to the facility of boundaries and also thedifferentiations of me from rather (or the lack of boundaries anddifferentiations). "The explanatory power of the new psychology of the me isnowhere as noticeable as v regard to the addictions" (Blaine and Julius, 1977, p. Vii). Kohut postulated thatpersons experiencing 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 come be capable of curing the central defect in theself.

he gulp down of the drug provides him through the self-esteem which the does notpossess. With the organization of the drug, he gives for himself thefeeling of gift accepted and thus of being self-confident; or he creates theexperience of being linked with the source of power that provides him the feelingof being strong and worthwhile (Blaine andJulius, 1977, pp. Vii-viii).

Each that the 4 schools of psychoanalytic theory presents discrete theories ofpersonality formation, psychopathology formation, and also change; approaches bywhich to command therapy; and also indications and also contraindications because that therapy.Psychodynamic therapy is identified from psychoanalysis in severalparticulars, consisting of the truth that psychodynamic therapy require not encompass allanalytic techniques and also is not performed by psychoanalytically trained analysts.Psychodynamic therapy is likewise conducted end a shorter period of time and withless frequency 보다 psychoanalysis.

Several the the short forms the psychodynamic therapy are taken into consideration lessappropriate because that use v persons with substance abuse disorders, partly becausetheir altered perceptions do it difficult to accomplish insight and problemresolution. However, countless psychodynamic therapists work with substance-abusingclients, in conjunction with traditional drug and also alcohol therapy programs oras the sole therapist for clients through coexisting disorders, using develops ofbrief psychodynamic therapy described in an ext detail below.


Introduction to quick PsychodynamicTherapy

The healing and also change process envisioned in irreversible psychodynamic therapytypically needs at the very least 2 year of sessions. This is because the score oftherapy is frequently to readjust an element of one"s identity or personality or tointegrate an essential developmental finding out missed when the customer was grounding at anearlier phase of emotional development.

Practitioners of short psychodynamic therapy believe that some transforms can happenthrough a an ext rapid process or the an initial quick intervention will begin anongoing procedure of adjust that walk not require the continuous involvement of thetherapist. A central concept in short therapy is the there need to be one majorfocus for the therapy fairly 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 occurred during the initial testimonial process, occurringduring the first session or two. This emphasis must it is in agreed on by the client andtherapist. The main focus singles the end the most important issues and thuscreates a structure and identifies a goal for the treatment. In short therapy,the therapist is intended to be fairly active in keeping the session focused onthe key issue. Having actually a clear focus makes it feasible to execute interpretive workin a fairly short time since the therapist just addresses thecircumscribed trouble area. As soon as using quick psychodynamic approaches to therapyfor the treatment of problem abuse disorders, the main focus will constantly bethe problem abuse in association v the main point conflict. Further, thesubstance abuse and also the core conflict will constantly be conceptualized within aninterpersonal framework.

The variety of sessions varies from one technique to another, yet briefpsychodynamic treatment is commonly considered to it is in no an ext than 25 sessions(Bauer and also Kobos, 1987).Crits-Christoph and also Barber included models enabling up come 40 sessions in theirreview of short-term dynamic psychotherapies due to the fact that of the divergence in thescope of treatment and also the species of objectives addressed (Crits-Christoph and also Barber, 1991). Because that example, somebrief psychodynamic models focus mainly top top symptom reduction (Horowitz, 1991), while rather target theresolution of the Oedipal problem (Davanloo, as understood by Laikin et al., 1991). The length oftherapy is usually concerned the ambitiousness that the therapy goals. Mosttherapists room flexible in terms of the variety of sessions they recommend forclinical practice. Regularly the number of sessions depends on a client"scharacteristics, goals, and the worries deemed main by the therapist.


Psychodynamic Psychotherapy because that Substance Abuse

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

Mark and also Faude asserted the although your therapeutic strategy was devisedspecifically for cocaine-dependent clients, these world often have actually multipledependencies, and also this method can be supplied to act a variety of substanceabuse disorders. However, clients should be fairly stable in regards to theirsubstance abuse before beginning this kind of treatment (Mark and Faude, 1995).

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

Effective SE therapy counts on proper use the what is termed thecore conflictual connection theme (CCRT), a ide firstintroduced through Lester Luborsky. According to Luborsky, a CCRT is at the center ofa person"s problems. The CCRT establishes from early childhood experiences, but theclient is unaware the it and also how the developed. It is assumed the the client willhave much better control over behavior if he knows much more about what he is act on anunconscious level. This knowledge is obtained by far better understanding ofchildhood experience (Bohart and also Todd,1988). The CCRT establishes out that a core response from others(RO), which to represent a person"s primary expectations orexperiences the others" internal and external reactions to herself, and also acore response of the self (RS), which describes a much more orless coherent combination of somatic experiences, affects, actions, cognitivestyle, self-esteem, and also self-representations.

Most world with substance abuse disorders have an especially negativeexpectations the others" perspectives toward them (that is, the RO), back itremains uncertain which came first--this an answer or the problem abuse disorder.Either way, the two end up being mutually reinforcing. Adhering to are examples ofstatements the reflect the main point RO that a human with a problem abuse disorder:

A 3rd 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 separation, personal, instance personality style. Those v substance abuse disordersoften have a wish to proceed using the problem without having to endure theconsequences. Put an additional way, castle would choose to be accepted (or loved orappreciated) as they are, without having to give up the satisfied they get fromtheir use (Levenson et al., 1997).Many people who have actually substance abuse disorders have actually much invest in denyingthat lock really have actually a problem, in showing themselves together helpless victims,and in disclaiming their function in the behavior that has brought them intotreatment.

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

The CCRT concept also can aid clients deal with relapse, which is concerned byvirtually all experts in the ar as one integral and also natural part of recovery.Relapse provides the client and the SE therapist the possibility to research howthe RO and RS can serve together triggers and to devise strategies to stop thesetriggers in the future. Finally, SE treatment is conducive to client participationin a self-help team such together Alcoholics Anonymous, or it can be provided as amechanism to research a client"s unwillingness to participate in this groups.


Stella and also Christopher: A instance Study

The case study in this section 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 viewed under many circumstances as warm and open. She appears to bethe sort of human being who wears her heart on her sleeve, but it is a large heartnonetheless, qualified of caring because that others with loyalty and also compassion. Inaddition, she has a tenacity of spirit; despite a horrific an individual historyshe completed her training as a clinical technician and also has worked in thatcapacity for lot of the critical 4 years. She therapist, Christopher, is awell-trained psychodynamically oriented therapist. He is an intelligent,serious, and measured person, who well-meaning nature comes v undermost circumstances in spite of his herbal reserve.

Stella has a background of polysubstance abuse, including the abuse ofprescription drugs, both anxiolytics and opioids. She operated as a medicaltechnician until she hurt her earlier 3 month ago. At the beginning oftreatment, she called Christopher the she to be going to request medicationfrom her doctor for her ago pain. After she eighth session, v herreluctant agreement, Christopher informed the medical professional that she to be intreatment for cocaine dependence. Christopher inquiry the physician to discover amedication various other than diazepam (Valium) because that Stella"s back pain.

Stella started the 19th conference complaining that ever since the doctor foundout she to be a drug user, he has actually treated her differently. "He think I"m ascumbag medicine addict," she said. Christopher action uncharacteristically: heoffered part advice. He argued that Stella consider telling her physicianhow she feels around his treatment. The intervention strikingly altered themood and productivity the the session. After ~ a short expression the sympathyfor she position, he concentrated on her excessive distress end the physician"streatment. That attempted to explain the intensity of her reaction in state ofprojection: the she comment so strongly due to the fact that of her negative view ofherself.

Matters obtained worse as the session continued. Stella connected a 2nd negativeincident when she described her treatment by the medical professional in a grouptherapy session. The group therapist responded, "Well, friend manipulatedoctors!" Stella had been furious.

Christopher motivated her to say more. Stella became frustrated atChristopher"s lack of understanding and explained the again, she feeling shewas gift treated choose a "scumbag," this time by the team therapist.Christopher said that Stella can tell both the physician and thegroup therapist exactly how she felt. The tension in the session disappeared, andStella remarked that she has constantly had trouble sticking up because that herself.

In supervision, Christopher realized automatically 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 Statistical hand-operated of MentalDisorders, fourth Edition (American Psychiatric Association, 1994). When shewas between 6 and also 8 years old, Stella"s maternal grand sexually abusedher. Her parents divorced when she was 10, and also she lived with her mother,who was often drunk and also physically abusive. Stella stated she to be closer toher father, whom she defined as gentle. He showed up to others together weak andineffectual.

At age 15, Stella ran off with a boyfriend who was also her pimp. After ~ 2weeks she went back home, was unable to leaving her mother, and also was diagnosedas having actually agoraphobia, because that which she take it chlordiazepoxide (Librium). Twoyears later she ran away with one more man, a particularly sadistic pimp. For5 years she was as well terrified to leave him. The was during this duration thatshe started using cocaine.

The cocaine both "disclaims action" and also affirms her "badness." she cocaineuse enabled her come avoid evaluating why she remained with her boyfriend andsimultaneously affirmed she badness. So, she deserves her fate. She woulduse the cocaine to clear her painful feelings and feel "strong andindependent," climate "feel choose a large baby for having actually to usage the drugs." Shethought of herself together a "big baby," because that returning come her mommy at period 15and for being can not to leave her existing boyfriend. She reactions tococaine are typical; a quick surge or a "high," adhered to by a crash.However, these common reactions additionally fit her core theme: she desires to beloved and also cared for but believes she will certainly be thwarted and also exploited byothers therefore wish. Her response then is to use drugs, i beg your pardon makesher feel strong and independent because that a quick time and additionally makes she seeherself as deserving of gift thwarted and exploited, which has happenedrepeatedly in interpersonal contexts in her life.

Stella"s medicine use became a part of the treatment in 2 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 recognized the results of her medicine screen, i m sorry was component of the program.She therefore confessed prior to being challenged by drug display screen results. She claimthat the prescription to be legitimate promoted her denial the she hasanything to be pertained to about.

Second, Stella announced she intention to ask her medical professional for diazepam, acommonly abused medication. By contacting her physician, Christopherreplayed a usual scenario in her life: she signals the someone have to takecontrol or treatment for her, climate resents it as soon as they do, feeling that she isbeing treated favor a "scumbag medicine addict." She can produce the largelyillusory feeling of gift cared for when someone treats her together a helplessincompetent. Was this how Christopher was treating her as soon as he referred to as herphysician?

When Christopher argued that she call the physician and also the grouptherapist exactly how she felt about the means they had actually treated her, his words mayhave given advice, however his communication actually conveyed covenant withStella"s position that she had been unfairly treated.

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Stella proficient Christopher"s agreement and support v hisintervention. However, what can have made this a much more powerful therapeuticinteraction would have been either because that Christopher to straight acknowledgehis misgivings about having taken charge and contacted the doctor or toexplore how Stella concerned hear his early obliqueness as giving her whatshe wanted--his care and also support.