Chapter 23. Psychodynamics

 

PSYCHODYNAMICS: INTRODUCTION

Psychoanalysis and psychodynamic theory are fundamental to modern psychiatric practice,

including addiction treatment. Although some investigators have argued that psychodynamic

treatment has only a minor role in the treatment of substance abuse (Vaillant 1995), others have

shown how psychodynamic understanding can add depth to work with individuals and groups,

further the rehabilitation process (Dodes and Khantzian 2004; Frances et al. 1989; Khantzian

1997), and increase the usefulness of 12-step programs (Dodes 1988). As part of a transtheoretical

integrated treatment model, sophisticated understanding of psychodynamic principles can be used

by the therapist to help the addicted patient recognize that he or she has a problem and then to

identify what might provide effective motivation for that individual to change. This approach helps

patients in actualizing their wish to change by helping them move along the continuum from

contemplation of a problem, such as smoking, to contemplation of the need for change, to taking

action and then maintaining abstinence.

In this chapter, we develop a rationale for the application of psychodynamic concepts in addiction

treatment, examine their indications and contraindications, and explore how psychoanalytic theory

can be used to enhance standard treatment techniques and deepen understanding of addiction

treatment. Finally, we provide a psychodynamic approach to addiction that includes neurobiological

findings.

PSYCHODYNAMIC THEORIES OF ADDICTION

Classical and Early Psychoanalysis

Psychoanalytic understanding of addiction derives from general psychodynamic theory.

Psychodynamic treatment is based on Freud’s work in discovering the importance of unconscious

phenomena; the development of a theory of the relationship between id, ego, and superego, with

an emphasis on resistance, defenses, and conflict; and the use of techniques such as free

association, clarification, and interpretation. Freud (1905/1953), Abraham (1908/1960), and Radó

(1984) each posited trauma-related developmental issues—including orality, regression toward

infantile fixations, defenses against homosexuality, sexual and social inferiority, emotional

immaturity, depressive tendencies, and insecurity—as psychopathological pathways leading to

substance abuse (Lorand 1948). Freud (1930/1964) also connected the elation of intoxication,

which he believed relaxed superego repression, to manic states. Glover (1932/1956) noted the

important role of aggressive drives in substance abuse.

Modern Psychoanalysis and Psychodynamics

As the focus of psychoanalytic theory has moved from drives to developmental and structural

deficits and affective experience, psychoanalytic approaches to addictions have been redrawn as

well. A number of theorists have contributed important ideas on the role of ego defenses, defense

deficit, and affective experience in drug abuse and alcoholism.

Affective regulation has been a major area of interest among those studying the psychodynamics of

addiction. Krystal (1982–1983) emphasized a defective stimulus barrier resulting from early

psychic trauma and the attempt to use substances to fortify against the onslaught of overwhelming

affects. He described the inability of patients to label affects, which he called alexithymia, and the

inability of addicted individuals to verbalize affective states. McDougall (1984) focused on drug use

as a dispersion of affects into action. Lewis (1987) highlighted pathological shame, affecting one’s

core sense of self, as an affect associated with substance abuse. Dodes and Khantzian (2004)Print: Chapter 23. Psychodynamics

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emphasized the addicted individual’s sense of helplessness and powerlessness, often in the face of

intolerable affects, and the drive to restore through drug use a sense of power and control to which

the individual feels entitled. In this perspective, the goal of substance use is pharmacological

control or change of one’s affect state.

Addictions have also been explained in terms of fixation or delay of psychosexual development.

Krystal (1982–1983) described an inability in addicted individuals to take over the internal

maternal functions associated with care of the self. Bean-Bayog (1988) described the addiction

itself and the resultant loss of control as a sort of severe psychic trauma that leads to characteristic

defensive patterns. Wurmser (1984) and Meissner (1986) emphasized narcissistic collapse as a

cause of substance use: individuals use substances to compensate for a punctured grandiose or

idealized self. According to Wurmser (1984), feelings of emptiness, boredom, rage, shame,

depression, and guilt are symptoms of narcissistic wounds and superego regression, which prompt

substance use. He further characterized addiction as self-medication for claustrophobia, a feeling of

being trapped, with substance use becoming a means of escape. These authors stressed the

severity of psychopathology underlying drug dependence. Silber (1974) emphasized the alcoholic

individual’s pathological identification with destructive or psychotic parents.

Some authors have attempted to analyze the substance itself, framing alcohol as a fetish object

(Keller 1992), or have described alcohol abuse in terms of falling in love with the reward state of

intoxication (DuPont 1998).

Both object relations and self-psychology perspectives have been applied to addictions. Kohut and

Wolf (1978) considered substance problems as narcissistic behavior disorders in that the drugs

serve as substitute idealized selfobjects for selfobjects missing developmentally in addicted

individuals. Kernberg (1991) described addictive behavior as a reunion with a forgiving parent, an

activation of “all good” self-object images, and a gratification of instinctual needs. Kernberg (1991)

identified subsets of addicted individuals with malignant narcissism, which is associated with

strong antisocial features.

Although the questions of primary and secondary effects of alcoholism were originally raised by

Hippocrates more than 2,000 years ago, they were raised again in 1911, when Bleuler (1911/1921)

hypothesized that drinking was often the cause of neurotic disturbances and that clinicians should

not be taken in by the “stupid excuses” of heavy drinkers. Ferenczi (1912/1916) and Freud and

Ferenczi (1908–1914/1993), on the other hand, viewed alcoholism as an “escape into narcosis”

from underlying psychodynamic causes. The self-medication hypothesis originated from this theory.

The self-medication hypothesis has evolved over the past three decades and is based on

observations of patients with dual diagnoses. Theorists such as Wieder and Kaplan (1969), Milkman

and Frosch (1973), and Khantzian (1997) have discussed the importance of the specific effects of

particular drugs on affect and the choice of a particular substance on the basis of specific

sought-after effects. Khantzian (1997) highlighted this self-medication hypothesis in describing the

use of opioids to assuage end-point feelings of rage and aggression and the use of cocaine to

counter feelings of depressive anergic restlessness or to augment grandiosity. Alcohol has been

related to deep-seated fears of closeness, dependence, and intimacy, with the effects of alcohol

promoting the tolerance of loving or aggressive feelings.

Moving the self-medication hypothesis beyond strict psychiatric diagnoses and toward underlying

psychological states, Khantzian (1997) emphasized affect regulation, tolerance, self-regulation of

affect, self-esteem, need satisfaction, relationships, and self-care. He also related psychodynamic

concepts to the total care of addicted patients, providing a better understanding of how 12-step

programs are helpful. He described substance-abusing individuals as lacking an internal,

comforting sense of self-validation. These individuals also have difficulty obtaining nurturance and

validation from others in a consistent, mature way. Self-care relates to the individual’s

developmental inability to anticipate danger or to worry about or consider the consequences of his

or her actions, resulting in self-defeating and self-destructive behavior. Galanter (2002)

emphasized the value of self-help groups and religious and social networks in providing a calming,Print: Chapter 23. Psychodynamics

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soothing release of anxiety and a support for failing functions of the individual’s ego and superego.

Luborsky (1984) and Klerman et al. (1984) stressed the importance of clarifying the impact of

drugs on the addicted individual’s interpersonal relationships. Empirical research (using structured

instruments) has failed to demonstrate high levels of dissociation among previously traumatized

adults with substance use disorders, and the theory has been promoted that alcohol subsumes the

expected dissociation (Langeland et al. 2002).

APPLICATION OF PSYCHODYNAMICS TO TREATMENT

Applied psychodynamic theory must be distinguished from psychoanalysis. Whereas psychoanalysis

is a specific form of therapy, psychodynamic principles can be used to inform individual and group

therapies, rehabilitation, and other aspects of addiction treatment. Aspects of psychoanalysis as a

treatment include seeing an analyst four or five times per week, with the analyst providing

relatively little feedback, being quite neutral, and providing little reassurance in order to allow the

patient to experience frustration and have regressive fantasies. The patient lies on a couch to

facilitate regression and the therapist interprets the fantasies as they relate to the patient’s

childhood experiences. Psychoanalysis is not appropriate for most recovering addicted patients.

Psychodynamic psychotherapy (also referred to as insight-oriented psychotherapy) is a modified

form of such treatment: individual sessions usually occur one or two times per week, possibly in

addition to other modalities, and the patient sits up, facing the therapist. (Use of a couch is

generally avoided because it facilitates regression.) Abstinence from the addictive substance is

essential for successful treatment. Vigilant efforts at relapse prevention and helping patients get

back on track after relapse are very much part of psychodynamic psychotherapy with addicted

patients. Psychodynamic psychotherapy and 12-step mutual self-help programs are compatible

approaches for the maintenance of long-term abstinence.

Today, the focus of psychodynamic approaches tends to be on current conflicts as they relate to the

past rather than on dwelling on childhood experiences. Psychodynamic understanding takes into

account the patient’s childhood history; temperament; existing conflicts at the oral, anal, phallic, or

genital levels; development of defenses; and ego and superego development, including object

relations and relationships with parents, siblings, and friends (Khantzian 1997). With these

insights, the therapist can help the patient to identify what motivates him or her for change. The

therapist, aware of the patient’s characteristic defenses and particular ego weaknesses and

strengths, provides empathic interpretations and takes an active and supportive role. The

therapist–patient relationship is discussed openly in order to work through resistance, and no

effort is made to foster further regression. Psychodynamic techniques aimed at increased

self-awareness, growth, and the working through of conflicts can be combined with cognitive

approaches, case finding, relapse prevention, motivational techniques, suggestions, education, and

provision of support and reassurance as indicated. Utilizing a transtheoretical treatment model, the

therapist can help that particular patient to move along through the stages of change and recovery.

A real danger in the history of psychoanalysis has been a reductionism in which attempts are made

to apply one theory or approach to every situation. A broad and flexible use of psychodynamic

thinking takes into account the total range of structural issues, including id, ego, and superego;

developmental factors; conflict theory; self psychology; affect regulation; and cognitive deficits.

Perry et al. (1987) clarified how three psychodynamic theoretical models—self psychology; object

relations; and classical ego, id, and superego conflict theory—can be used to fit the metaphor that

is most useful to a particular patient or psychodynamic history.

INDICATIONS AND RATIONALE FOR PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic principles are applicable throughout psychiatry and are relevant to addiction

treatment. Insight-oriented therapy may be especially sought out by individuals for whom this kind

of approach represents a particularly good fit. Individual psychodynamic psychotherapy may be the

sole treatment or may be combined with group, family, psychopharmacological, self-help, and

cognitive-behavioral therapy, as well as other treatment approaches. Individual psychodynamicPrint: Chapter 23. Psychodynamics

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psychotherapy may be reserved for treatment-resistant cases, or it may be the treatment of choice

because of patient factors. Some patients refuse to participate in group or self-help programs and

seek out individual psychodynamic therapy because of a wish for privacy, confidentiality, and

insight. Patients with certain characteristics may especially seek out psychodynamic

psychotherapy; positive characteristics of such patients may include high intelligence, interest, and

insight; psychological mindedness; a wish to understand or find meaning in behavior; a capacity for

intimacy; identification with a therapist; ample time; ample funds; and a wish to change aspects of

self that are not acceptable. As with most forms of psychotherapy, positive prognostic indicators

are higher socioeconomic status, marital stability, less severe psychopathology, and minimal

sociopathy (Woody et al. 1986). Some relatively negative characteristics associated with other

treatments are social phobia, avoidance, and fears, which make attendance at Alcoholics

Anonymous (AA) and Narcotics Anonymous (NA) meetings difficult. Factors that may lead some

individuals to consider psychodynamic psychotherapy instead of other treatments include initial

reactions of distaste toward spirituality, as may occur in some atheists; strong negative reactions

to groups in general; unwillingness to take medication when indicated; and a lack of a rational

approach to the world (patients with such a lack might benefit from cognitive-behavioral

treatment).

Adolescents and young adults sorting out identity issues, problems regarding individuation, and a

need for independence may especially benefit from an insight-oriented approach. For patients in

whom denial, projection, splitting, and projective identifications are prominent defenses, consistent

interpretation of defenses may be needed to form a working alliance that can be used to achieve

sobriety and growth. Patients who continue to be anxious, depressed, and troubled after

detoxification are more likely to seek out additional psychotherapy. In many ways, patients who

benefit from psychodynamic psychotherapy and have abused substances are similar to those who

benefit from such therapy and have not abused substances. At the same time, however, many

patients who failed to respond to psychodynamic psychotherapy when they were drinking find that

they do benefit from this form of treatment when they are sober. Insight-oriented psychotherapy

may be used to achieve or maintain the benefits of abstinence and to prevent relapse.

Those affected by disasters such as the Oklahoma City bombing or the September 11 terrorist

attacks often turn to substances for relief of painful affects. Psychotherapy might prevent addiction

or relapse in vulnerable individuals. Alcohol and substance use can increase vulnerability to

posttraumatic stress disorder, and the disorder itself can increase alcohol and drug problems. In

one study, alcohol use was decreased among victims of the Oklahoma City bombing, and alcohol did

not alleviate symptoms but in fact increased functional impairment in these individuals

(Pfefferbaum and Doughty 2001).

Recovering addicted patients are often members of families with heavy addiction, and the danger

of relapse is greater among patients who have conflicts about enjoying and enhancing their

success. These patients may fear being more successful than an addicted parent or sibling, and

insight into the sources of self-defeating behavior can be essential to preventing relapse. In the

case of patients for whom self-care, self-destructiveness, suicidality, and masochism are major

issues, an awareness of unconscious forces of self-destructive behavior can be useful to both

patient and therapist. Many patients are not aware that their alcoholism may be what Menninger

(1938) called “a slow form of suicide.” Awareness of risk-taking aspects of behavior may lead the

patient to take greater caution. Addiction and suicide are long-term solutions to what are often

short-term problems, and the therapist’s job is to help the patient realize this.

The rationale for using psychodynamic principles is frequently based on an in-depth clinical

understanding of a particular patient’s life situation. There is good evidence that alcoholism is

influenced by genetic and environmental factors. Biological factors, such as the dopamine reward

pathways and the mesolimbic reward system, have also enhanced understanding of the brain basis

of addiction (Koob and Le Moal 1997; Kreek and Koob 1998; Leshner 1997; O’Brien 1997a, 1997b;

Volkow et al. 1997). Studies indicate that medications such as lithium and valproate may be

neurotrophic for patients with bipolar disorder, and it will be interesting to see which forms ofPrint: Chapter 23. Psychodynamics

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psychotherapy may also have neurotrophic effects (Manji et al. 2000). The study of temperament is

leading to intriguing implications for psychiatric treatment, including treatment of addictions

(Cloninger 1987). Psychodynamics are used to deepen the patient’s understanding of the

rehabilitation process and group psychotherapy and to help him or her understand how self-help

groups work (Frances et al. 1989). Awareness of the importance of an unconscious wish to return

to drinking, especially during periods of stress, is used in treatment. When unconscious factors

have repeatedly led to relapse, exploratory psychotherapy may be particularly useful (Dodes and

Khantzian 2004). For example, a patient’s association of a “lost weekend,” a drunk dream, or a

planned vacation to a location where relapses frequently occurred in the past may be a warning

sign of a possible relapse and can be used to help the patient to recognize that a craving still exists

and should be addressed.

An awareness of reasons not to drink and the strengthening of that side of the patient’s internal

conflict may help, along with increased insight into the sources of the internal struggle. The

greatest focus of attention has been on how substances may be used to self-medicate for other

psychiatric disorders or to self-regulate affect, and how their use may be a symptom of an

underlying problem (Khantzian 1997). Abused substances may be used to push painful thoughts

from one’s consciousness and to numb feelings associated with painful knowledge, or they may be

used to gain access to unconscious material and to facilitate the experience or expression of anger

and other feelings that may be avoided during sobriety.

For patients for whom affect regulation is an issue, psychodynamic psychotherapy may be

especially valuable. A patient with an underlying dysthymia, depression, or affective disorder may

need to understand how he or she has used substances to cope with unmanageable feelings. Given

that alcohol or drugs invariably cause additional life difficulties, psychodynamic approaches may

help the patient deal with the psychosocial effects associated with the toxic metabolic

complications of substance use. The application of psychodynamic theory to the treatment of

comorbid psychiatric problems such as Axis II personality disorders (including borderline,

narcissistic, and avoidant personality disorders) is important, especially because alcoholism and

drug abuse are overrepresented in these patients. The literature on comorbidity of Axis I and Axis

II disorders is extensive, and a presentation of findings is beyond the scope of this chapter (for

further discussion, see Kessler et al. 1997). It may be especially hard to identify the boundaries of

temperament, acute substance-induced personality change, other Axis I disorders, secondary

personality features, and independent personality disorders. Exploratory psychotherapy with

patients with borderline personality disorder who have a history of addiction must be informed by a

good knowledge of addiction psychiatry and an emphasis on structure and limit setting in

treatment, including the vital parameter of abstinence.

Kernberg (1991) discussed the deception and projection often seen in the initial therapeutic

alliance with patients with borderline or narcissistic personality disorder, as well as the need to

confront distorted views of reality in the therapeutic relationship. The use of insight in interpreting

negative transference and acting out may deepen a positive transference and ultimately foster

open expression. As a patient develops a clearer picture of his or her life through exploratory

psychotherapy, the value of openness and honesty becomes apparent, and the tie to the therapist is

cemented. Frequently, addicted patients have lied to themselves and others and are tired of feeling

false and phony. The therapist’s healthy ability to tolerate being conned by highly skilled,

manipulative patients may minimize damaging countertransference reactions. If the therapist finds

himself or herself doing something with a patient (either positive or negative) that is out of the

ordinary, some examination of countertransference is always warranted.

Early in treatment, it may be hard to tell whether a personality change is resulting from a gradual

return to better function because of physical, social, and psychological recovery from addiction

effects; whether the initial diagnosis of personality disorder was correct; or whether

psychodynamic therapy and/or 12-step programs have effected personality change. Some patients

experience a rebound high that is analogous to the practicing subphase of development in the

second year of life, when there is a burst of autonomous development (Mahler et al. 1975).Print: Chapter 23. Psychodynamics

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Many addicted patients who have narcissistic traits or personality disorder, and in whom the toxic

effects of addiction heighten narcissism, feel a sense of specialness and entitlement, have no

empathy for others, are unable to allow themselves gratification of dependence needs, and

experience loneliness. For these patients, rehabilitation often involves acceptance of vulnerability

and of being ordinary and similar to others with the same problem; a reaching out for help; and

encouragement to develop a new humility. Whether this rehabilitation is achieved through 12-step

programs, application of Beck’s cognitive therapy (A. T. Beck et al. 1993; J. S. Beck et al. 2004), or

psychodynamic exploration of the narcissistic vulnerability, these issues should be dealt with in this

substantial subpopulation.

Dodes (1996) suggested that addictions are in the same category as compulsions, and because

compulsions have been seen as treatable with traditional psychodynamic psychotherapy, addictions

should also be treatable by similar approaches. Evidence indicates that alcohol problems can either

cause or result from anxiety disorders and that more often than not, agoraphobia, social phobia,

and obsessive-compulsive disorder precede rather than follow an alcohol problem (Kushner et al.

1990). Although cognitive-behavioral and pharmacological approaches may be first-line treatments

for panic disorder, agoraphobia, and social phobia, psychodynamic approaches are often used with

patients whose conditions have been resistant to, or have only partially responded to, other

psychotherapies and medications (Frances and Borg 1993).

CONTRAINDICATIONS FOR PSYCHODYNAMIC PSYCHOTHERAPY

Contraindications for psychodynamic psychotherapy include active use of substances, severe

organicity, psychosis, and, for the most part, antisocial personality disorder. Some patients who

regress too readily in individual therapy, who develop psychotic transferences, or who develop

negative therapeutic reactions benefit from the diffusion of transference that takes place in group

therapy. If the principal problem is marital, family therapy is the treatment of choice.

INITIATION OF TREATMENT

Some authors recommend waiting 6 months to 1 year before beginning psychodynamic

psychotherapy with a patient (Bean-Bayog 1988). We believe that psychodynamic treatment can be

initiated early; however, timing should be tailored to the patient. The greatest opportunity to

develop a treatment alliance is often early, while the patient is in crisis. Supportive elements, such

as confrontation, clarification, support of defenses, and building on ego strengths, may be more

prominent early in treatment. The therapist should also take into account state-related problems of

organicity, physical illness, and affective vulnerability, all of which can lead to an inability to utilize

interpretations. In their work on initiating treatment, Prochaska et al. (1992) discussed the stages

in which patients develop awareness of their addiction problems. Focusing on motivational aspects

of treatment and confronting denial of a need for help are essential elements in initiating

treatment. Promoting identification as a recovering person can boost self-esteem and provide

stability.

The psychodynamic psychotherapist needs to consider the effects of intoxication and withdrawal

and the chronic organic effects of alcohol. However, during intoxication or withdrawal, there are

patients for whom psychodynamic interpretations are indicated from the very outset of treatment,

regardless of the stage of addiction. Interpretations may help the patient work through resistances

to accepting help. They may also provide a meaningful explanation for destructive patterns, one

that can inspire a wish for change.

Timing of interpretations is crucial. A patient who may need to project blame and responsibility for

his or her actions onto substances early in recovery may later be able to accept responsibility for

those actions. For example, one patient admitted later in treatment that having an affair,

embezzling money, and being abusive were things he wanted to do anyway and that he used

alcohol and cocaine abuse as an excuse. The individual may not be ready to take full responsibility

for his or her actions early in abstinence, but over time, these issues can be explored and pointed

out, denial can be worked through, and acceptance of responsibility can be achieved. Defenses may

need to be supported at first, including denial of affect related to some of the losses. InterpretingPrint: Chapter 23. Psychodynamics

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those defenses may be most effective when the patient is facing life challenges that offer a

particular motivation for change. Consider, for example, the 67-year-old man who utilized the

defenses of denial and displacement to avoid the grief he felt at how he had sabotaged his

relationship with his children throughout their lives. When presented with the opportunity for a

relationship with his grandchildren, he was more able to face his desperate wish to win back

respect and love from his family.

Confrontation should concentrate initially on denial surrounding addictive behaviors. Clarification,

confrontation, and interpretation of denial, lying, splitting, and projective defenses in other areas

ultimately need to be expanded. However, in selected cases, with repeated treatment failure, an

initial intervention may require active, across-the-board confrontation and interpretation of

inconsistencies and denial in order to help the patient accept a need for change. In patients with

alexithymia or constricted affect, interpretations are aimed at increasing the patient’s awareness of

feeling states and helping him or her connect thoughts and feelings without the use of substances.

SESSION FREQUENCY, SETTING, AND GOALS

Psychodynamic psychotherapy with alcoholic patients is usually conducted one to two times per

week, is often combined with group psychotherapy, and includes a parameter of abstinence and a

long-term goal of sobriety. It can be done during an inpatient stay or in an organized outpatient or

office practice, and it can be time limited and focused or long-term. It is foolhardy for

psychotherapists to promise that once underlying causes of a “symptom of drinking” are dealt with,

the patient will be able to return to controlled drinking. Similarly, it is unwise to promise that once

a patient is fully treated with psychoanalytically oriented psychotherapy, he or she will never need

additional help through 12-step programs or additional psychotherapy. A treatment model that

integrates multiple modalities is most likely to facilitate real change. For most alcoholic individuals,

shifting from dependence on a chemical such as alcohol to dependence on a therapist, group, or

spiritual belief or involvement with anything human is a major step in the direction of growth.

Although issues of dependence may be worked through partially, an ongoing positive identification

with a therapist, a sponsor, and/or recovering friends may be a major positive outcome of

treatment. Active dialogue with the patient and an attitude of empathic concern and sharing on the

part of the therapist are optimal. Issues of termination of individual therapy or graduation from

phases of treatment may bring earlier conflicts back to the surface and trigger relapse. The goal of

psychodynamic treatment for addicted patients is to help them maintain abstinence, provide them

with a richer understanding of and control of their inner lives, and reduce psychological triggers for

relapse. Achieving this goal helps improve patient self-esteem, self-care, and affect regulation

(Khantzian 1997).

GENERAL TECHNICAL ASPECTS OF TREATMENT

Advances in object relations theory, ego psychology, and modern psychodynamic understanding of

conflicts and affect regulation can be applied to addiction treatment. Psychodynamic principles are

applied in conjunction with an understanding of the clinical exigencies of addiction treatment.

Techniques need to be modified, especially those related to attaining and sustaining abstinence,

and the effects of regression should be monitored carefully. However, well-established techniques

and principles of brief and long-term psychodynamic treatment are generally maintained. The

therapist listens for themes relating to the patient’s intrapsychic conflicts, developmental

impairments, and defenses, paying special attention to how they may relate to substance abuse

and relapse potential.

The therapist has some important objectives: to obtain a careful developmental history of the

patient, with attention to achievement of milestones of ego development; to evaluate temperament

in the patient and significant caretakers; to examine the patient’s capacity to identify with and to

separate from important figures of identification, including parents, siblings, and admired peers;

and to explore the patient’s affect regulation, especially in relation to substance use. The

therapist’s tools include free association, “slips,” and dreams, which are examined to find meaning

in the unconscious derivatives of behavior (such as an unconscious wish to drink, expressed in aPrint: Chapter 23. Psychodynamics

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dream about being drunk). For example, a 45-year-old male patient described an ambivalent

relationship with his father, who had failed in business and was devalued by the patient’s

overbearing mother. The patient expressed loving and sad feelings for his father. He had developed

a pattern of sabotaging his own potential for success with alcoholic relapses. During an extended

period of sobriety, he began to dream that he had killed his father and was drinking at his father’s

funeral. The interpretation of this dream helped the patient to begin to examine his unconscious

need to fail so that he would not surpass his father, as well as suppressed rage at his father for his

helplessness.

Treatment Parameters

Treatment parameters for patients with addictions, such as structure, clear boundaries, and

abstinence, are similar to those used effectively in treating borderline personality disorder.

Structure and boundaries help the patient reestablish control and self-regulation and help him or

her express feelings verbally rather than by acting them out. The conventional practice of

psychodynamic psychotherapy with limit setting is generally helpful, although on rare occasions a

more active approach may be needed. For example, a therapist may need to mobilize a family to

bring a suicidal alcoholic patient to the emergency room or to the physician’s office after a relapse.

While the therapist works through the patient’s resistance and defenses, he or she should be aware

of how alcohol provides the patient with an escape, can numb or facilitate expression, and can

itself alter defensive operations, especially in terms of heightening denial. The therapist should

watch closely the interplay of ego function, feeling states, and chemical effects in the patient.

Most therapists in the addiction field believe that abstinence is necessary for psychotherapy to be

effective. Many think it is best to first develop a solid relationship with the patient and then aim for

gradual achievement of abstinence (Dodes and Khantzian 2004). We believe that although

flexibility is often needed for patients with severe psychiatric illness, psychiatric problems for the

most part must be treated in synchrony with the addiction disorder, and abstinence is vital to this

approach. Unfortunately, sometimes continuation of psychodynamic psychotherapy can enable the

addicted patient to continue substance use. Psychodynamic psychotherapy can also raise conflicts

that may lead to worsening of the addiction, and thus the treatment can be contraindicated. The

following case illustrates such a situation:

A 37-year-old successful journalist was in psychoanalysis 5 days per week for a severe alcohol addiction.

He frequently arrived at sessions intoxicated or missed them altogether. During years of analysis, his

addiction to alcohol progressed. His family tried to convince him to see an addiction psychiatrist. He

protested that he had a good relationship with his analyst, thought that he was being helped, and used

this as a rationale to avoid effective treatment.

This patient achieved poor results in treatment because his psychoanalyst was not knowledgeable

about addictions and was adhering to a technique that was wrong for the patient. The issue of

abstinence was crucial here, but it was ignored.

Other Treatment Tools

A combination of psychodynamic approaches, such as clarification, interpretation, and genetic

reconstruction, may be used along with directive approaches, such as assertiveness training, social

skills training, self-efficacy groups, modeling, positive reinforcement, cognitive awareness, and

suggestion. A sophisticated familiarity with typical problems that occur in alcoholic or drug-abusing

individuals and their families and the use of psychoeducation about these issues help the therapist

establish a positive alliance with his or her patient. The literature on adult children of alcoholic

patients can aid the therapist’s understanding and be used in educating patients and their families.

The following case illustrates the use of combined approaches:

A 42-year-old recovering alcoholic woman with panic attacks and agoraphobia had special problems

when flying. Psychodynamic psychotherapy was useful when added to desensitization, relaxation therapy,Print: Chapter 23. Psychodynamics

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exposure to flying, and closely monitored medication for panic attacks (paroxetine and benzodiazepines

taken 2 hours before airplane trips). The anxiety persisted at a significant level, frequently interfering

with the patient’s plans. Her fears of flying were related to childhood conflicts about having to take

planes to visit her father after her parents divorced. She was the “apple of her father’s eye” and had

clearly won out over her mother, although she had considerable guilt over her especially favored

position. Her oedipal guilt persisted, contributing to difficulty in reaching orgasm with her husband and

feelings of guilt about enjoying her sexuality. At the time of treatment, the flights she feared most were

those related to visits with her father and those involved in pleasure trips with her husband. Although

none of the treatments totally allayed her fears, she was able to travel without drinking and was better

able to understand and cope with her fears of flying, having gained enhanced insight into the roots of her

fears. She was increasingly allowing herself to enjoy gradual steps toward success without relapsing (see

Ballenger 1999 for a discussion of anxiety disorder treatments).

INITIAL FOCUS AND PHASES OF TREATMENT

The phases of intervention include initial screening, evaluation and intervention, rehabilitation, and

aftercare. The initial focus is often on conflicts related to the acceptance of addiction as a problem,

the patient’s reluctance to acknowledge dependence and the need for treatment, and conflicts

resulting from the complications of alcoholism (including the loss of relationships, health, and jobs)

and from missing alcohol itself. As emphasized above in “Treatment Parameters,” the first goal is

abstinence. More often than is usually the case in insight-oriented psychotherapy, the patient may

initially be forced into the consultation by an employer, probation officer, family member, or

physician. Especially when coercion has occurred, the therapist must make a considerable effort to

develop trust and a working alliance with the patient. This is achieved through careful review of the

patient’s history and the ways in which addiction has interfered with work, family relationships,

and other relationships or has caused legal problems, all of which have contributed to pain and the

need to escape it. The therapist’s integrity, adherence to confidentiality, and ability to be helpful all

contribute to the establishment of trust.

The patient is helped to accept a diagnosis and to accept the need for help, which may lead to

positive transference. These steps are similar to the first two AA steps, in which patients admit

their powerlessness over alcohol and accept their need for help or acknowledge their own

dependence needs, which in AA is called “accepting a higher power.” A psychodynamic perspective

may aid in the confrontation of denial and other defenses, and through interpretations patients

achieve a deeper understanding of certain destructive patterns that have led to the present

problem. It is especially challenging to help the patient acknowledge dependence needs that have

been channeled into the addiction.

Therapy is a process in which a need for substances is shifted back into a need for people, including

the therapist. Patients who abuse drugs often refuse to take medications because of fears of using

them in compulsive ways, becoming dependent on drugs for relief, and becoming dependent on the

therapist to obtain the medications. From early in treatment, issues of trust, dependence,

separation, loss, disappointment, and truthfulness are frequent themes. In the later stages, the

focus of exploratory psychotherapy should not be imposed from the outside—that is, it should not

be based on purely theoretical considerations. Rather, the focus should be on the most pressing

issue of the moment that may relate to the patient’s drinking: a particular conflict; a relationship

with a family member or employer; a problem with self-esteem, self-destructiveness, or

self-medication for panic; or other painful affects.

Other major themes include specific conflicts over assertiveness, handling of aggression, and

issues of control and inhibition. The disinhibiting role of addiction, leading to risk-taking behavior

(including increased sexual activity), may be an issue. Alternatively, alcohol may play a role in

distancing the individual from sexual life, or drinking may substitute for sexual activity.

RELAPSE

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useful, and meeting with family and other sources of collateral information may be essential in

order to get a true picture before confronting patients who dissimulate. As mentioned earlier in

“Indications and Rationale for Psychodynamic Psychotherapy,” psychodynamic therapy can help in

relapse prevention. Consider the following case:

A 47-year-old pediatric surgical nurse frequently relapsed in her addiction to diazepam on evenings after

she had had to deal with families of children with disastrous surgical results. As a child, she had been

traumatized by a younger sister’s postoperative death due to a brain tumor. Her parents had tried to

protect her by never discussing her sister’s death, and she had always found this to be strange. Her

relapses were triggered by unresolved conflicts and grief regarding her dead sister, whom she envied,

loved, and, at self-destructive moments, wished to join in death. Her initial treatment plan involved

detoxification, support, and an aim of abstinence. However, the effectiveness of relapse prevention was

enhanced by psychodynamic treatment that helped her mourn her sister and eliminate an important

trigger for relapse.

ACCEPTANCE OF SELF IN RECOVERY

An important part of recovery is a change in self-awareness and self-perception. An enormous shift

for the patient is the acceptance of a diagnosis of alcoholism as an illness. This entails not only

shifting from a moral model (in which the patient sees himself or herself as weak, shameful, and

bad for being alcoholic) but also being aware that a problem exists about which a great deal is

known, that the problem is treatable, and that it does not have to lead to hopelessness and despair.

Sometimes this awareness leads to reaction formation, in which the patient feels grateful for being

alcoholic and turns a disability into an advantage. There may have been real advantages in terms of

broadening of experience, overcoming a vulnerability, and developing a pride that can occur in any

group that finds a way to overcome a stigma. The patient’s feeling of relief after he or she is no

longer experiencing the consequences of alcoholism and addiction often leads to a rebound after

initial abstinence—a rebound that can approach euphoria. This euphoria is often followed by a

letdown when awareness of the multitude of problems that the addiction caused occurs.

AN EGO PSYCHOLOGICAL MODEL OF REHABILITATION

Assessment of ego function needs to include a search for strengths, talents, and positive qualities

that can be used to help the patient. All too often, therapists miss opportunities to enhance

self-esteem in patients whose self-criticism leads them to overlook real and potential opportunities

for growth. One way to combine positive insight with support is to help patients recall periods in

which their values were in place and to give them hope for a return to a higher level of function.

Even very damaged, impaired individuals from deprived and disadvantaged backgrounds have

dreams in their lives that they have buried. Rekindled dreams can foster renewed hope and

improve self-esteem. The stigma of the illness can also be lessened by discussing positive role

models, such as Betty Ford, who have struggled with the same illness and have worked hard at

recovery. An ego psychological model can be applied to the biopsychosocial effects of addiction and

to rehabilitation. Chemicals and psychosocial consequences have effects and may lead to

regression and impairment of defenses, object relatedness, judgment, reality testing, and

superego. It may take time and practice for good ego and superego function to return. The

following case demonstrates recovery of function:

A 47-year-old narcissistic man who had drunk heavily for 25 years had disuse atrophy of ego functions

and was pushed to function better as part of rehabilitation. He thought of his wife only in terms of what

she could do for him, as a part object or a need-satisfying object, and only with practice and with time

sober could he relate to her in a more complex way as having needs of her own. He would idealize or

devalue everyone and everything, and it took him a long time to relate to others as having both good

and bad qualities. To develop friendships and break isolation, he had to practice relatedness in individual

therapy, couples therapy, group therapy, and self-help groups.

In this case, the superego had been dissolved in chemicals for years, and it took external structure

and parameters to gradually awaken the sleeping policeman within—that is, for the superego toPrint: Chapter 23. Psychodynamics

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start working again. The program requirements and the external norms of the groups helped him

regain structure. His superego was initially inconsistent and vacillated from a lack of restraint and

self-indulgence to a primitive punitive masochistic rigidity. Cognitive impairment, especially in the

nondominant hemisphere functions of spatial and temporal relationships, was present and

improved over time with abstinence.

The defenses initially encountered in treatment are usually the most primitive and include denial,

rationalization, splitting, projection, and projective identification. With time and treatment,

higher-level defenses such as intellectualization, reaction formation, repression, and sublimation

may be more in the forefront. For example, instead of denying alcoholism and projecting poor

self-esteem, a patient may feel grateful to have alcoholism and honored to be part of a group that

initially was perceived as stigmatizing. Denial of alcohol’s harmful effects on the liver, which can be

addressed through psychoeducation, can be replaced with curiosity and intellectualization about

how liver damage occurs. Use of reaction formation may also lead to noncompliance with

psychiatric and other prescribed medications, with the rationale that they could have unknown

negative effects on liver and other organ functions. Denial of losses related to addiction may be

replaced with repression over time, after grieving over the losses has occurred.

APPLICATIONS OF PSYCHODYNAMICS TO GROUPS AND SELF-HELP

The addition of group psychotherapy, AA, or NA is especially needed when individual therapy alone

is not helping the patient maintain abstinence. Group treatments help diffuse some of the powerful

negative transference that may be impossible to overcome early in treatment. Groups can focus on

self-care, self-esteem, affect regulation, sharing, and exposure to feared social situations. They can

provide social support and models for identification and coping skills, and they can help patients

work through family problems. Groups can be targeted to specific additional diagnoses such as

anxiety disorders or to specific subpopulations such as persons with chronic mental illness, those

with medical complications, women, and adolescents. Groups can be homogeneous (e.g.,

recovering physicians with anxiety disorders) or heterogeneous (e.g., all patients in a

detoxification unit). Khantzian (1997) described a model of modified psychodynamic group therapy

for substance-abusing patients involving self-care, self-esteem, and affect regulation. Together the

patient and the individual therapist can look at how the patient projects feelings toward other AA,

NA, or group members who, for example, remind the patient of his or her alcoholic relatives.

Character flaws can be actively worked on, with immediate and multiple feedback from group

members. If the individual therapist is also the group therapist, the individual work may be used to

encourage the patient to try a new behavior in the group; conversely, conflicts observed in the

group can be worked on individually.

Aspects of 12-step programs may readily lend themselves to integration with psychodynamic

treatment. These aspects include accepting a diagnosis, accepting dependence needs, being aware

that one cannot control drinking alone, taking a personal inventory (often discussed in terms of a

higher power), working at change, dealing with sobriety one day at a time, accepting the structure

of a treatment program, and enhancing self-esteem by helping others with the problem, thus living

up to an ego ideal. The 12-step programs provide education, auxiliary ego and superego support,

and powerful role models for positive identification. Steps in AA that involve taking a personal

inventory and making amends can be used in conjunction with the psychotherapeutic process of

self-exploration and insight aimed at behavioral change. The addition of AA is especially helpful

during periods of relapse and during periods when the therapist is unavailable because either the

patient or the therapist is away. Because alcoholism and drug abuse are often chronic relapsing

illnesses, both the patient and the therapist must be prepared for the possibility of a relapse. The

therapist should be both nonjudgmental and unafraid of confrontation.

THE PATIENT–THERAPIST RELATIONSHIP

Many problems related to working with addicted patients concern the challenge of establishing a

positive therapeutic relationship between the patient and the therapist. Frequently, errors in

treatment occur because of negative feelings and attitudes that therapists have toward addictedPrint: Chapter 23. Psychodynamics

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patients. Typical mistakes include providing inadequate empathy or overly identifying with

patients. A major source of countertransference is the uncritical acceptance by a clinician of roles

projected onto him or her in the patient’s transference. In many cases, an understanding of the

patient’s specific transference that may either evoke countertransference problems or prevent

compliance with treatment may be essential for good management and a successful alliance with

the patient. Typical transference may result from growing up in a household in which the parents

were addicted, inconsistent, and either overly harsh or indulgent. Children of alcoholic parents

frequently have authority problems and will often trust siblings, peers, and other alcoholic

individuals more readily than they will trust teachers, nurses, doctors, or police. When a patient

describes a therapist as cold, neglectful, uninvolved, or detached, this may be transference to a

parent who fits this description and may lead the therapist to unconsciously behave in this way. It

is helpful for the therapist to be able to interpret negative transference and to know how to

manage and appropriately use therapist’s countertransference.

Alcoholic patients frequently will try to evoke feelings of fear, anger, and despair in their therapists

and will reenact relationships with alcoholic parents, siblings, and spouses through the

transference. They may project critical attitudes onto the therapist and keep secrets out of fear that

the therapist will respond like a parent. When the patient feels that the therapist is like a parent,

sibling, or friend, this feeling may have been evoked for specific reasons. The greater the

therapist’s awareness of what is happening, the more this issue can be brought into the treatment

in a constructive way.

A second major source of countertransference in treating addicted patients is a therapist’s weak

knowledge base about addiction and its treatment. The more knowledgeable the therapist is about

addiction psychiatry and about the patient, the less likely the therapist is to project his or her own

problems onto the patient. Attitudinal problems on the part of the therapist can be reduced by good

training and the experience of having worked through issues related to stigma. The more the

therapist is in command of a treatment armamentarium, the less frightened he or she is in the face

of what can be a dreadful disease. Ultimately, patients are the best teachers. By listening carefully,

the therapist can learn about the addictive experience, addictive practices, and the street language

of addiction.

A third source of countertransference is based on a therapist’s mostly unconscious transference,

related to his or her past or present problems. Transference may relate to the therapist’s attitudes

about substances; present or past problems with addiction; or experience with a parent, spouse, or

child with a substance use problem. The therapist’s own envy, fear, hopes, and needs can adversely

affect his or her prescribing practices and lead to overinvolvement, avoidance, hopelessness,

jealousy, and burnout. Some clinicians who have chosen to work in the addiction field because of

their wish to overcome personal problems related to addictions may have special difficulty dealing

with patients’ problems if they have not worked out their own. Frequent mistakes include excessive

self-revelation of personal problems and a tendency not to see the specifics of patients’ problems

clearly because of a need to see everyone as similar to the self. A recovering clinician might

consider a patient’s problem minor compared with his or her own. Alternatively, some clinicians see

every problem only in relation to addictive problems. This results in misdiagnosis and

overdiagnosis. One extreme of overinvolvement is sexual or aggressive acting out with a vulnerable

substance-abusing patient; this has disastrous consequences for both patient and therapist.

Seeking out second opinions from or supervision by experienced practitioners is advisable when

working with difficult patients. Thorough self-exploration by the therapist in personal therapy also

helps. Clinicians with maturity, a good support system, and a secure personal life are better

protected against countertransference problems. Additional protection is given by working in a

team: team members can point out one another’s blind spots and assist in improving one another’s

technique. Feedback from patients and their families can be another means of supervision for the

clinician who listens carefully. A wise clinician admits his or her mistakes, learns from them, and

tries to avoid future mistakes (Committee on Alcoholism and Addictions 1998).Print: Chapter 23. Psychodynamics

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MYTHS AND PITFALLS TO AVOID IN PSYCHODYNAMIC PSYCHOTHERAPY

Clinical experience suggests that there are common misperceptions (myths) about the role of

psychotherapy in treating addictions that can negatively affect treatment planning. There are also

avoidable problems (pitfalls) that may arise in psychotherapies by even the most seasoned and

well-meaning therapists. The following lists cannot be comprehensive, but they address some of

the most frequent and relevant myths and pitfalls in psychodynamic psychotherapies with patients

who have addictions.

Myths

One can first develop a therapeutic relationship and then gradually wean the patient off substances.

Substance use will disappear with understanding.

Once conflicts have been resolved, the patient can safely return to drinking.

If the problem is narcotic addiction, alcohol is safer and legal.

Addiction is always a symptom, not a primary problem.

Use of motivational interviewing, cognitive-behavioral techniques, group therapy, and 12-step

programs cannot be integrated with insight-oriented therapy.

Pitfalls

The therapist believes the patient’s explanation for drinking, without awareness of rationalization and a

patient’s need to justify his or her behavior.

The therapist does not check out the patient’s story.

The therapist conducts treatment as if psychodynamic interpretations were “golden” and other

interventions less valuable. Treatment approaches and sequence should be selected on the basis of the

patient’s needs.

The therapist does not have a healthy respect for the patient’s dependence needs and has too-high

expectations for resolving these needs. It is better for the patient to depend on therapists or on AA

than on substances, and an endless relationship with AA is a desirable goal—not a compromise of a

therapist’s goal of self-reliance on the patient’s part.

The therapist is overinvolved or overly distant. Therapists in recovery themselves sometimes have

blind spots or may share with the patient more than the patient needs to know.

The therapist has a bias toward one or another form of treatment and lacks theoretical and practical

flexibility. Even moderate biases of this type can be a disservice to the patient.

TREATMENT OUTCOME RESEARCH

The state of the art in addiction treatment involves being aware of the results of treatment

outcome studies but also selecting a combination of treatments that takes into account current

knowledge and patient characteristics. Treatment recommendations depend on a wide range of

considerations, and trial results are only one factor. The American Psychiatric Association (1995)

developed practice guidelines for the treatment of substance use disorders based on reviews of the

literature on treatment and outcomes. These guidelines recommend individualizing treatment

planning and include treatment of comorbid conditions.

Woody et al. (1986) showed meaningful differences in efficacy between supportive-expressive

psychotherapy and drug counseling in patients receiving methadone maintenance treatment.

Carroll et al. (1994) pointed out that there is a delayed emergence of effects of psychotherapy after

cessation of short-term treatments in cocaine-dependent patients. O’Malley et al. (1996) compared

psychotherapy with or without naltrexone therapy in alcoholic patients and found that the

combined treatment had favorable results.

With managed care entering the arena of health care, studies of cost-effectiveness and outcomes

are becoming increasingly important. Humphreys and Moos (1996) found reduced

substance-related health care costs in a study involving veterans participating in AA. O’Brien

(1997a) found favorable efficacy when comparing specific treatment approaches for addictive

disorders with other chronic disorders such as diabetes and asthma. O’Brien (1997b) also pointedPrint: Chapter 23. Psychodynamics

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to studies that have shown a cost saving of $4–$12 for every dollar spent on substance abuse

treatment.

It is too early in addiction outcome research to make hard-and-fast recommendations regarding

treatments to be used. Treatment guidelines and the treatment outcome studies discussed in this

volume provide useful information but are not definitive instructions to clinicians. Although

clinicians agree on some points (e.g., the usefulness of abstinence as a goal, pharmacological

treatment of comorbid disorders such as panic attacks, the value of adding education and cognitive

and behavioral approaches), the value of 12-step programs and psychodynamic psychotherapy has

not been strongly proved in controlled studies, although each treatment has a commonsense

rationale. Where definite answers are still lacking, clinicians need to be aware of a growing

literature of outcome study findings, of the methodological problems involved in conducting good

studies, and of the problems in reliability and validity in applying these results. Uncertainties about

the exact value of psychodynamic and combined treatments should not deter clinicians from using

what has seemed useful, especially with patients who have specific favorable characteristics such

as motivation and capacity for insight and who have destructive patterns amenable to

interpretation. When definitive conclusions about the effectiveness of treatment components have

been drawn, targeting of treatment will improve.

NEUROBIOLOGY

Psychodynamics integrated with neurobiological models of addiction provide a deeper

understanding of the patient and the factors that may help a particular patient to change. From a

neurobiological perspective, psychotherapy can be understood as a controlled form of learning that

occurs in the context of a therapeutic relationship (Etkin et al. 2005). And research into the

plasticity of the brain has shown that once genes are activated by cellular developmental

processes, the rate at which those genes are expressed is highly regulated by environmental

signals (Gabbard 2000). The interplay of psychotherapy, abstinence, and pharmacotherapy in the

treatment of addictions can be understood now more than ever as a learning process that may

produce alterations of gene expression and thereby alter the strength of synaptic connections.

Researchers have made great advances in recent years toward clarifying the biological factors that

appear to modulate both the predisposition to addiction to illicit drugs and the risk for relapse. The

neurobiology of pleasure and reward circuitry in the limbic system, which modulates the effects of

substances of abuse and is fundamental to the process of addiction, involves dopaminergic and

endogenous morphinergic signaling (Esch and Stefano 2004). Ongoing research explores genetic

polymorphisms in these neuroendocrine pathways, including the mesolimbic system and the

ventral tegmental area (Kreek 2000). The acute and chronic reinforcing effects of drug addiction

lead to long-lasting neurobiological changes in the brain that undermine voluntary control (Volkow

and Li 2004). Research into the positive and the negative reinforcing effects of drugs of abuse has

demonstrated how the processes recruit numerous neurotransmitter systems, including dopamine,

opioid peptides, serotonin, -aminobutyric acid (GABA), and glutamate- and corticotropin-releasing

factor; the overall effect is a change in set point for drug reward that may represent prolonged

functional dysregulation affecting vulnerability to relapse (Koob 2000).

There is a growing body of evidence, particularly as demonstrated by neuroimaging studies, that

psychotherapy influences biological activity in the brain. Although the evidence to date is limited,

studies of basal brain metabolism and blood flow as well as studies of stimulus-response imaging

have demonstrated that psychotherapy produces changes in the brains of patients who have been

diagnosed with anxiety and mood disorders; some of these changes may be shared with those

induced by pharmacotherapy and others may be modality specific (Etkin et al. 2005). Recent

research into the neural bases of nondeclarative memory suggests how psychotherapy may work in

the brain to modify pathological thought and behavior patterns by helping the brain to forget these

patterns on a synaptic and molecular level. Long-term modifications of synaptic transmissions that

underlie maladaptive memory trace encodings and present as compulsions, addictions, or anxiety,

may be affected by two effects of psychotherapy: inhibition of memoryPrint: Chapter 23. Psychodynamics

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consolidation/reconsolidation and extinction. Modification of implicit memory occurs both through

reversing the plasticity associated with memory maintenance and through protein

synthesis–dependent synaptic remodeling (Centonze et al. 2005).

Psychological factors and a psychodynamic perspective clearly must be integrated with current

scientific understanding of brain mechanisms in relation to the etiology and treatment of

addictions. Further knowledge about the biology of conscious and unconscious processes will

advance psychoanalytic understanding (Leshner 1997). Greater understanding of the process and

psychology of addiction is achieved through psychodynamic psychotherapy. This understanding

may add to the development of treatment methods, such as improved cognitive-behavioral

techniques (A.T. Beck et al. 1993) that take into account not only complex human motivating

factors but also the functional characteristics of that individual’s brain. Sophisticated

understanding of a patient’s intrapsychic conflicts and motivations allows the therapist to help that

patient move through the stages of change into recovery. For a patient with a dual diagnosis (a

term most commonly used to indicate addiction plus another mental illness), an integrated

approach geared toward treating both the mental illness and substance abuse yields better results.

A psychodynamic understanding frequently enhances the treatment of anxiety disorders,

depression, and personality disorders occurring with substance abuse.

IMPLICATIONS FOR RESEARCH

New research is needed to identify the patients for whom psychodynamic treatment is appropriate.

Specifically, investigators must determine which Axis I or Axis II disorders, which age group, what

timing, and which patient characteristics are best suited for this approach, and they must

determine which psychodynamic interventions should be used and combined with what other

treatments. It is hard to find good databases of what is often clinically subjective material.

Premature closure on any of these questions because of the challenge and expense of studying the

particular area may lead to overly narrow, poorer-quality treatment approaches. It will take time,

the pooling of large amounts of clinical data, and the collaboration of many clinical researchers to

obtain these answers. Initially, nonrandomized, noncontrolled, and descriptive studies will be

needed. Ultimately, randomized studies will best exclude even moderate biases, and with large

samples, it will be possible to correct for both false positive and false negative results.

CONCLUSION

Psychodynamic theory can play an important role in enriching and informing substance abuse

treatment and improving the therapeutic relationship. However, rigid application of psychoanalytic

technique is inappropriate in substance abuse treatment and can be counterproductive. Application

of psychodynamic understanding—including attending to the unconscious, child development, ego

function, affect regulation, and efforts to enhance self-esteem and deal with shame and other

narcissistic vulnerability—widens the range of patients who can be treated.

Greater academic and scientific attention are needed if progress is to be made in this area of the

addictions. Currently, definitive outcome studies of psychodynamic psychotherapy in

substance-abusing patients are rare. A rich descriptive clinical experience in this area will bring

improved understanding of addicted patients in both theoretical and practical settings.

KEY POINTS

Sophisticated, dynamic understanding of an individual’s conflicts can help motivate patients to accept that

they have a problem, help patients accept a need for change, aid in treatment, and be used to maintain

progress.

Psychodynamic understanding can be integrated with cognitive, behavioral, and pharmacological

approaches to enhancing treatment.

More research needs to be done on how influencing the mind can affect brain function, including addictive

behavior.

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SUGGESTED READING

Prochaska JO, DiClemente CC, Norcross JC: In search of how people change: applications to addictive

behaviors. Am Psychol 47:1102–1114, 1992

Vaillant GE: The Natural History of Alcoholism Revisited. Cambridge, MA, Harvard University Press, 1995, pp

362–373

Volkow ND, Li TK: Drug addiction: the neurobiology of behaviour gone awry. Nat Rev Neurosci 5:963–970,

2004

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