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


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Psychodynamic therapy focuses on unconscious procedures as they are materialized in theclient"s present behavior. The goals of psychodynamic therapy are clientself-awareness and understanding that the influence of the past on current behavior.In its short form, a psychodynamic approach allows the customer to examine unresolvedconflicts and symptoms that arise from past dysfunctional relationships and manifestthemselves in the need and also desire come abuse substances.

Several various approaches to short psychodynamic psychotherapy have progressed frompsychoanalytic theory and have to be clinically applied to a wide variety ofpsychological disorders. A growing body of research supports the efficacy the theseapproaches (Crits-Christoph, 1992; Messer and also Warren, 1995).

Short-term psychodynamic therapies can add to the armamentarium of treatmentsfor problem abuse disorders. Short psychodynamic therapies probably have the bestchance to be reliable when castle are combined into a fairly comprehensivesubstance abuse treatment routine that has drug-focused interventions such asregular urinalysis, drug counseling, and, for opioid-dependents, methadonemaintenance pharmacotherapy. Short psychodynamic therapies space perhaps an ext helpfulafter abstinence is well established. They may be much more beneficial because that clients withno better than moderate severity of substance abuse. It is additionally 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 contemporary therapies. Together such, the is based ina extremely developed and also multifaceted theory of human advance and interaction.This thing demonstrates how rich that is because that adaptation and further advancement bycontemporary therapists for certain purposes. The product presented in thischapter gives a fast glance in ~ the usefulness and also the complex nature the thistype that therapy.


Background

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

Freudian psychology is based upon the theories an initial formulated by Sigmund Freud inthe early part of this century and is occasionally referred to as the journey orstructural model. The significance of Freud"s theory is the sexual and also aggressiveenergies originating in the id (or unconscious) room modulatedby the ego, i beg your pardon is a collection of features that moderates betweenthe id and also external reality. Defense mechanisms space constructions that the egothat operate to minimization pain and also to maintain psychic equilibrium. Thesuperego, formed during latency (between period 5 andpuberty), operates to manage id drives through guilt (Messer and also Warren, 1995).

Ego Psychology derives from Freudian psychology. Its proponents emphasis their workon enhancing and maintaining ego duty in accordance v the demands ofreality. Ego Psychology emphasize the individual"s capacity for defense,adaptation, and also reality testing (Pine,1990).

Object relations psychology was very first articulated by number of British analysts,among lock Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and Harry Guntrip.According come this theory, people are always shaped in relationship to thesignificant others surrounding them. Ours struggles and also goals in life emphasis onmaintaining connections with others, while at the same time differentiatingourselves from others. The internal representations that self and others acquiredin childhood are later played the end in adult relations. Individuals repeat oldobject relationship in an effort to understand them and become freed from them(Messer and also Warren, 1995).

Self Psychology was established by Heinz Kohut, M.D., in Chicago throughout the 1950s.Kohut observed the the self describes a person"s late of his experienceof his self, consisting of the presence or absence of a sense of self-esteem. The selfis regarded in relation to the facility of boundaries and also thedifferentiations of self from others (or the lack of borders anddifferentiations). "The explanatory strength of the new psychology the the self isnowhere as apparent as v regard come the addictions" (Blaine and Julius, 1977, p. Vii). Kohut postulated thatpersons suffering from substance abuse disorders additionally suffer indigenous a weak inthe main point of your personalities--a defect in the formation of the "self."Substances appear to the user to be capable of curing the central defect in theself.

he ingestion of the drug provides him v the self-esteem which the does notpossess. Through the incorporation of the drug, he offers for self thefeeling of gift accepted and thus of gift self-confident; or he create theexperience of being combined with the resource of power that provides him the feelingof being solid and worthwhile (Blaine andJulius, 1977, pp. Vii-viii).

Each that the four schools of psychoanalytic concept presents discrete theories ofpersonality formation, psychopathology formation, and change; techniques bywhich to conduct therapy; and also indications and also contraindications because that therapy.Psychodynamic treatment is distinguished from psychoanalysis in severalparticulars, consisting of the truth that psychodynamic therapy require not encompass allanalytic techniques and also is not conducted by psychoanalytically trained analysts.Psychodynamic therapy is likewise conducted end a shorter duration of time and withless frequency 보다 psychoanalysis.

Several the the quick forms the psychodynamic treatment are taken into consideration lessappropriate for use with persons through substance abuse disorders, partially becausetheir transformed perceptions do it challenging to accomplish insight and problemresolution. However, countless psychodynamic therapists work with substance-abusingclients, in connect with traditional drug and also alcohol treatment programs oras the single therapist for clients with coexisting disorders, using forms ofbrief psychodynamic therapy described in an ext detail below.


Introduction to quick PsychodynamicTherapy

The healing and change process envisioned in long-term psychodynamic therapytypically needs at the very least 2 years of sessions. This is due to the fact that the score oftherapy is frequently to readjust an element of one"s identity or personality or tointegrate an essential developmental discovering missed when the customer was stuck at anearlier stage of emotional development.

Practitioners of short psychodynamic therapy think that some changes can happenthrough a an ext rapid process or that an initial short intervention will begin anongoing procedure of change that go not require the continuous involvement that thetherapist. A central concept in short therapy is the there have to be one majorfocus because that the therapy rather than the an ext traditional psychoanalytic practiceof enabling the client to combine freely and also discuss unconnected problems (Malan, 1976). In brief therapy, thecentral emphasis is emerged during the initial testimonial process, occurringduring the first session or two. This emphasis must be agreed on by the client andtherapist. The main focus singles the end the most vital issues and also thuscreates a structure and identifies a goal because that the treatment. In brief therapy,the therapist is supposed to be relatively active in keeping the session focused onthe key issue. Having actually a clear emphasis makes it feasible to carry out interpretive workin a reasonably short time because the therapist just addresses thecircumscribed difficulty area. Once using short psychodynamic ideologies to therapyfor the therapy of substance abuse disorders, the central focus will always bethe substance abuse in association v the core conflict. Further, thesubstance abuse and also the core conflict will always be conceptualized in ~ aninterpersonal framework.

The variety of sessions different from one technique to another, yet briefpsychodynamic therapy is typically considered to be no an ext than 25 sessions(Bauer and Kobos, 1987).Crits-Christoph and Barber had models permitting up come 40 sessions in theirreview of temporary dynamic psychotherapies because of the aberration in thescope of treatment and the varieties of purposes 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 that the Oedipal dispute (Davanloo, as understood by Laikin et al., 1991). The size oftherapy is usually regarded the ambitiousness the the therapy goals. Mosttherapists room flexible in terms of the number of sessions they recommend forclinical practice. Regularly the number of sessions counts on a client"scharacteristics, goals, and the issues deemed main by the therapist.


Psychodynamic Psychotherapy because that Substance Abuse

Supportive-expressive (SE) psychotherapy (Luborsky, 1984) is one brief psychodynamic method that has beenadapted for use with people with problem abuse disorders. It has actually been modifiedfor use v opiate dependency in conjunction v methadone maintenancetreatment (Luborsky et al., 1977) andfor cocaine usage disorders (Mark and Faude,1995; Mark and Luborsky,1992). There have actually been numerous studies that the use of SE treatment forsubstance abuse disorders, causing a far-ranging body of empirical data onits effectiveness in dealing with these difficulties (see below).

Mark and also Faude asserted that although your therapeutic approach was devisedspecifically for cocaine-dependent clients, these human being often have multipledependencies, and also this technique can be provided to treat a variety of substanceabuse disorders. However, clients need to be sensibly stable in terms of theirsubstance abuse before beginning this type of therapy (Mark and also Faude, 1995).

Mark and also Faude theorized the substances the abuse substitute a "chemicalreaction" in place of experiences and also that these chemically induced experiencescan block the affect of other external events. The human being with a substance abusedisorder will because of this have a "tremendously impoverished and also impaired capacityto experience," and traditional psychotherapy might have to it is in augmented withtechniques that emphasis on increasing a client"s capacity to experience (Mark and also Faude, 1995, p. 297).

Effective SE therapy counts on proper use the what is termed thecore conflictual partnership theme (CCRT), a concept firstintroduced through Lester Luborsky. Follow to Luborsky, a CCRT is at the facility ofa person"s problems. The CCRT develops from early on childhood experiences, but theclient is unaware the it and also how the developed. The is assumed the the customer willhave much better control over habits if that knows more about what the is doing on anunconscious level. This understanding is acquired by far better understanding ofchildhood experience (Bohart and Todd,1988). The CCRT develops out the 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 an answer of the self (RS), which refers to a much more orless coherent mix of somatic experiences, affects, actions, cognitivestyle, self-esteem, and also self-representations.

Most civilization with substance abuse disorders have specifically negativeexpectations that others" attitudes toward them (that is, the RO), return itremains unclear which come first--this an answer or the problem abuse disorder.Either way, the two become mutually reinforcing. Adhering to are instances ofstatements the reflect the core RO that a human being with a problem abuse disorder:

A 3rd component of CCRT is a person"s wish; it shows whatthe client yearns for, desire for, or desires. The client"s "wish" is largelybased on separation, personal, instance personality style. Those with substance abuse disordersoften have actually a great to continue using the substance without having actually to endure theconsequences. Put an additional way, they would like to be welcomed (or love orappreciated) together they are, without having to give up the pleasure they gain fromtheir usage (Levenson et al., 1997).Many civilization who have actually substance abuse disorders have actually much invest in denyingthat they really have actually a problem, in showing themselves as helpless victims,and in disclaiming their role in the behavior that has carried them intotreatment.

Once therapy has been initiated, the therapist and client can occupational together toput the client"s goals right into the CCRT framework and also explore the meaning,function, and repercussion of she substance abuse, feather in details at howthe RO and RS have added to the problem. The CCRT framework likewise can beused to determine potential obstacles in the recovery procedure as the therapistand customer explore the client"s suspect responses indigenous others and also fromherself and discuss just how these awareness will adjust when she stops abusingsubstances.

The CCRT concept also can assist clients attend to relapse, i m sorry is regarded byvirtually all professionals in the field as an integral and natural component of recovery.Relapse offers the client and the SE therapist the possibility to examine howthe RO and also RS have the right to serve together triggers and also to devise tactics to avoid thesetriggers in the future. Finally, SE therapy is conducive to customer participationin a self-help team such together Alcoholics Anonymous, or it deserve to be provided as amechanism to examine a client"s unwillingness to participate in this groups.


Stella and also Christopher: A case Study

The situation study in this ar came from the NIDA collaborative Cocaine Study(Mark and also Faude, 1997; adaptedwith permission). SE is the therapeutic strategy used.

While dependent and also impulsive, Stella, a 28-year-old cocaine-dependent woman,would be viewed under plenty of circumstances together warm and also open. She shows up to bethe sort of human who wears she heart on her sleeve, yet it is a large heartnonetheless, capable of caring because that others with loyalty and also compassion. Inaddition, she has a tenacity that spirit; despite a horrific personal historyshe completed her training together a clinical technician and also has operated in thatcapacity for lot of the critical 4 years. She therapist, Christopher, is awell-trained psychodynamically oriented therapist. That is one intelligent,serious, and also measured person, who well-meaning nature comes v undermost circumstances regardless of his herbal reserve.

Stella has a history of polysubstance abuse, consisting of the abuse ofprescription drugs, both anxiolytics and opioids. She worked as a medicaltechnician until she hurt her earlier 3 month ago. At the start oftreatment, she said Christopher the she was going to inquiry medicationfrom her medical professional for her ago pain. After her eighth session, through herreluctant agreement, Christopher notified the physician that she to be intreatment because that cocaine dependence. Christopher asked the medical professional to discover amedication various other than diazepam (Valium) because that Stella"s ago pain.

Stella began the 19th session complaining the ever since the physician foundout she was a drug user, he has treated she differently. "He think I"m ascumbag drug addict," she said. Christopher action uncharacteristically: heoffered part advice. He said that Stella take into consideration telling her physicianhow she feels around his treatment. The treatment strikingly transformed themood and also productivity of the session. ~ a quick expression the sympathyfor her position, he focused on her extreme distress end the physician"streatment. He attempted to define the strongness of her reaction in terms ofprojection: that she comment so strongly due to the fact that of her an unfavorable view ofherself.

Matters acquired worse as the conference continued. Stella associated a 2nd negativeincident as soon as she explained her therapy by the physician in a grouptherapy session. The team therapist responded, "Well, friend manipulatedoctors!" Stella had been furious.

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

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

Diagnostically speaking, Stella has actually a borderline personality disorder asdefined by the Diagnostic and Statistical manual of MentalDisorders, 4th Edition (American Psychiatric Association, 1994). As soon as shewas between 6 and 8 year old, Stella"s maternal grand sexually abusedher. She parents divorced as soon as she to be 10, and also she lived with her mother,who was often drunk and also physically abusive. Stella said she to be closer toher father, whom she explained as gentle. He showed up to others as weak andineffectual.

At period 15, Stella ran off with a boyfriend who was likewise her pimp. ~ 2weeks she reverted home, was unable to leave her mother, and also was diagnosedas having agoraphobia, because that which she took chlordiazepoxide (Librium). Twoyears later she ran far with another man, a particularly sadistic pimp. For5 year she was too terrified to leave him. The was throughout this duration thatshe started using cocaine.

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

Stella"s medicine use came to be a component of the treatment in two ways. In the firstsession, Stella told Christopher that she had actually taken chlordiazepoxide forseveral days before their appointment, to relieve her anxiety. She pointedout that it had actually been prescribed by a doctor. Presumably, Christopher wouldhave well-known the results of her medicine screen, i m sorry was part of the program.She thus confessed prior to being confronted by drug screen results. She claimthat the prescription was legitimate promoted her denial the she hasanything to be came to about.

Second, Stella announced she intention to ask her doctor for diazepam, acommonly abused medication. By contacting her physician, Christopherreplayed a usual scenario in she life: she signals the someone need to takecontrol or care for her, climate resents it as soon as they do, emotion that she isbeing treated choose a "scumbag drug addict." She can develop the largelyillusory sense of gift cared for once someone treats her as a helplessincompetent. To be this how Christopher was treating her as soon as he referred to as herphysician?

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

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Stella competent Christopher"s agreement and also support through hisintervention. However, what might have do this a an ext powerful therapeuticinteraction would have been either for Christopher to straight acknowledgehis misgivings about having taken charge and contacted the medical professional or toexplore exactly how Stella came to hear his initial obliqueness as giving her whatshe wanted--his care and support.