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Psychodynamic Therapy - From
NIDA
Psychodynamic therapy focuses on unconscious
processes as they are manifested in the client's present behavior. The
goals of psychodynamic therapy are client self-awareness and
understanding of the influence of the past on present behavior. In its
brief form, a psychodynamic approach enables the client to examine
unresolved conflicts and symptoms that arise from past dysfunctional
relationships and manifest themselves in the need and desire to abuse
substances.
Several different approaches to brief psychodynamic
psychotherapy have evolved from psychoanalytic theory and have been
clinically applied to a wide range of psychological disorders. A growing
body of research supports the efficacy of these approaches (Crits-Christoph,
1992; Messer and Warren, 1995).
Short-term psychodynamic therapies can contribute to
the armamentarium of treatments for substance abuse disorders. Brief
psychodynamic therapies probably have the best chance to be effective
when they are integrated into a relatively comprehensive substance abuse
treatment program that includes drug-focused interventions such as
regular urinalysis, drug counseling, and, for opioid-dependents,
methadone maintenance pharmacotherapy. Brief psychodynamic therapies are
perhaps more helpful after abstinence is well established. They may be
more beneficial for clients with no greater than moderate severity of
substance abuse. It is also important that the psychodynamic therapist
know about the pharmacology of abused drugs, the subculture of substance
abuse, and 12-Step programs.
Psychodynamic therapy is the oldest of the modern
therapies. As such, it is based in a highly developed and multifaceted
theory of human development and interaction. This chapter demonstrates
how rich it is for adaptation and further evolution by contemporary
therapists for specific purposes. The material presented in this chapter
provides a quick glance at the usefulness and the complex nature of this
type of therapy.
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The theory supporting psychodynamic therapy
originated in and is informed by psychoanalytic theory. There are four
major schools of psychoanalytic theory, each of which has influenced
psychodynamic therapy. The four schools are: Freudian, Ego Psychology,
Object Relations, and Self Psychology.
Freudian psychology is based on the theories first
formulated by Sigmund Freud in the early part of this century and is
sometimes referred to as the drive or structural model. The essence of
Freud's theory is that sexual and aggressive energies originating in the
id (or unconscious) are modulated by the ego, which is a
set of functions that moderates between the id and external reality.
Defense mechanisms are constructions of the ego that operate to minimize
pain and to maintain psychic equilibrium. The superego, formed
during latency (between age 5 and puberty), operates to control id
drives through guilt (Messer and Warren, 1995).
Ego Psychology derives from Freudian psychology. Its
proponents focus their work on enhancing and maintaining ego function in
accordance with the demands of reality. Ego Psychology stresses the
individual's capacity for defense, adaptation, and reality testing
(Pine, 1990).
Object Relations psychology was first articulated by
several British analysts, among them Melanie Klein, W.R.D. Fairbairn,
D.W. Winnicott, and Harry Guntrip. According to this theory, human
beings are always shaped in relation to the significant others
surrounding them. Our struggles and goals in life focus on maintaining
relations with others, while at the same time differentiating ourselves
from others. The internal representations of self and others acquired in
childhood are later played out in adult relations. Individuals repeat
old object relationships in an effort to master them and become freed
from them (Messer and Warren, 1995).
Self Psychology was founded by Heinz Kohut, M.D., in
Chicago during the 1950s. Kohut observed that the self refers to a
person's perception of his experience of his self, including the
presence or lack of a sense of self-esteem. The self is perceived in
relation to the establishment of boundaries and the differentiations of
self from others (or the lack of boundaries and differentiations). "The
explanatory power of the new psychology of the self is nowhere as
evident as with regard to the addictions" (Blaine and Julius, 1977, p.
vii). Kohut postulated that persons suffering from substance abuse
disorders also suffer from a weakness in the core of their
personalities--a defect in the formation of the "self." Substances
appear to the user to be capable of curing the central defect in the
self.
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[T]he ingestion of the drug provides him with the
self-esteem which he does not possess. Through the incorporation of the
drug, he supplies for himself the feeling of being accepted and thus of
being self-confident; or he creates the experience of being merged with
the source of power that gives him the feeling of being strong and
worthwhile (Blaine and Julius, 1977, pp. vii-viii).
Each of the four schools of psychoanalytic theory
presents discrete theories of personality formation, psychopathology
formation, and change; techniques by which to conduct therapy; and
indications and contraindications for therapy. Psychodynamic therapy is
distinguished from psychoanalysis in several particulars, including the
fact that psychodynamic therapy need not include all analytic techniques
and is not conducted by psychoanalytically trained analysts.
Psychodynamic therapy is also conducted over a shorter period of time
and with less frequency than psychoanalysis.
Several of the brief forms of psychodynamic therapy
are considered less appropriate for use with persons with substance
abuse disorders, partly because their altered perceptions make it
difficult to achieve insight and problem resolution. However, many
psychodynamic therapists work with substance-abusing clients, in
conjunction with traditional drug and alcohol treatment programs or as
the sole therapist for clients with coexisting disorders, using forms of
brief psychodynamic therapy described in more detail below.
The healing and change process envisioned in
long-term psychodynamic therapy typically requires at least 2 years of
sessions. This is because the goal of therapy is often to change an
aspect of one's identity or personality or to integrate key
developmental learning missed while the client was stuck at an earlier
stage of emotional development.
Practitioners of brief psychodynamic therapy believe
that some changes can happen through a more rapid process or that an
initial short intervention will start an ongoing process of change that
does not need the constant involvement of the therapist. A central
concept in brief therapy is that there should be one major focus for the
therapy rather than the more traditional psychoanalytic practice of
allowing the client to associate freely and discuss unconnected issues (Malan,
1976). In brief therapy, the central focus is developed during the
initial evaluation process, occurring during the first session or two.
This focus must be agreed on by the client and therapist. The central
focus singles out the most important issues and thus creates a structure
and identifies a goal for the treatment. In brief therapy, the therapist
is expected to be fairly active in keeping the session focused on the
main issue. Having a clear focus makes it possible to do interpretive
work in a relatively short time because the therapist only addresses the
circumscribed problem area. When using brief psychodynamic approaches to
therapy for the treatment of substance abuse disorders, the central
focus will always be the substance abuse in association with the core
conflict. Further, the substance abuse and the core conflict will always
be conceptualized within an interpersonal framework.
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