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Substance Abuse Treatment Modalities: Literature Review

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Psychotherapy or Psychodynamic Techniques

Over the years, psychodynamic psychotherapy has often been evaluated as a treatment for alcohol and other drug problems, and it is not a frequent component of treatment programs. At its core, psychodynamic psychotherapy considers alcohol and other drug problems to be symptoms of unconscious core psychological conflicts. Early psychodynamic approaches stemmed from psychoanalytic theory and therefore tended to explain addictions as reflecting arrested psychosexual development (Knight, 1973). Later approaches considered the social environment to be an important contributor to personality development and, therefore, that problem behaviours could relate to conflicts over such matters as social roles (e.g., Transactional Analysis; Steiner, 1971). The important feature of all of these approaches is that treatment is conducted as a long-term, insight-oriented process, and that the understanding produced by insight into the core conflicts is expected to resolve the conflict (by bringing it to consciousness) and therefore to result in the removal of the symptoms. A problem in conducting psychodynamic psychotherapy with substance abusers is that the insight-oriented approach is inconsistent with the need to reduce or stop the substance use as soon as possible. Insight-oriented treatment typically is performed over and extended period of time (i.e., several months or even years) with insights occurring only when the client is ready to accept and understand them (e.g., several months into treatment the therapist may offer a male client the interpretation that much of the individual's behaviour toward his spouse can be explained by unresolved conflicts regarding his relationship with his mother). During the interval between insights, continued excessive drinking or drug use can result in severe, even deadly consequences for the client. For this reason, psychodynamic approaches have typically been modified for application to substance abuse problems (e.g., Silber, 1974).

In recent years, some treatment approaches have been used that might be considered psychodynamic, although in practice they incorporate many cognitive-behavioural techniques. Interactional therapy is based on the assumption that maladaptive behaviour arises from dysfunctional or unfulfilling interpersonal relationships (Allen & Kadden, 1995). Treatment is typically conducted in a group format, with the group focusing on relationship issues. Like psychoanalytic approaches, however, the focus of treatment is on relationship issues, and it is assumed that substance use will become less of a problem if relationship conflicts are resolved. In an evaluation of interactional therapy compared with coping skills training, it was found that persons with less severe problems and lower in sociopathy did better with interactional therapy (Kadden et al., 1989). Surprisingly, in that same study neuropsychologically impaired individuals did better if they were treated with interactional therapy than with coping skills treatment, a finding that was unexpected since interactional therapy would appear to be more dependent upon complex cognitive processing than coping skills training.

Overall there have been few controlled studies of psychodynamic psychotherapy for alcohol problems, and the few that have been reported have not yielded positive findings (Miller et al., 1995). A small number of studies, largely from one research group, have explored the use of psychotherapy as an adjunct to counselling for methadone maintenance clients, although the psychotherapy has sometimes been cognitive behavioural. Although the addition of psychotherapy was somewhat beneficial overall, the major gains were confined to clients who have severe psychiatric problems as well as drug abuse. In another study using methadone maintenance clients, Woody et al. (1987) found that professional psychotherapy was associated with some gains in personal adjustment, but that they fared no better than clients treated with standard counselling in terms of drug use outcomes. The evidence for the effectiveness of psychotherapy with substance abusers, therefore, has been inconsistent, with positive findings only appearing in the literature recently. In the case of those positive findings, an important consideration was that the psychotherapy was delivered at an institution known to excel in psychotherapy research and training. It is not known whether psychotherapy delivered in everyday clinical contexts would produce similar effects. Also, psychotherapy typically is conducted by professionals, most usually psychologists and psychiatrists. Thus, even if psychotherapy produced consistent and substantial positive results, it would still need to be determined whether the provision of psychotherapy on a broad scale was cost-effective. A few recently published books discuss state of the art psychodynamic approaches, but these approaches have yet to be evaluated in controlled studies (e.g., Khantzian et al., 1990; Kaufman, 1994).

References for Psychodynamic Psychotherapy Modality

Allen, J.P. & Kadden, R.M. (1995), “Matching Clients to Alcohol Treatments”, In: R.K. Hester & W.R. Miller, Eds. Handbook of Alcoholism Treatment Approaches: Effective alternatives. Second Edition. Boston: Allyn and Bacon, pp. 278-291.

Blane, H.T. (1968),. The Personality of the Alcoholic: Guises of dependency. New York: Harper and Row.

Blane, H.T. (1971), “Psychotherapeutic approach”, In: B. Kissin & H. Begleiter, Eds. Social Aspects of Alcoholism: The Biology of Alcoholism. Vol. 4. New York: Plenum Press, pp. 105-160.

Blum, E.M. (1966), “Psychoanalytic views of alcoholism: A review”, Quarterly Journal of Studies on Alcohol, 27, 259-299.

Cooney, N.L., Kadden, R.M., Litt, M.D., & Getter, H. (1991), “Matching alcoholics to coping skills or interactional therapies: Two-year follow-up results”, Journal of Consulting and Clinical Psychology, 59, 598-601.

Hester, R.K., & Miller, W.R. (Eds.) (1995), Handbook of Alcoholism Treatment Approaches: Effective alternatives. Second Edition. Boston: Allyn and Bacon.

Hill, M.J., & Blane, H.T. (1967), “Evaluation of psychotherapy with alcoholics: A critical review”, Quarterly Journal of Studies on Alcohol, 28, 76-104.

Kadden, R.M., Cooney, N.L., Getter, H., & Litt, M.D. (1989), “Matching alcoholics to coping skills or interactional therapies: Post treatment results” Journal of Consulting and Clinical Psychology, 57, 698-704.

Kaufman, E. (1994), Psychotherapy of Addicted Persons, New York: Guilford Press.

Khantzian, E.J., Halliday, K.S., & McAuliffe, W.E. (1990), Addiction and the Vulnerable Self: Modified dynamic group therapy for substance abusers., New York: Guilford Press.

Knight, R.P. (1937), “The dynamics and treatment of chronic alcohol addiction”, Bulletin of the Meninger Clinic, 1, 233-250.

Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.F., Montgomery, H.A., Hester, R.K., & Tonigan, J.S. (1995), “What works? Methodological analysis of the alcohol treatment outcome literature”, In: R.K. Hester & W.R. Miller, Eds. Handbook of Alcoholism Treatment Approaches: Effective alternatives. Second Edition. Boston: Allyn and Bacon, pp. 278-291.

Silber, A. (1974), “Rationale for technique of psychotherapy with alcoholics”, International Journal of Psychoanalytic Psychotherapy, 3, 28-47.

Steiner, C. (1971), Games Alcoholics Play, New York: Grove Press.

Woody, G.E., McLellan, A.T., & Lubrosky, L. (1984), “Psychiatric severity as a predictor of benefits from psychotherapy” American Journal of Psychiatry, 141, 1171-1177.

Woody, G.E., McLellan, A.T., Lubrosky, L. & O'Brien, C.P. (1985), “Sociopathy and psychotherapy outcome”, Archives of General Psychiatry, 42, 1081-1086.

Woody, G.E., McLellan, A.T., Lubrosky, L. & O'Brien, C.P. (1987), “Twelve-month follow-up of psychotherapy for opiate dependence”, American Journal of Psychiatry, 144, 590-596.