Therapist client relationship from psychodynamic perspective in child

therapist client relationship from psychodynamic perspective in child

The characteristics of children who will benefit from psychodynamic that there is inconsistency in a student's ability to learn theory and to learn therapeutic skills . . Prior to his death, J's father was in good health and had a good relationship. The therapeutic relationship is central to psychodynamic therapy. It can demonstrate how a person interacts with their friends and loved ones. difficulties can be addressed through a therapeutic relationship that assumes .. child, the psychodynamic approach can be also used helpfully.

I may be wrong, but I also don't believe it will be useful for your psychotherapy. I know you see this differently.

therapist client relationship from psychodynamic perspective in child

Perhaps some therapists could see their way clear to do this. I can't do it. We may have to agree to disagree about this matter. If he decided to attend the church, the therapist would terminate the psychotherapy and, if he wished, refer him elsewhere for treatment. Sam responded with a sense of betrayal and rage that threatened to destroy all he had achieved as well as the therapeutic relationship.

Although angry and feeling betrayed, he decided to remain in treatment to understand his feelings and experience because he felt this relationship had been of great value to him and their work was not finished. Holding firm to the boundaries allowed Sam to relive, not merely remember, the problematic past in relationship with the therapist. The therapist understood that the conversation was as important as any decision about where to set the boundary. Power was mutually shared through the process of each participant deciding what he felt he could and could not do.

The therapist offered Sam a new relational experience by acknowledging and owning his personal feelings, including what Sam might experience as limitations. Sam did have a choice here. As the boundaries were renegotiated, the therapist could see more of what his patient needed from him.

therapist client relationship from psychodynamic perspective in child

Convinced that his therapist had reached an unambivalent decision, Sam was more open and willing to engage in the exploration of his deep sense of injury and rage. The therapist offered himself as an authentic presence who was committed to understanding Sam's dilemmas and willing to tolerate his aggression in the service of protecting his treatment and his development. Sam needed to experience his therapist as failing him and betraying him. His therapist was able to tolerate the frustration, anger, and devaluing involved in assisting this man to differentiate his past relationships from his present ones and to have a different affective experience and outcome.

Sam's acceptance of his rage and sadism toward himself and others were crucial to his psychotherapy. Although disagreeing with his therapist's decision, Sam acknowledged the value of being enraged at an important other without the destruction or denigration of either participant. Negotiating the intense affect and sense of betrayal while remaining in connection was a positive experience for Sam.

Psychodynamic Psychotherapy for Children and Adolescents: An Old Friend Revisited

This vignette is not intended as a prohibition against therapists and patients attending the same church. Often, particularly in rural communities, therapists discover that their professional and personal lives overlap with those of their patients. Such overlap may be handled in and out of the consulting room in a range of clinically useful ways.

The case of Sam illustrates the process of engaging patients in a sustained interpersonal and intrapsychic inquiry that leads to construction of affect, meaning, and deeper understandings. Such conversations and eventual understandings allow therapists to determine where to set boundaries in any particular treatment.

Emma, an attractive woman in her late thirties, began weekly psychotherapy almost against her better judgment. In a state of chronic depression, rage, and anxiety, she worried about how little she understood about the effect she had on others and how greatly that blind spot affected her relationships. Furthermore, she struggled to control her anger, with very mixed results, and deeply worried that she was or would become the raging women her mother was.

She reported a childhood history of severe emotional neglect and abuse with a rageful mother who always knew best. She developed a close friendship, by uncanny coincidence, with a woman in a similar profession who was a group psychotherapy patient of her therapist. Emma began playing with thoughts of what she could ask for from her therapist. She initiated the conversation by bringing up information from her colleague's treatment relationship with the therapist.

Emma wanted to be treated the same. The therapist felt Emma's determination to get her fair share at last. Emma was unable to identify or express her personal wishes. She was not interested in discussing her experience of her therapist's particular manner of caring for her or how the therapist experienced or felt about her.

She wanted treatment identical to her friend's. Emma expressed sadness, frustration, and impotent rage at her inability to control her therapist or her colleague.

The therapist commented that although Emma longed to be first, she wanted to punish someone for all the times she felt denigrated, marginalized, and not chosen.

Someone should make up for her heartache. Emma was committed to the feeling that she would be second best. Across the years of Emma's treatment, she had never asked her therapist about her personal vacation plans and had never been told. Now, Emma was curious and wanted the same treatment as her colleague. The therapist inquired about Emma's request, her feelings, and the meaning of knowing this information. Emma was unable to identify her curiosity, longing, or sense of loss about her therapist and the vacation.

Emma was vacillating between recasting and inducting the therapist in the role of the abusive mother and assuming that role herself by bullying her therapist.

Although knowing Emma was anguished, the therapist felt predominantly bullied and mistreated and unsure of how to proceed. Informing patients about her vacation plans was not unusual when it had a relational and therapeutic purpose.

However, in Emma's case the feelings of being coerced made her disinclined to share this information. She and Emma seemed deadlocked and unable to move beyond feelings of insult and anger. Emma remained fixed on her angry, competitive feelings with her colleague and on her right to know. The therapist fantasized about Emma's unexpressed envy and jealous feelings toward her that were expressed through the colleague.

This is about me. Emma, however, seemed unable to understand the dilemma dyadically. Emma pulled out all the stops before the therapist's vacation, demanding to know where the therapist was going on vacation and accusing the therapist of behaving in a patronizing manner. The therapist felt trapped in a no-win situation. She had no particular interest in withholding this information from Emma.

Yet she felt strongly about not disclosing data under duress or if it did not make contextual, clinical sense. The therapist wondered if Emma might be experientially communicating just how she felt as a child, trapped in a no-win situation despite her best efforts to remedy it. The therapist commented on Emma's anger and grief. I feel confused and hurt. Although she understood some of the significance of the meaning of the request, she was most captured by Emma's angry and threatening posture.

Emma did not share her sadness and her hurt, even though the therapist sensed they were there. The tone and packaging of the request made the therapist very uncomfortable with sharing any information. It is not my intent.

I think, and I know you disagree, that understanding these feelings and the process within and between us is very important. I don't believe it's useful for me to share personal data when I feel uncomfortable.

She is hurt or disappointed, is out of touch with the deep anger this triggers, and proceeds by demanding what she wants from others. Then she is upset and surprised when her colleagues respond with anger toward her.

therapist client relationship from psychodynamic perspective in child

Perhaps the therapist's vacation and differing treatment of her colleague made Emma feel diminished, hurt, and angry. Emma protects herself from hurt by assuming the less vulnerable position of being angry and proceeds to provoke anger in others. In Emma's case, only a beginning exploration of the dynamic and transference-countertransference occurred before the therapist's vacation. Because of the level of aggression involved and the unfinished processing of the request, the therapist felt it was clinically most useful not to disclose the data requested.

Was she angry and fed up with this patient as she stimulated some personal piece of unfinished business? Although she clearly felt angry, her annoyance was commingled with a sense of sadness and grief.

She and Emma were a feeling-state away from owning and negotiating these affects and issues. She took some comfort in knowing the conversation was interrupted and not over.

therapist client relationship from psychodynamic perspective in child

She hoped Emma would also discover that they could survive Emma's self-expression and self-exploration. The therapist wished she had been able to expand the space between them for engagement and understanding.

The dyad was at an impasse that required an authentic, affective response from the therapist about the process. She felt it was important to reveal some of her observations and experiences but to draw the boundary short of revealing the vacation plans.

The therapist remained open to an examination of her own contribution to the interaction. Her internal boundary and processing remained open to an honest exploration of what she would learn from this treatment with Emma. Sharing her thinking was an effort to provide Emma with an alternative way of understanding her therapist's behavior. The therapist hoped to model the experience of explicitly acknowledging and discussing feelings and observations about their relationship. The boundary at this moment in this therapeutic dyad was determined by the therapist's experience and understanding that containment and her patient's full expression of anger, longing, and grief were being negotiated.

The therapist acknowledged the patient's feelings and understood her need to relive aspects of her childhood. Naming and holding these feelings and relational dilemmas without a rupture of relatedness would provide the opportunity for Emma to begin to experience herself and others differently. Although therapists assume an open attitude with regard to the crucial boundary negotiations that illuminate the patient's most painful transference issues, often, particularly when a patient cannot grasp any perspective but her own, the therapist's construction of a boundary may make no sense to the patient.

As in the case above, despite the therapist's best efforts to engage in a conversation that could lead to deeper understanding and co-construction of a boundary, the patient feels wounded, feels a sense of loss, and, at least initially, experiences the therapist as sadistic or withholding.

The hope is that through mutual exploration, the patient will come to accept the boundary as protective of the psychotherapy and her future development. Despite the therapist's best effort to engage in an authentic process of negotiation and exploration about the meaning and construction of a therapeutically useful boundary, it is often not possible to know in advance where to set the boundary.

Trial, error, and time may also bear out that a boundary was too flexible or too rigid. The most thoughtful, well-intentioned boundary decisions may have untoward effects. On occasion, some patients may be unable to negotiate such an understanding and may abandon therapy.

These requests often represent extraordinary events or interventions that would never be routinized in everyday practice. Therapists who are comfortable with more uncharted treatment approaches within ethical frames and favor a process of mutual discovery between therapist and patient may explore and keep open the possibility of, for example, attending a patient's event, giving or accepting a gift from a patient, or sharing personal information in the service of therapeutic goals.

These events are extraordinary in that they are rare occurrences in a therapeutic relationship undertaken for a particular therapeutic purpose after thorough investigation. Therapists who are willing to construct untraditional but clinically useful boundaries demonstrate a willingness to cope with the unknown and to be influenced and educated by their patients about the therapeutic value of these events.

The interpersonal and intrapsychic exploration of the meaning of these events and the associated feelings to the therapist-patient dyad establish a context for safety, which opens up space for a deeper, more intimate conversation whether or not the therapist decides to honor the request. Through sustained engagement with the patient about such requests, the therapist may come to understand the layers of meaning and significance of such overtures.

The effort to study the meaning and qualities of mutual experience in these moments creates the space and conditions for an intimate encounter 21 — 2333 that might be impossible without an openness to the dynamic, creative setting of therapeutic boundaries. It is difficult for the independent practitioner who is often struggling with intense feelings and overwhelming clinical dilemmas to know how to integrate a psychological containment field with sensitive, useful, clinical interventions.

Therapists ambivalent about where to set therapeutic boundaries and confused about the nature of therapeutic action retreat from open, honest conversations with patients. Sometimes therapists simply have little idea of how to proceed in an unformulaic fashion and have had few mentoring or supervisory opportunities to assist in the development of a psychodynamic understanding of boundaries and boundary maintenance. In other cases, the more comfortable position for the therapist is to remain protected behind a professional mask or veneer that forecloses the experience of intense affect, therapeutic possibilities, and deep conversations.

When startled, therapists may set unhelpful therapeutic boundaries as a way to manage their own anxiety. Consider the following case: A transsexual male wanted to attend psychotherapy sessions cross-dressed. The therapist was unable to join the patient's experience and explore the layers of meaning of this behavior. This clinical boundary decision was framed as protective of the patient and the psychotherapeutic process.

However, it is also easy to understand this clinical decision as primarily protective of the therapist. Therapists may be startled by the intensity of their own affective responses and uncertain how best to make therapeutic use of such feelings. Being open to influence from within and between participants in a psychotherapy provides contextual safety and the possibility of creative, novel, deeply personal, and transforming conversations. Engaging patients and ourselves in a sustained interpersonal and intrapsychic inquiry leads to co-construction of affect, meaning, and deeper understandings.

It is precisely such conversations and eventual understandings that allow clinicians to determine where to set boundaries in any particular treatment dyad. Clinicians are well informed about ethical conduct and yet remain confused about how to psychodynamically understand and construct therapeutically useful boundaries in psychotherapy.

Within an ethical framework, the conversation about boundary decisions is as important to the psychotherapy as any decision about where to set the boundary. An integrated approach, one that honors traditional parameters and yet encourages an openness to creative, uncharted, outcomes within ethical frames, is useful and captures many clinicians' actual experience.

Clinicians strive to navigate through this minefield of controversy by choosing a mix of traditional and innovative parameters and concepts to guide them in their care of patients.

More discussion in the literature of treatments that borrow from several schools of thought and model integration of practice methods would be valuable. An intrapsychic and interpersonal focus on therapeutic boundaries allows reciprocal influence, construction of meaning, and novel interpersonal and affective outcomes.

Such an approach also offers containment and holding of intense, unconscious, affective experiences and interpersonal dramas. The interpersonal and intrapsychic exploration of the associated feelings and meaning of these clinical issues opens up space for expanded possibilities and deeper therapeutic dialogue.

Such dialogues provide unexpected therapeutic opportunities that may add a novel, valuable dimension to the therapeutic relationship that advances the clinical work. Epstein R, Simon RI: Bull Menninger Clin ; Assessing boundary violations in psychotherapy: Boundaries and Boundary Violations in Psychoanalysis.

New York, Basic Books, 5. The concept of boundaries in clinical practice: Am J Psychiatry ; The prevention of psychotherapist sexual misconduct: Am J Psychother ; After a brief expression of sympathy for her position, he focused on her extreme distress over the physician's treatment.

He attempted to explain the intensity of her reaction in terms of projection: Matters got worse as the session continued. Stella related a second negative incident when she described her treatment by the physician in a group therapy session. The group therapist responded, "Well, you manipulate doctors! Christopher encouraged her to say more. Stella became frustrated at Christopher's lack of understanding and explained that again, she felt she was being treated like a "scumbag," this time by the group therapist.

Christopher suggested that Stella might tell both the physician and the group therapist how she felt. The tension in the session disappeared, and Stella remarked that she has always had trouble sticking up for herself. In supervision, Christopher realized immediately that he was indirectly letting Stella know that he understood and agreed with her. When she was between 6 and 8 years old, Stella's maternal grandfather sexually abused her.

Her parents divorced when she was 10, and she lived with her mother, who was often drunk and physically abusive. Stella said she was closer to her father, whom she described as gentle. He appeared to others as weak and ineffectual. At age 15, Stella ran off with a boyfriend who was also her pimp. After 2 weeks she returned home, was unable to leave her mother, and was diagnosed as having agoraphobia, for which she took chlordiazepoxide Librium.

Two years later she ran away with another man, a particularly sadistic pimp. For 5 years she was too terrified to leave him. It was during this period that she started using cocaine. The cocaine both "disclaims action" and affirms her "badness. So, she deserves her fate. She would use the cocaine to clear her painful feelings and feel "strong and independent," then "feel like a big baby for having to use the drugs. Her reactions to cocaine are typical; a brief surge or a "high," followed by a crash.

However, these typical reactions also fit her core theme: Her response then is to use drugs, which makes her feel strong and independent for a brief time and also makes her see herself as deserving of being thwarted and exploited, which has happened repeatedly in interpersonal contexts in her life.

Stella's drug use became a part of the therapy in two ways. In the first session, Stella told Christopher that she had taken chlordiazepoxide for several days before their appointment, to relieve her anxiety. She pointed out that it had been prescribed by a doctor. Presumably, Christopher would have known the results of her drug screen, which was part of the program.

She thus confessed before being confronted by drug screen results. Her claim that the prescription was legitimate facilitated her denial that she has anything to be concerned about. Second, Stella announced her intention to ask her physician for diazepam, a commonly abused medication.

Getting Help - Psychotherapy: Crash Course Psychology #35

By contacting her physician, Christopher replayed a common scenario in her life: Was this how Christopher was treating her when he called her physician? When Christopher suggested that she tell the physician and the group therapist how she felt about the way they had treated her, his words may have given advice, but his communication actually conveyed agreement with Stella's position that she had been unfairly treated.

Stella experienced Christopher's agreement and support through his intervention. However, what could have made this a more powerful therapeutic interaction would have been either for Christopher to directly acknowledge his misgivings about having taken charge and contacted the physician or to explore how Stella came to hear his initial obliqueness as giving her what she wanted--his care and support.

Research on the Efficacy of Supportive-Expressive Therapy It is only since the s that psychosocial components of the treatment of substance abuse disorders have become the subject of scientific investigation.

Most research on the efficacy of psychotherapy for the treatment of substance abuse disorders has concluded that it can be an effective treatment modality Woody et al. Comparisons among specific models of therapy have become the focus of much interest. As mentioned above, SE psychotherapy has been modified for use with methadone-maintained opiate dependents and for cocaine dependents.

In SE therapy, the client is helped to identify and talk about core relationship patterns and how they relate to substance abuse. One study compared SE therapy and cognitive-behavioral therapy with standard drug counseling for opiate dependents in a methadone maintenance program. Clients were offered once-weekly therapy for 6 months. Adding professional psychotherapies either SE or cognitive-behavioral to drug counseling benefited clients with higher levels of psychopathology more than using drug counseling alone.

However, drug counseling alone was helpful for clients with lower levels of psychopathology Woody et al. Another study involving three methadone programs was also positive regarding the efficacy of SE therapy Woody et al. In this study, clients receiving SE therapy required less methadone than those who received only standard substance abuse counseling, and after 6 months of treatment these clients maintained their gains or showed continuing improvement.

Gains tended to dissipate in those who received drug counseling only Woody et al. One study compared SE psychotherapy with structural family therapy for the treatment of cocaine dependence Kang et al. Both types of therapy were offered once a week. The researchers found that once-weekly therapy, of either type, was not associated with significant progress. Dropout rates were high, and overall abstinence in both groups did not appear to differ from that expected from spontaneous remission.

therapist client relationship from psychodynamic perspective in child

The main conclusions were that the lack of treatment effects may have resulted because these treatments did not offer enough frequency and intensity of contact to be effective for cocaine-dependent people in the initial stages of recovery. This study had at least two flaws, however.

One was that the therapists were not well-trained in SE therapy; therefore, it is questionable whether or not the treatment they provided was actually SE therapy. The other was that the therapy was provided in a municipal office building where courts and social services were administered, thus this setting lacked many features of traditional substance abuse treatment settings.

More recently, a large multisite study of persons receiving treatment compared SE therapy with cognitive therapy and drug counseling for cocaine dependence Crits-Christoph et al. Each of the three conditions included, in addition to the individual treatment, a substance abuse counseling group. A fourth condition received group counseling without additional individual therapy. This study was a theoretical descendant of the methadone studies mentioned earlier.

It was hypothesized that SE and cognitive therapy might be more effective than individual drug counseling for clients with higher levels of psychiatric severity.

The results showed that each type of treatment was associated with significantly reduced cocaine use. However, for this population of outpatient cocaine-dependent clients, drug counseling was more successful at reducing substance use than SE or cognitive therapy Crits-Christoph et al. One implication of this finding is that drug-focused interventions are perhaps the optimal approach for providing treatment for substance abuse disorders Strean, What this means for practitioners of psychodynamically oriented treatments is that in addition to providing the more dynamic interventions, it is important to also incorporate direct, drug-focused interventions.

This can be accomplished by one therapist combining both models or, in a comprehensive treatment program for substance users, one therapist providing dynamic therapy and an alcohol and drug counselor providing direct, drug-focused counseling. It can be argued that this is why SE therapy was so helpful in the methadone studies. In those studies, psychodynamic therapy was well integrated into a comprehensive methadone maintenance program. In other words, in addition to the dynamic therapy, clients received substance abuse disorder counseling along with methadone Woody et al, One study conducted a small, controlled trial comparing SE therapy to a brief one-session intervention for marijuana dependence.

The SE approach was adapted for use in treatment of cannabis dependence Grenyer et al. Results showed that both interventions were helpful but SE therapy produced significantly larger reductions in cannabis use, depression, and anxiety, and increases in psychological health Grenyer et al.

Psychodynamic Perspective on Therapeutic Boundaries

The authors concluded that SE therapy could be an effective treatment for cannabis dependence. Clients Most Suitable for Psychodynamic Therapy Brief psychodynamic therapy is more appropriate for some types of clients with substance abuse disorders than others. For some, psychodynamic therapy is best undertaken when they are well along in recovery and receptive to a higher level of self-knowledge.

Although there is some disagreement in the details, this type of brief therapy is generally thought more suitable for the following types of clients: Those who have coexisting psychopathology with their substance abuse disorder Those who do not need or who have completed inpatient hospitalization or detoxification Those whose recovery is stable Those who do not have organic brain damage or other limitations due to their mental capacity Psychodynamic Concepts Useful in Substance Abuse Treatment Psychodynamic theories endeavor to provide coherent explanations for intrapsychic and interpersonal workings.

Because of the importance of this approach in the development of modern therapy, the techniques that stem from these theories are inevitably used in any type of psychotherapy, whether or not it is identified as "psychodynamic.

Counselors whose clients have an immediate and strong negative reaction to them often benefit from an understanding of the concept of "transference. Therefore, counselors who treat clients with substance abuse disorders can benefit from understanding the basic concepts of general psychodynamic theory discussed in this section, even if they do not use a strictly psychodynamic intervention.

The Therapeutic Alliance The alliance that develops between therapist and client is a very important factor in successful therapeutic outcomes Luborsky, This is true regardless of the modality of therapy. The psychodynamic model has always viewed the therapist-client relationship as central and the vehicle through which change occurs. Of all the brief psychotherapies, psychodynamic approaches place the most emphasis on the therapeutic relationship and provide the most explicit and comprehensive explanations of how to use this relationship effectively.

Luborsky and colleagues are among those who have documented the profound effect that the therapist-client relationship has on the success of treatment, however brief Luborsky et al. The psychodynamic model offers a systematic explanation of how the therapeutic relationship works and guidelines for how to use it for positive change and growth. In all psychodynamic therapies, the first goal is to establish a "therapeutic alliance" between therapist and client.

In most cases, the development of a therapeutic alliance is partially a process of the passage of time. The more severe the client's disorder, the more time it will take. The capabilities of the therapist to be honest and empathic and of the client to be trusting are also factors. A therapeutic alliance requires intimate self-disclosure on the part of the client and an empathic and appropriate response on the part of the therapist.

However, in brief psychodynamic therapy this alliance must be established as soon as possible, and therapists conducting this sort of therapy must be able to establish a trusting relationship with their clients in a short time. One study of the therapeutic alliance and its relationship to alcoholism treatment found that for alcoholic outpatients, ratings of the therapeutic alliance by the patient or therapist were significant predictors of treatment participation and of drinking behavior during treatment and at month followup, though the amount of variance explained was small Connors et al.

Among cocaine-dependent patients, another study found that patients' ratings of the therapeutic alliance predicted the level of current drug use at 1 month but not at 6 months Barber et al.

The alliance at 1 month, however, predicted improvement in depressive symptoms at 6 months. These findings suggest that the therapeutic alliance exerts a moderate but significant influence on outcome in the treatment of substance abuse disorders.

The specific outcomes measured vary from study to study but include length of participation in treatment, reduction in drug use, and reduction in depressive symptoms. Developmental Level Psychodynamic theory emphasizes that the client's level of functioning should determine the nature of any intervention.

In Freudian psychoanalytic theory, substance abuse is considered a symptom associated with the oral or most primitive stage of development and represents an attempt to establish a need-gratifying symbiotic state Leeds and Morgenstern, Analytic theorists within the Object Relations school hold that substances stand in for the functions usually attributed to the primary maternal or care-giving object. As a result, the substance abuser relates to the substance based on the disturbed pattern of relating that he experienced with the maternal object Krystal, This would be considered a variant of borderline psychopathology, which is viewed as a fairly severe disturbance of ego functioning and object relations.

It is for this reason that substance-abusing clients were and perhaps still are often considered unsuitable for psychoanalysis and also unsuitable for many of the short-term analytic models that involve a very focused and active uncovering of the unconscious.

Contemporary analytic theorists who concern themselves with substance abuse disorders typically do not focus on the idea that addiction is linked to a developmentally primitive level of ego functioning, although they may endorse it.

One reason is that this idea leads to a rather pessimistic belief regarding the outcome of analytic treatments for substance abuse disorders. Another reason is that it does not contribute helpful information to the therapeutic approach, and it can impede the development of an empathic and respectful therapeutic alliance.

Furthermore, there is increasing empirical evidence for the idea that severe substance abuse is largely driven by biobehavioral forces and that individual psychological factors are of lesser importance Babor, Although analytic theories have tended to ignore this Leeds and Morgenstern,it has become increasingly a part of the knowledge base in understanding substance abuse disorders.

Insight Another critical underlying concept of psychodynamic theory--and one that can be of great benefit to all therapists--is the concept of insight. Psychodynamic approaches regard insight as a particular kind of self-realization or self-knowledge, especially regarding the connections of experiences and conflicts in the past with present perceptions and behavior and the recognition of feelings or motivations that have been repressed. Insight can come through a sudden flash of understanding or from gradual acquisition of self-knowledge.

So, for example, a client who feels depressed and angry and subsequently drinks comes to realize that his feelings toward his father are stimulated by an emotionally abusive supervisor at work.

This type of realization gives the client new options. These options include learning to separate his reactions to the supervisor from his feelings about his father, working through his feelings about his father of which he may not have been previously awareactively choosing alternative behaviors to drinking when he feels bad e. A broader definition of insight, also promoted by brief psychodynamic therapies, is simply any realization about oneself, one's inner workings, or one's behavior.

For example, a client who says, "the only emotion I really feel is anger," has opened the door to understanding the effect others have on her, and vice versa. She can then begin to develop alternative behaviors to those that previously followed automatically from her anger such as drinkingas well as to understand why her emotional repertoire is so limited. Insight involves both thoughts and feelings. A purely intellectual exercise will not lead to behavior change. True insight involves a powerful emotional experience as well as a cognitive component and leads to a greater acceptance of responsibility for feelings and behavior.

In treating substance abuse disorders, it is important to recognize that insight alone is often not sufficient to create change.

Substances of abuse are powerful behavioral reinforcers and the therapist needs to help the client counter the strong compulsive desire for them. Many therapists who conduct substance abuse treatment from a psychodynamic perspective are comfortable combining insight-oriented therapy with concrete, behavioral interventions.

Defense Mechanisms And Resistance In psychoanalytic theory, defense mechanisms bolster the individual's ego or self. Under the pressure of the excessive anxiety produced by an individual's experience of his environment, the ego is forced to relieve the anxiety by defending itself. The measures it takes to do this are referred to as "defense mechanisms.

Some defense mechanisms are adaptive and support the mature functioning of the individual, while others are maladaptive and hinder the individual's growth. Generally the defenses hamper the process of exploration in therapy, and for this reason they are often confronted in the more expressive models of analytic therapy.

However, in more supportive types of therapy, adaptive defenses are supported, and even the maladaptive defenses may not be confronted until the therapist has enabled the client to replace them with a more constructive means of coping.

In the treatment of substance abuse disorders, defenses are seen as a means of resisting change--changes that inevitably involve eliminating or at least reducing drug use. Mark and colleagues noted that two defenses frequently seen in those with substance abuse disorders are denial and grandiosity Mark and Luborsky, Particularly with this group of clients, handling defenses can degenerate into an adversarial interaction, laden with accusations; for example, when a therapist admonishes the client by saying, "You are in denial" Mark and Luborsky, They recommend avoiding ineffective adversarial interactions around the client's use of defenses by using the following strategies: Working with the client's perceptions of reality rather than arguing Asking questions Sidestepping rather than confronting defenses Demonstrating the denial defense while interacting with the client to show her how it works Figure defines the most common mechanisms clients use to defend themselves from painful feelings or to resist change.

Pretending that a threatening situation does not exist because the situation is too distressing to cope with. A child comes home, and no one is there.

He says to himself, "They are here. I'll find them soon. Transference Effective use of the therapeutic relationship depends on an understanding of transference. Transference is the process of transferring prominent characteristics of unresolved conflicted relationships with significant others onto the therapist. For example, a client whose relationship with his father is deeply conflicted may find himself reacting to the therapist as if he were the client's father.

The opening session in psychodynamic therapy usually involves the assessment of transference so that it may be incorporated into the treatment strategy. Strean found that, "all patients--regardless of the setting in which they are being treated, of the therapeutic modality, or the therapist's skills and years of experience--will respond to interventions in terms of the transference" Strean,p. An initial goal of brief psychodynamic therapy is to foster transference by building the therapeutic relationship.

Only then can the therapist help the client begin to understand her reasons for abusing substances and to consider alternative, more positive behavior. A longer term goal--necessitated by the brevity of the process--is to increase the client's motivation and participation in other modalities of treatment for substance abuse disorders.

Etiology Four contemporary analytic theorists have offered valuable psychodynamic perspectives on the etiology of substance abuse disorders. Wurmser, a traditional drive theorist, suggests that those with substance abuse disorders suffer from overly harsh and destructive superegos that threaten to overwhelm the person with rage and fear.

Abusing substances is an attempt to flee from such dangerous affects. These affects are the result of conflict between the ego and superego, brought about by the harshness of the superego. Given this understanding, Wurmser's main focus is the analysis of the superego. He believes that a moralistic stance toward the substance-abusing behavior is counterproductive and that substance abusers' problems consist of too much, rather than too little, superego.

Wurmser recommends that the therapist provide a strong emotional presence and a warm, accepting, flexible attitude. Khantzian theorizes that deficits, rather than conflicts, underlie the problems of those with substance abuse disorders. That is, weakness or inadequacies in the ego or self are at the root of the problem.

Khantzian and colleagues developed Modified Dynamic Group Therapy MDGT to address these issues in a group therapy format, and this approach has some empirical support.

Psychodynamic Perspective on Therapeutic Boundaries

Khantzian put forth the self-medication hypothesis, which essentially states that substance abusers will use substances in an attempt to medicate specific distressing psychiatric symptoms Khantzian, It follows, then, that substance-dependent persons will express a strong preference for a particular drug of choice to medicate their particular set of symptoms.

For example, those dependent on opioids are thought to be medicating intense anger and aggression that their egos are unable to contain. Cocaine-dependent people are believed to be seeking relief from intense depression or emotional lability as in bipolar disorders or attention deficit disorder. This continues to be a popular theory although most researchers and therapists now would say that this can offer only partial answers to the questions of how abusers develop drug preferences and what the meaning is of such preferences.

It is important to consider the social and physical environmental context of substance abuse as well. That is, whatever drugs are most readily available in a person's community and what his peers and associates are using also have a strong influence on a user's drug preference. Krystal offers two possible theories of the etiology of substance abuse disorders.

One is based on an object-relations conceptualization. In this theory, the substance abuser experiences the substance as the primary maternal object. The substance abuser relates to the substance in the same maladaptive relationship patterns that she experienced developmentally with the mother.

The second theory focuses on the substance abuser's disturbed affective functions, known as alexithymia. It is thought that individuals with alexithymia do not recognize the cognitive aspects of feeling states. Instead, they experience an uncomfortable, global state of tension in response to all affective stimuli. Thus they seek to relieve this discomfort with substances.

McDougall views substance abuse as a psychosomatic disorder. It is a way of dealing with distress that involves externalizing and making physical what is essentially a psychological disturbance. Substance abuse then is the habitual use of an externalizing defense against painful or dangerous affects. McDougall suggests that these painful affects are the response to deep uncertainty about one's right to exist, one's right to a separate identity, and one's right to have control over one's body limits and behavior.

The abuse of drugs is part of a "false self" that the individual creates to ward off these painful feelings. Some critics have argued that a major limitation of those psychoanalytic theories is that they do not make allowances for the biological bases of substance abuse disorders Babor, However, contemporary psychoanalytic theorists acknowledge that biology plays a role in behaviors related to substance abuse. But the unanswered question remains whether biological or psychological factors come first: Why does a person start using substances?

Analytic concepts are useful here, in that they can be said to facilitate the resolution of problems that contribute to emotional distress and to help explore the connection among interpersonal patterns, emotions, and substance abuse. Levenson and colleagues offer such a theory Levenson et al. They describe a biopsychosocial conceptualization of substance abuse disorders that can, in part, be addressed by brief psychodynamic therapy.

In this model, substance abuse disorders are particularly difficult to treat because, unlike other psychological disorders, there is a "primary urge" to abuse substances--an urge that can take precedence over every other aspect of life.

Furthermore, the symptom substance abuse is often considered pleasurable by the client, in contrast to the symptoms of other psychological disorders such as anxiety or depression. Thus, "[psychodynamic] therapy should be considered as part of an overall treatment plan that includes some kind of drug counseling and possibly other interventions as well, such as medications and family therapy" Levenson et al.