Psychotherapy with substance abusers: integration of psychodynamic and cognitive-behavioral approaches.

Integration of Psychodynamic and Cognitive-Behavioral Approaches Historically, psychotherapeutic approaches utilized with substance abusers have been a reflection of the most prominent modality being used at that particular time to treat mental disorders. Initially, the principles of psychoanalysis and psychodynamic psychotherapies were applied to substance abusers (1, 2). The concept that all symptoms arose from some underlying and often unconscious psychological conflicts was applied to the symptoms of drug abuse (3). Without resolution of the underlying conflict, symptom substitution would occur, e.g., depression or phobias. Unfortunately, using psychoanalysis or psychodynamic psychotherapy as the only treatment modality yielded disappointing outcomes. The therapist's typically neutral, passive stance that is essential to the development of transference and exploration would be ineffective in controlling the active symptoms of drug abuse. The lack of structure and limit setting allowed the ongoing drug use to undermine the treatment. The anxiety-arousing aspect of free association would elicit more drug use. Patients dropped out of treatment. Perhaps in response to the failure of psychodynamic therapies, other psychosocial treatments, geared specifically to substance abusers, were developed. These include Alcoholics Anonymous (AA) and therapeutic communities. Subsequently, the principles of cognitive, behavioral, and client-centered therapies began to be modified for application to addicted patients (4, 5). In addition, biological treatments, such as methadone maintenance for opiate dependence (6) and disulfiram for alcohol abuse (7), were introduced. The prevailing strategy that is now central to all psychotherapeutic modalities is to primarily focus on the achievement of abstinence from drug use. Once drug use becomes controlled and abstinence is attained, then the recovering addict can begin to address issues of social rehabilitation, interpersonal functioning, and even resolution of intrapsychic conflicts. There is growing evidence that individual psychotherapy can be an effective modality for substance abusers (8). The key is to match the appropriate modality to the patients' needs, depending on their stage of recovery. The sequence and timing of psychotherapeutic modalities ranging from cognitivebehavioral therapies to the integration of psychodynamic principles enhance the possibility of successful outcomes. The following is a brief description of how the various psychotherapeutic approaches can be integrated into the treatment of substance abusers. Multiple factors may influence what brings a drug abuser into treatment. But rarely is the initial motivation a desire to stop drug use altogether. Typically, the motivating factors are externally driven. These can include legal consequences of drug or alcohol use (e.g., DWI), marital or family difficulties, and school or employment jeopardy, as well as physical consequences of drug use (e.g., hepatitis, cirrhosis, HIV disease, etc.). The general motivation is that if these external consequences could be alleviated, then the substance use would not be seen as a problem. Women tend to enter treatment via the mental health or primary care system with psychological complaints of depression and anxiety and only on further questioning does it become clear that there is comorbid drug or alcohol use (9). Certain investigators have hypothesized stages in the development of drug abusers' readiness to stop drug use (10, 11). These range from precontemplation to contemplation and on to action and determination. These motivational approaches hinge on meeting patients "where they are at." In order to build the resolve to stop, the ego-syntonic aspects of drug use (e.g., pleasure, social gratification, relief of painful affects) need to be counterbalanced by the ego-dystonic aspects of drug use (e.g., medical sequelae, loss of job, divorce). This motivational form of therapy uses cognitive principles to help set the goals and framework for the psychotherapy. …