Psychoanalytic psychotherapy in addictive disorders.

Psychoanalytic psychotherapy can afford a viable treatment option for certain carefully chosen patients whose needs go beyond the immediate control of substance use. Though the evidence base specifically for addictions is lacking, an emerging body of evidence has demonstrated good effect in the commonly seen co-morbid conditions such as depression, anxiety and personality pathology.

WHAT IS PSYCHOANALYTIC PSYCHOTHERAPY?

Psychoanalytic Psychotherapy helps individuals achieve a deeper awareness of themselves, their unconscious desires, motivations and conflicts. Awareness does not in itself bring about change, however, it offers the individual a choice; a choice to not repeat unhelpful and self-damaging patterns. The individual may choose to not use the awareness that they have worked hard in therapy to achieve but in our experience most people do.

Psychodynamic and psychoanalytic psychotherapies have their roots in the clinical work of Sigmund Freud, Melanie Klein, Donald Winnicott and others. The focus of these therapies is the transference relationship between the therapist and the patient. Psychodynamic therapy happens at a frequency of once or twice a week and is done with the therapist and patient facing each other. They can be brief and may even have a focus or predetermined goal. Psychoanalytic psychotherapy is more exploratory in nature. The patient is on the couch, facing away from the therapist and sessions happen at a frequency of 3 to 5 times a week. With increasing frequency, the work and the transference relationship become more intensive.

For the purpose of this article the word psychoanalytic psychotherapy has been used to designate both psychoanalysis and psychoanalytically informed therapies.

Current Evidence

The evidence base for psychoanalytic psychotherapies has been generally considered weak. This belies the vast body of peer reviewed published work that exists in the field. Unfortunately, the research has largely not translated to the standards expected of modern evidence based practice but this deficit is being rectified. Over the last two decades there has been an emerging body of good quality longitudinal studies looking at specific outcome measures1234. Randomization has been a problem but that is also being addressed for example in the recently published work by Taylor et al. in 20125.

Psychoanalytic writing has also been criticized for its lack of focus on specific disorders and syndromes. This is inherent in the way psychoanalytic psychotherapy approaches symptoms, as an indicator of the underlying pathology but not the main focus of treatment. Studies looking at effectiveness specifically in addictions are few in number. Establishing efficacy and effectiveness requires standards of control that are more difficult to maintain in long term, open ended therapies6.

A review of the available literature reveals some important findings. Psychoanalytic Psychotherapy shows impressive effect sizes as a long-term therapy378. Effect sizes are greater at longer follow ups than immediately after the end of therapy suggesting that those who have undergone psychoanalytic psychotherapy keep making gains long after the therapy has ended1910. The inclusion of psychoanalytic techniques and process in non-psychoanalytic interventions can increase effectiveness of these treatments1. There are significant positive findings in treatments for personality pathology311.

When looking specifically at addictions we find that there are more exploratory studies looking at process rather than outcome.

Yalisove and Daniel12 recommend the use of modified psychoanalysis as a treatment for addiction and review the outcome research for such therapy. They suggest “modifications to traditional psychoanalysis that may be made for persons with addiction include an initial phase of treatment that is supportive and didactic, followed by more psychoanalytically oriented treatment; a therapist who is active rather than passive; the forestalling of transference; and the recommendation for participation in Alcoholics Anonymous.” 2 out of 3 studies in which modified psychoanalysis was used with persons with addiction found that those subjects derived significant benefit from the therapy.

Prochaska and Diclemente13, state that change processes traditionally associated with Experiential, Cognitive and Psychoanalytic traditions are most helpful during contemplation and pre-contemplation stages whereas change processes associated with behavioural and existential processes are most suitable during action and maintenance stages. Mc Govern and Caroll14 in their paper on evidence based practice for substance use disorders found psychodynamic supportive–expressive psychotherapy as developed by Luborsky15 to be an effective intervention for opiate use disorders, especially when delivered by skilled therapists.

Rosenthal in 200816 asserts that both CBT and pharmacotherapy have high dropouts when working with pathological gambling while psychodynamic psychotherapy with its focus on therapeutic relationship and the meaning of the patient's destructive behaviour, could provide better results.

In his doctoral study, ‘Therapy with couples with Addiction: A psychoanalytic perspective’, Loveland17 concludes that use of Psychodynamic approach is effective since each couple is unique and morphing and a manualized approach is not helpful. He also recommends that his psychodynamic colleagues challenge their anxieties regarding working with couples with addictions.

To summarize, the evidence specifically for psychoanalytic psychotherapy in addictions is limited but there is a definite interest.

Psychoanalysis and Addictions: A road less travelled

The website of the British Psychoanalytic Council has a quotation from Jane Milton's book (18) “if you are a heavy user of drugs or alcohol, you are unlikely to benefit from exploratory psychotherapy until you are completely free of the substance you are dependent on, and physically recovered. Only then you will have a clear enough head, and enough self-control, to be able to work together with the therapist and to hold onto what happens in the session. While you are still using the substance, a structured educational approach aiming to help you free yourself of the addiction will probably make most sense or a self-help approach like Alcoholics Anonymous or Narcotics Anonymous”. This polite notice succinctly summarizes the stance psychoanalysts have held but more importantly the stance psychoanalysis is believed to hold by the wider community.

This is a common view, very much in practice, that the patient needs to be ‘clean or dry’ before they can start psychoanalytic psychotherapy. Also, treatment is stopped if the patient uses again. A young man, to whom I was trying to explain that psychoanalytic psychotherapy is not the right course for him since he was actively using substances said ‘but you want me to be cured of that which I need treatment for! ‘ I thought he had a point but I also believed that a man who will just smoke away the anxiety after each session cannot be helped by psychoanalytic psychotherapy. People prone to addictions can use the understanding afforded by the psychotherapy to justify their actions and their helplessness.

Looking back, however, I used to manage my own analysis by walking into the various pretty boutiques that lined the way to my analyst's office and often giving into the impulse to buy the bright, shiny, beautiful objects they sold. What a relief! We all use addictive states to get rid of distress but for some this is a very entrenched compulsion.

Addictive behaviours are desperate attempts to get rid of overwhelming emotional states and is successful in short spurts. Addictive behaviours aim at getting rid of anxieties while psychoanalytic psychotherapy aims at staying with a difficult experience to understand it better. In a way this is similar to exposure therapy but here the exposure is to unconscious internal states. Many people would hence not wish to work analytically with individuals suffering from addictions. Equally, psychoanalytic psychotherapy does not focus overtly on presenting symptoms which would make it unsuitable as a first line of treatment.

However, none of what we have said is untrue for other presentations. All patients present to the psychotherapist with a symptom. All symptoms are an individual's way of managing their anxieties and anyone can misuse knowledge or use psychotherapy as an intellectual escape. Dodes, in his 2003 paper expands on this view19. The particular difficulty with addictions, I think is the individual's tendency to become addicted; a state where something is used repetitively for immediate and short term relief. While psychotherapy offers a safe space to think, it can easily be manipulated to offer an addiction. These reasons could have kept psychoanalysts away from working with persons with addictions. Addictions are a difficult condition to treat because at their core it is an addiction to something destructive20.

In the preface of the book ‘Addictive States of Mind’21, Bower writes about the essential core of psychoanalytically informed treatments in addictions. The “strong commitment to tolerate, and to work with, often very extreme degrees of trauma, disturbance, perversity, and horrifying cycles of self- and other- destructive behaviours of a kind that makes such patients very hard to reach” and the “maintaining of a psychoanalytic attitude of mind can be seen to support the capacity to contain anxiety and also ‘to think under fire’.”

What we think Bower is stating is that not only is psychoanalytic psychotherapy used to work with individuals with very deep seated and entrenched addictive states of mind but that even where the setting uses different types of interventions a psychoanalytically supported thinking space has been found to be very useful.

Here we would specifically like to mention the Tavistock and Portman clinics both of which are bastions of psychoanalytic psychotherapy. The Portman largely deals with patients who have come into contact with the legal system and amongst whom the prevalence of addictions both to substances and paraphilias is higher. Hence it would be ignorant to think that psychoanalytically oriented therapies are ineffective in treating addictions.

Understanding Addictions – A psychoanalytic perspective

In our work, we see individuals suffering from addictions even if they are not abusing any substance. An addiction is a tendency to use repetitively and hence without thought, something - a substance, a state, an experience or a relationship. The addiction can be in the form of gambling, pornography, use of the internet, shopping and in perverse ways of relating. This either provides immediate relief or at least a distraction from something that feels unbearable. The individual sets up a repetitive cycle that offers a retreat from real life, ‘real’ others and importantly, allows for the illusion of complete control.

Most people come to psychotherapy because they are troubled by something and because they feel that their problems are having an adverse impact upon those they love and care for. They are troubled by the fact that despite talent they have become stuck in their lives. In contrast a person with addiction is often brought by others. Most persons with addictive disorders are not able to think about changing anything, at least not in themselves. Usually people suffering from a drug or alcohol use disorder do not come to see a psychotherapist. People suffering from sex addictions might because they may think that sex is of interest to a psychotherapist. They do not realize that their problem is not sex, but addiction to something repetitive and meaningless and an absence of any real relationships.

Early psychoanalytic theories on addictions stressed on pleasurable and aggressive drives. Today, however, psychoanalysis takes a much broader perspective, understanding addictive states as ways to manage intolerably painful and confusing affect. It is like self-medicating states of subjective stress and suffering22. That it comes at a cost often does not form a part of the addicted individual's visual field and if at all they are irked by guilt or loss those too can be dealt with via the addiction.

Clinical Implications

Working with a person suffering from an addiction is a challenge. It requires one to be able to bear something that is destructive and perverse. Psychoanalytic space can allow for thinking and provide a containment of overwhelming anxieties23.

When working with addictive states psychoanalytically, the emphasis is not so much on discrete symptomatology but rather on the whole person and how particular defense mechanisms came into existence. Persons suffering from an addiction protect themselves from unbearable pain and confusion by developing a narcissistic defense organization that combines omnipotence with denial of dependency (24). This pathological defense organization rests on a split and confusing world which is both strengthening and overpowering; secure and abusive; all in one. Understandably, alcohol and drugs are often referred to as self- medication chasing away depression, anxiety and even psychosis242526.

Given that addictive states can be so destructive both to the individual and others trying to help them we have to be constantly aware of our countertransference. Psychoanalytic thinking can offer a space to multidisciplinary groups to maintain compassion and a wish to understand under such an attack. The work is always through transference and countertransference. Dysfunctional, abusive dynamics get transferred to the therapist, the team or the family easily. The dynamic of ‘I don't depend on anyone’ is very much reflected in the rigidly hierarchical systems in teams, where it would be unthinkable that every member of staff irrespective of their position can stand in for anyone else.

Case Vignette

Mr A is a young married man, living abroad. He sought a consultation because his wife of 3 years was unable to have sex with him and he managed the situation by having sex with multiple women he met on dating websites. He would meet a girl only a few times, for the express purpose of having sex. He did not want a relationship, because that could lead to a divorce, which was unthinkable for him. He said he was sexually active before marriage; however the only women he had sex with were sex workers. He had two girlfriends but never had sex with them because he was terrified of their fathers.

He would often send his wife back to India and then go through an elaborate process of cleansing the house of her presence. He would then invite women home. He would also meet the women in hotel rooms during work hours. He said his work was flexible. The girls all believed him to be unmarried. He said that recently he had met a girl and was now ‘completely hooked on to her’. However, she did not wish to see him for some time. This had made things very difficult for him and hence he had written to me and had come down to India to see me for a one off consultation. I told him that since his girlfriend will not have him he has come to me for a one night stand. It did not seem that he wished to seriously think about his predicament.

He said that the girl had a few other regular partners but since he had met her he had only wanted her. He felt that sex with this girl was the best he had because she did not ask him to use a condom. I was surprised. I checked again that did he not say that she had a few other partners. He said yes. I asked him why he would have unprotected sex with a woman who had multiple partners. He looked unclear about my question and said ‘because I trust her!’ I observed that on the one hand he did not wish to have a long term relationship with anyone of them but on the other hand they all knew his address despite having created a false profile on Tinder. Once again he looked confused.

Mr A appears very confident of his elaborate plans, completely unaware of the many ways things that could go wrong. In his mind it was all foolproof. He had seen a few psychiatrists by himself. He did not think his wife should be exposed to discussions regarding sex. She was naive in such matters, he said smiling. What was interesting however, is the split in his mind. There were women one had sex with and there were women who one had a relationship with. One is stained and sexually potent, the other pure and virginal, with a powerful and threatening father watching over her. As we explored this issue he said that he grew up in a house with his mother and his sister. His father worked abroad and came down only once a year. His parents fought a lot and his father would beat up his mother and him, if angered in the slightest. He was terrified of him. He said that in contrast, his parents in law treated him like a son. He told me that the only girl he had fallen in love with was his first cousin. He had wanted to marry her but her father, his uncle, was dead against it.

As a psychoanalytic psychotherapist, I notice three things about his presentation. First, that he was addicted to a particular type of sexual relationship. The lies, the hiding, the charade is foreplay. He engages in his habit secretly and the shame and fear of exposure are essential ingredients to heighten excitement. He justifies the entire set up by stating that his wife cannot have sex.

Second, I notice a repetition. A young boy growing up as the man of the house with two women, who he loves and respects and whom he must protect from all that is experienced as murky and dark in him; his sexual feelings and fantasies. There is also the figure of a frightening father looming in the background who thrashes him regularly as if he knew.

Third, the nature of the relationship such a split creates. He does not have a real, adult relationship with anybody; with neither man nor woman. It is as though the only relationships he can have are these rushed sexual encounters in a hotel room, just like the rushed consultation with me. I am very sure that he will cleanse his mind of me as quickly as he cleanses his body of the women he has been with. He can have sex but he cannot relate with another person. He believed that his wife cannot have sex but I think equally he cannot have sex with a woman who lives in the house with him and whose father treats him like his own son.

When I shared these thoughts with him he said that he had not thought about things in this way but it didn't feel completely alien. He said that his sister was born within less than one year of his birth and he had always felt he rushed into growing up. He shared memories of coming to his mother distressed or scared and seeking warmth and contact but his mother would tell him that he was a big boy, there to look after her. She would constantly fill him up with stories of how his father mistreated her and remonstrated that he must never become like his father. He didn't think he had a close relationship with anyone.

CONCLUSION

The idea of finding out the meaning and origin of the addictive behaviour and treating it at its source is an appealing and seemingly logical proposition, one that many persons suffering from an addiction themselves seek. Alas, what seems logical and clear is in practice beset with obstructions and blind alleys. The addiction itself often becomes a hurdle to a fuller and deeper engagement with the analytic process as it can anaesthetize the anxieties that this process brings up. This necessitates a careful assessment process before recommending this method as a treatment option. Where there is a good match the process and outcome can be fruitful for both the patient and the therapist.