How to Dig for the Deeper Meaning in Substance Use

By Judy Levitz PhD 03/04/15

There's more than one way to practice addiction psychotherapy.


As our understanding of the biopsychosocial complexity of addiction evolves, the best clinicians continuously strive to incorporate new developments in theory and technique into their practices. While it is assumed that a practicing clinician will have mastered the use of relapse prevention and motivational interviewing techniques, the ability to combine these basic addiction therapy approaches with more nuanced psychotherapeutic advances that have developed independently of addiction practice gives clinicians an ability to dig deeper and go further with patients. Dr. Judy Levitz provides a master class on the incorporation of psychoanalytic principles and techniques in working with addictive disorders…Richard Juman, PsyD.

“Steven” misses his second session in a row, having called just an hour in advance to say that an unexpected partners’ meeting will prevent him from getting to his appointment on time. I will call him back later in the day to offer a make-up session and ask him if he is drinking again. “Sarah” texts me 20 minutes into our scheduled session, saying that she just woke up and won’t make it in; she writes that she’ll see me next week at the regular time. I text her back immediately, letting her know that I will call in two minutes so we can finish the session by phone. “Mona” is always early, so when she hasn’t shown up seven minutes into her normal session time, I call her and leave a message, letting her know I hope all is well and that she is en route.

So what does a truly broad skill set for working as an addiction therapist consist of?

What these clients all have in common is that they are all substance users having difficulty keeping their therapy appointments. What they do NOT have in common is everything else! One of the greatest challenges in doing clinical work is knowing how and when different approaches and interventions work effectively to foster lasting change. Is the client defended and requiring space or dissociated and needing active engagement? Will a flexible treatment contract foster the most secure foundation for ongoing work, or is a firm, consistent frame, which offers reliable boundaries required? How can we best equip ourselves to make these therapeutic judgment calls?

Most addiction treatment practitioners now agree that integrated treatment orientations are optimally effective in dealing with substance misuse issues since each person, situation, and addictive profile is so totally different. The strength in this growing ideology in our professional community lies not only in loosening the dogmatic and judgmental attitudes surrounding addiction, but also in that it fosters refinement and expansion of various approaches, including the medical/biological, the socio-cultural, and the psychological. 

There is further consensus that the variables of a) personalized, non-rigid treatment; b) ongoing respectful collaboration; and c) a broad clinical skill set for the clinician are fundamental necessities for an adaptive treatment outcome. So what does a truly broad skill set for working as an addiction therapist consist of?

All credentialed substance use counselors are required to obtain a sound knowledge of the biochemical effects of substances on the body and mind, an ability to accurately assess various phases of use and misuse, and a balanced knowledge of 12 step and detox resources. But, as the complexities of the addictive process continue to gain acceptance in the treatment community, it has become apparent that it is imperative to go into a person’s unique conscious and unconscious experience in order to help uncover the deeper meaning of substance use. This requires further skills to effectively apply cognitive, behavioral and psychodynamic theories and techniques. 

Psychoanalytic approaches, in particular, are more varied and applicable to work with addictions than ever before. Because of the greater understanding we have about addiction, thanks to the work of pioneers like Edward Khantzian, talk therapy is no longer viewed as a way to avoid dealing with the substance use itself. Analytically oriented therapists have further contributed to the field by bringing more attention to the underlying addictive attributes of behaviors such as eating disorders, shopping compulsions, gambling, pornography and sexual compulsions, gaming and even compulsive use of social media technology. When these “process” addictions are added to the list of familiar addictive behaviors, it is hard to find anyone in a private practice or clinic setting whose caseload doesn’t contain a sizable portion of individuals suffering from a related problem. Specially modified psychoanalytic approaches are constantly evolving to help relieve suffering and transform destructive addictive behaviors into adaptive, creative patterns of functioning and relating. 

The participants in a psychoanalytic treatment are no longer the blank screen therapist with the neurotic, hysterical patient on the couch! And, the analytic process is no longer an endless, four-times-a-week spelunking adventure into experience-distant memories and depth associations that unlock hidden and repressed sources of sexual anxiety and conflict. Most importantly, analytic treatments now engage people of every character type, whether sober, abstinent, moderating or struggling. Modern psychoanalytic sessions are vibrant, related, collaborative explorations of here-and-now problems and patterns with the added benefit of having such sessions led by an extensively trained clinician who helps bring underlying causative factors to light. It is a distinct advantage to have an analytically oriented therapist who has studied multiple in-depth theories and has been trained to apply these to patients with substance use problems.

For example, Contemporary Drive and Ego Psychology theories enhance the clinician’s ability to identify problems of impulse control, self-regulation, inflexible defenses and maladaptive behavior patterns. This directly informs my approach. Lane drinks because he is socially shy and can’t ask a woman on a date without a drink. I understand that alcohol serves to silence the self-critical voices in his head and thus loosen his inhibitions. I then focus in treatment on how to relieve his very harsh superego and help him discharge more anger. On the other hand, Andrew, who is angry and impatient all the time and uses a drink to take the edge off his irritability, needs my help to control and inhibit that anger. So, my interventions with him have the opposite aim—they are geared instead towards ego-strengthening to help him tolerate and inhibit his anger. 

Self and Object Relations theories shine light on the complex and intricate fabric of a person’s internal sense of self, how their patterns of relating have been solidified by their early experiences of how others related to them, and how these “organizing principles” and expectations predispose them to repeat interpersonal behaviors that no longer serve them well in the present. For example, in the early stages of engagement with Karen, a 46 year old math professor and alcoholic whose history predisposed her to expect and fear my judgments about her drinking, and who struggled with feelings of inadequacy and depression, I worked slowly and supportively to ensure that she didn’t experience my questions or interventions as challenging or critical. On the other hand, Matt, a 32 year old hedge-fund partner and cocaine addict, expected me to be detached and unconcerned about his activities. His fragile veneer of grandiosity obscured his terror of abandonment and loss. So unlike Karen, he needed me to be pro-active, engaged and to ask a lot of questions. A quiet, supportive stance with him would too easily be mistaken for disinterest. 

A Modern Analytic approach teaches clinicians distinct technical concepts and methods for maintaining alliances in the face of difficult negative feelings, while studying and managing ever-present counter-transferential feelings. One such concept is the “Contact Function,” which helps the therapist gauge when the patient actively seeks connection and is emotionally ready to use a particular intervention. Another concept is the “Developmental Moment,” which enables therapists to assess the developmental stage and need of patients in the moment, helping inform the therapists about how to use their own feelings, and whether an empathic, directive, reflective or interpretive intervention would be more effective. A third concept is called the “narcissistic defense” —a defense which takes many forms, such as self-attack, self-destructive drinking or drug use, somatization, and more—which helps the patient protects others from angry feelings by turning them against the self.

Following guidelines such as these and using unique interventions called “Emotional Communications,” I am able to fine tune my work to best meet the needs of my patients. For instance, with Josh, who constantly craves my feedback, I have a green light to comment—even interrupt him—anytime I have a thought or observation. But with Aideen, who hides and defends against my input, such spontaneity would be experienced as an assault and I must wait each time she speaks to be invited to participate. When Terry misses sessions, and I hypothesize that this is linked to her chaotic core, attention deficits and dissociative states, I will call her in advance to remind her, accept her lateness without confrontation, and gently inquire about her affect states. But with Barry, who devalues the treatment and skips appointments when he is actively using, I must simultaneous establish clear expectations and interpret his underlying shame. Across the board, the need to reverse the narcissistic defense heightens my awareness of the need to help all my patients gradually tolerate and express their negative feelings so as to relieve and reverse their self-attacking  and self-destructive behaviors.

Relational approaches emphasize the impact of the real and authentic interaction between therapist and patient, but go further by deepening the clinician’s awareness of the timeliness of self-disclosures and the impact of the patient’s feelings on the therapist and vice-versa.  

The unique relationship of the therapeutic dyad stands alongside transferential aspects of the relationship, and well-trained therapists harness all of these components and use them to therapeutic advantage. Combined with a knowledge of attachment theory, the role that substances play in bringing patients a greater sense of interpersonal security is revealed, and I can help patients become aware of this dynamic.

For example, when I understand that Cory’s attachment style is insecure/anxious, while Maya’s is ambivalent/disorganized, I can then understand what is transpiring transferentially. Cory’s corrective experience will depend upon my being emotionally present and not retreating from him. Maya’s on the other hand will depend more on my ability to be consistent and not act on the angry countertransference feelings that come with her alternating rejection of and dependency on me. 

Addiction treatment has come a long way from treatment approaches that require the patient fit the treatment. We know that sustained, ongoing treatment of individuals with addiction issues is required, because there is a much greater risk of relapse and destructive regression without ongoing therapy and support. For some individuals, gradual and partial abstinence is the only mode of survival, for others total abstinence is the goal. But in all cases, learning different psychoanalytic orientations enables the clinician to work more effectively with the broadest range of dual diagnosis patients, which pretty much accounts for all our patients!

Whether the substance or mental health issue is primary, secondary or co-implicated, a solid knowledge base in both fields is essential for rounding out the practitioner’s skill sets. When possible, learning multiple approaches in a setting where additional attention is also paid to the evolving research in infant development, trauma theory, and neuroscience further ensures the therapist is evenly equipped to help patients with such different diagnoses, personal histories, life circumstances, and different reasons for using. Many clinicians are able to acquire such knowledge at their job or agency and become well positioned to do this difficult work. For others, dedicated advanced training that specifically integrates psychodynamic, psychoanalytic and addictions treatment theory and technique can be just what is needed.  

Judy Levitz, Ph.D., NCPsyA is the founder of the Psychoanalytic Psychotherapy Study Center, a Caron Foundation Award Winner for Educational Excellence. It offers multi-orientational training programs in psychoanalytic psychotherapy, psychoanalysis and addictions training.

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Judy Levitz, Ph.D., NCPsyA is the founder of the Psychoanalytic Psychotherapy Study Center, a Caron Foundation Award Winner for Educational Excellence. It offers multi-orientational training programs in psychoanalytic psychotherapy, psychoanalysis and addictions training. Dr. Levitz maintains a private practice in Manhattan where she also teaches and runs supervision groups.