Psychodynamic Interpersonal Psychotherapy for Addicted Substance Users

Could Psychodynamic Interpersonal psychotherapy (PI), or The Conversational Model (Barkham et al., 2017), be used as an effective brief intervention for clients affected by substance use and/or addictions? In this article, I discuss the development of the PI model, evidence for its efficacy in specific populations, and exploration of its potential utility in addiction-affected populations.

I will also consider whether PI could be an effective intervention for clients with comorbid substance use and mental health disorders in this context. This article uses the terms Conversational Model and Psychodynamic Interpersonal interchangeably.

Table of Contents

What is Psychodynamic Interpersonal Psychotherapy?

Aims of Psychodynamic Interpersonal Psychotherapy

Current Research on Psychodynamic Interpersonal Therapy for Substance Use and Addictive Disorders

Comorbidity

Using IP in AOD Outpatient Services

Evidence for the Efficacy of Psychodynamic Interpersonal Psychotherapy

Further Considerations for Research

References References

What is Psychodynamic Interpersonal Psychotherapy?

Psychodynamic Interpersonal Psychotherapy (PI) was originally developed by colleagues Robert Hobson and Russell Meares in the 1960s. The model was formed as a response to the limitations of traditional psychodynamic approaches, which failed to help their more complex patients.

Traditional psychodynamic approaches, (such as classic Psychoanalysis, Transference Focused Psychotherapy and Self Psychology) which emphasise analytical interpretation (Barkham et al., 2017), placed the therapist in a more authoritative role. Meares and Hobson wanted to create a therapy that was more “humanistic”, (Meares, 2004, p.54) collaborative and relationship focused.

Their approach was more like a conversation than traditional psychotherapy, hence its alternative name of the “Conversational Model”. These complex patients were considered difficult to treat and had not responded to other forms of therapy. Many of these patients would be considered ‘borderline’ today, however, at the time they were considered to be “unanalysable” (Meares, 2004).

Aims of Psychodynamic Interpersonal Psychotherapy

According to Meares (2004), Psychodynamic Interpersonal Psychotherapy has two core aims. The first is to repair disruptions in the client’s experience of “self,” and the second is to address traumas that have caused injury in the past and are significantly impacting the present.

The concept of “self,” borrowed from William James, is described as a coherent, defined “stream of consciousness” (James, in Meares, 2004, p.53) that floats on a background of positive feelings or well-being when it is well integrated and healthy.

According to Meares, trauma interrupts this flow at certain key points, causing a rupture that allows negative perceptions of self and others to seep in. This rupture remains open unless it is in some way healed. This healing, or repair, may often occur within the context of a positive, caring, and healing relationship with another human being or in a therapeutic relationship.

Meares describes the healing therapeutic relationship as one that fosters a sense of “alone-togetherness” (Meares, 2004), a term his colleague Robert Hobson used. Alone-togetherness is a state in which being alone is no longer equated with feelings of intense isolation and abandonment, which is often the case with borderline clients.

Meares speaks of a third element created out of an empathic conversation that appears to develop within a therapeutic relationship. This is different from the desperate attempts at fusion with another person that tends to wreak havoc in the lives of severely personality-disordered people and their desired ‘self-objects’. Another way to describe this phenomenon is that the therapeutic relationship models a “secure attachment” style of relationship, as described in Object Relations therapy (Gilliland & James, 2003).

Another key self-attribute is a sense of duality or reflective awareness. In simplistic terms, it is the sense of self-awareness, a separation that occurs when one can take a step back and observe or reflect on one's behaviours and actions in the past and, through the process of engaging in therapeutic conversation, increasingly in the present.

These two attributes are central to the model, as a strengthened and renewed core self can assist with mature evaluations and responses to interpersonal conflict, which can help the client have healthier and more positive relationships moving forward.

This duality is not dissimilar to the concept of mindfulness or of “wise mind” which is taught as a skill in Dialectical Behaviour Therapy (DBT), a popular treatment option for borderline personality disorder. Wise Mind is conceived as a form of inner wisdom that can be achieved by blending the two opposing forces of emotional and rational reasoning. It can be achieved through developing and practising reflective, mindful awareness (Linehan, 2015).

Current Research on Psychodynamic Interpersonal Therapy for Substance Use and Addictive Disorders

There is currently limited research on psychodynamic interpersonal therapy for substance use and addictive disorders. The majority of research has been conducted in clinical settings on clients with general mental health and personality disorders, including depressed, self-harming and borderline personality disordered patients.

This author could find no studies of PI found which focused solely on substance use or addiction. However, a 1999 study of complex mental health patients, described as “high utilisers of mental health services” (Barkham et al., 2017, p.28), was found, which was of interest and could be co-opted for this article. The participants of this study were clients with comorbid physical and mental health conditions, including substance use dependence.

Comorbidity

There is significant research on the comorbidity of mental health and substance use disorders. The National Institute on Drug Abuse (2018b) reports that approximately half of people diagnosed with substance use disorder also have a mental health disorder. The prevalence of comorbid substance use and serious mental health issues in Victoria is also estimated to be high (50%), with anxiety disorders (including Post Traumatic Stress Disorder), depression and personality disorders being the most common comorbid mental health conditions (Health. Vic, 2013).

Many more clients present with sub-clinical symptoms of mental health disorders that either do not meet the criteria for diagnosis or have not yet been diagnosed (Health. Vic, 2013). The Comorbidity Guidelines, (2016) also state that “clients with comorbidity present to treatment with a more complex and severe clinical profile, including poorer general physical and mental health, greater drug use severity, and poorer functioning,” (p.14).

Psychodynamic Interpersonal psychotherapy, with its transdiagnostic approach, could be a suitable intervention for these complex clients, who might also be described as ‘high-end’ utilisers of community health services.

Using IP in AOD Outpatient Services

Although the Conversational Model was developed when working with severely disturbed patients in a hospital setting, it has been described as a transdiagnostic approach, which is “potentially of benefit in a wide variety of conditions” (Barkham, et al. 2017, p. 16). As mentioned above, however, its efficacy has not been tested in clients presenting with addiction or substance use disorders, specifically.

However, given the high rates of comorbidity in clients presenting to AOD (Alcohol & Other Drug) services, many of whom have complex histories and mental health diagnoses, the potential for the Conversational Model to be an effective intervention for such clients is promising.

A case could also be made that many AOD clients present with similar issues to those often found in borderline clients, such as poor relationships or an inability to sustain positive, healthy relationships due to their ongoing substance use, poor impulse control and often a history of complex trauma (Comorbidity Guidelines, 2016). Indeed, a substance user’s obsession with obtaining their drug of choice at almost any cost could be seen as similar to the desperate attempts at unhealthy fusion with an “other” that often characterises borderline relationships (Meares, 2004).

In fact, the concept of addiction as a “pathological relationship” with an addictive substance or behaviour is not new. Patrick Carnes used the phrase in his seminal book on sexual addiction, Out of The Shadows (Carnes, 2001). In Kohutian terms, the substance takes the place of the self-object and becomes the focus of an intense attachment. Levin, (2001) makes a case for addiction as regression to a state of “pathological narcissism” in which the core self is fragmented and incomplete.

The addicted person, haunted by inner feelings of emptiness, chronically low self-esteem and an inability to self-soothe, tries desperately to fill this undefined void with substances and/or behaviours which approximate a sense of security and completeness (as in the case of opioids for example) or grandiosity and specialness (in the case of stimulants) but which fail to deliver the desired outcome again and again, and again. The repetitive disappointment often leaves the addict feeling frustrated, empty and shattered.

I have found IP’s emphasis on repairing the fragmented and traumatised self makes it well suited as a therapeutic intervention for clients who present with comorbid mental health and addiction problems. In particular, clients presenting with comorbid borderline personality disorder, which has a high prevalence of 30% in AOD services, (Ross et al., 2005) seem to benefit from the relational emphasis of the model.

Barkham et al. (2017) highlighted three main elements in the model which are effective for various presentations. Firstly, the focus is on a shared, mutual language between client and therapist, which captures the clients’ experience empathically and genuinely (a collaborative, non-judgemental approach). Secondly, the experiential element, in which clients are supported to express formerly avoided feelings in the ‘here and now’ of the therapy session with an attuned therapist, and thirdly, the centrality of the relationship between client and therapist.

Some might note that these elements sound similar to the Rogerian core conditions of empathy, congruence and unconditional positive regard. Rogers’ emphasis on the centrality of the therapeutic relationship is well-established (Geldard & Geldard, 2012). However, it is perhaps the experiencing of previously avoided emotions, so common in addiction, that is of particular benefit in the treatment of AOD clients, who are not used to feeling intense emotions due to their dependency on an alleviating substance or behaviour.

Evidence for the Efficacy of Psychodynamic Interpersonal Psychotherapy

Psychodynamic Interpersonal Psychotherapy holds an enviable position as being one of the most studied psychodynamic therapies available. Numerous studies have been undertaken since the model was first conceived in 1965. The first major study was conducted in 1987 (Shapiro and Firth, 1987) in England, which focused on comparing PI with Cognitive Behaviour Therapy for clients presenting with depression. A follow-up study was conducted in 1994 (Shapiro et al., 1994) and in 1996 (Barkham et al., 1996).

These studies all showed that PI was as effective as Cognitive Behaviour Therapy in clients presenting with mild to moderate depression. However, PI proved more effective in clients who presented with interpersonal difficulties, self-harm, mixed mental health and other symptoms.

The Guthrie et al. (1999) study sampled 110 people with complex mental health issues who had been receiving treatment for 6 months in specialist mental health services with little to no improvement. These participants had several comorbid psychiatric diagnoses such as depression, anxiety disorders, personality disorders and substance use disorders. The study showed that participants who received PI therapy showed a reduction in mental health symptoms and an overall improvement in wellbeing and psychosocial functioning six months post treatment, compared with the control group.

They also represented a cost savings for healthcare costs post-treatment, requiring less inpatient treatment, medication, and staff costs. This research suggests that PI may be ideally suited to comorbid mental health and substance use presentations.

Further Considerations for Research

The PI model was intended by Hobson and Mears to be a teachable and accessible therapeutic intervention that could be used in various physical and mental health settings. A study was conducted by Guthrie and colleagues in 2004 (Guthrie et al., 2004) in which the PI model was taught to counsellors in a primary care setting who then treated 41 patients who presented with complex mental health and substance use problems.

The results showed positive improvement in the patients post-treatment, with 50% showing clinically significant improvement overall (Barkham et al., 2017).

There is a lack of research on Psychodynamic Interpersonal Psychotherapy and addiction or AOD clients, particularly those presenting to outpatient services, including private counsellors. However, given the high rates of comorbidity in clients presenting with substance use disorders, the evidence described above indicates that PI therapy would be an appropriate model for this client group.

Clients seeking support for substance use & addiction often present with a variety of mental health, social and physical addiction-related problems. It makes sense that a transdiagnostic approach, such as the conversational model, would be an appropriate and ideal modality to address the complex, overlapping and interwoven issues accompanying such presentations.

References References

Barkham, M., Guthrie, E., Hardy, G.E., & Margison, F. (2017). Psychodynamic- Interpersonal Therapy. A conversational model. London: Sage Publications.

Corey, G. (2009). Theory and practice of counselling and psychotherapy (8th ed.). Belmont, CA: Thomson Brooks/Cole.

Carnes, P., & Carnes, P. (2001). Out of the shadows: understanding sexual addiction (3rd ed.). Center City, MN: Hazelden Information & Edu.

Comorbidity Guidelines. (2016). Comorbidity Guidelines [PDF]. Retrieved from https://comorbidityguidelines.org.au/pdf/comorbidity-guideline.pdf

Geldard, D., & Geldard, K. (2012). Basic personal counselling: a training manual for counsellors (7th edition.). Frenchs Forest, New South Wales: Pearson.

Gilliland, B. E., & James, R. K. (2003). Psychoanalytic theory and object relations therapy. In Theories and strategies in counselling and psychotherapy (5th ed., pp. 69- 101). Boston, MA: Allyn & Bacon.

Guthrie, E., Margison, F. R., Mackay, H. Chew-Graham, C., Moorey, J. and Sibbald, B. (2004). Effectiveness of psychodynamic interpersonal therapy training for primary care counsellors. Psychotherapy Research, 14: 161-75.

Haggedy, J. (July 24, 2013) Psychodynamic Therapy. Retrieved from http://psychcentral.com/lib/psychodynamic-therapy/000119

Health.Vic. (2013). Dual Diagnosis. Retrieved from https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/specialist- responses/dual-diagnosis

Health.Vic. (2018). Alcohol and Other Drug Program Guidelines. Retrieved from https://www2.health.vic.gov.au/about/publications/policiesandguidelines/alcohol-and- other-drugs-program-guidelines

Health.Vic. (n.d.) Funding of Alcohol and Other Drug Services. Retrieved from https://www2.health.vic.gov.au/alcohol-and-drugs/funding-and-reporting-aod-services/funding-of-aod-services

Jacobs, M. (2003). Freud’s major theoretical contributions. In Sigmund Freud (2nd ed.,pp. 33-66). Thousand Oaks, CA: Sage Publications.

Jacobs, M. (2004). Introducing the psychodynamic approach. In Psychodynamic counselling in action (3rd ed., pp. 1-24). Thousand Oaks, CA: Sage Publications.

Jung, C.G. (1957). The Undiscovered Self. New York: Mentor.

Levin, J. D. (2001). Addiction as regression to pathological narcissism. In Therapeutic strategies for treating addiction: From slavery to freedom (pp. 71-97). New Jersey, NJ: Jason Aronson.

Linehan, M. (2015). DBT skills training manual (2nd ed.). New York: The Guilford Press.

Luke, C., Redekop, F., & Jones, L. K. (2018). Addiction, stress, and relational disorder: A neuro-informed approach to intervention. Journal of Mental Health Counseling, 40(2), 172-186. doi:http://dx.doi.org.ezproxy.navitas.com/10.17744/mehc.40.2.06

Markowitz, J. C., Svartberg, M., & Swartz, H. A. (1998). Is IPT time-limited psychodynamic psychotherapy? The Journal of psychotherapy practice and research, 7(3), 185–195.

Marsh, A., O'Toole, S., Dale, A., Willis, l. & Helfgott, S. 2013. Counselling guidelines: alcohol and other drug issues 3rd edition. Mount Lawley, WA, Australia Drug and Alcohol Office. Retrieved from https://www.mhc.wa.gov.au/media/1178/aod-counselling-guidelines.pdf

Meares, R. (2004). The conversation model: An outline. American Journal of Psychotherapy 58(1), 51-66.

NIDA. (2018a). Common Comorbidities with Substance Use Disorders. Retrieved from https://www.drugabuse.gov/publications/research-reports/common-comorbidities- substance-use-disorders/introduction

NIDA. (2018b). Comorbidity: Substance Use Disorders and Other Mental Illnesses. Retrieved from https://www.drugabuse.gov/publications/drugfacts/comorbidity- substance-use-disorders-other-mental-illnesses on 2019, October 19

Public Library of Science. (2013, May 28). Different types of psychotherapy have similar benefits for depression. ScienceDaily. Retrieved October 18, 2019 from www.sciencedaily.com/releases/2013/05/130528181023.htm

Ross, J., Teesson, M., Darke, S., Lynskey, M., Ali, R., Ritter, A., & Cooke, R. (2005). The characteristics of heroin users entering treatment: findings from the Australian Treatment Outcome Study (ATOS. Drug and Alcohol Review, 24(5), 411–418. https://doi.org/10.1080/09595230500286039

Strachey (Trans.). Introductory lectures on psychoanalysis Vol 1. (pp. 219-234) London: Penguin. (Original work published 1917).

Storr, A. (1983). The Essential Jung: Selected Writings Introduced by Anthony Storr. London: Fontana Press.

Sublette, M. E., & Novick, J. (2004). Essential techniques for the beginning psychodynamic psychotherapist. American Journal of Psychotherapy, 58(1), 67-75.