It is possible that children and young people presenting with internalizing difficulties improve their insight about their difficulties thanks to being in treatment Further studies could investigate which internal or psychotherapeutic processes occur and facilitate this growing capacity in children and adolescents, in order to evaluate what works best and for whom The psychodynamic approach to therapy enhances exploration and reflection on the client's emotional sphere, their affects and thoughts.
The literature seems to highlight that time-limited psychodynamic psychotherapies are less effective on Externalizing symptoms and it may be possible that different, multimodal approaches 54 — 57 or mixed treatment approaches—including cognitive-behavioral techniques—are needed with this array of difficulties from the onset of treatment 58 , An added layer of complexity while working clinically with young people and their parents in this study was represented by the variety of ICD diagnostic categories of this sample.
Our results seem to partly support the hypothesis according to which psychodynamic psychotherapy might not be as effective as other approaches in treating such disorders, whereas it constitutes an eligible treatment for depression, anxiety, eating disorders, somatic, and personality disorders With these regards, a study by Gonzalez 61 evaluated that psychodynamic psychotherapy seemed to be effective only on the depressive symptoms of clients affected by bipolar disorder.
On the whole, parents are reported in literature to be better equipped to recognize Externalizing problems in their children's behavior because these are more visible than internal problems or intrapsychic difficulties. Internalizing problems might also be more socially acceptable because of the limited impact they have on the outside world The parents' supportive intervention offered in the Neuropsychiatric Service aimed to help parents recognize their child's and their own emotional difficulties 63 , Whilst the children and adolescents' psychopathology had improved after therapy; in our study, adults' parenting skills did not seem to follow the same trend and no positive change was evaluated in the domain of family empowerment.
This result may be motivated by a number of reasons. It may be that increasing parents' awareness of specific issues might prompt a sense of incompetence and guilt, independently from their children's clinical outcome.
Interestingly, parents reported greater improvements, in their children's symptoms, than their children 12 months after treatment. Furthermore, it would have been helpful to explore if feelings linked to ending the treatment impacted parents' ratings on the Family Empowerment Scale.
It may also be important to consider that clients presented with high levels of comorbidity at referral and received an ICD diagnosis following their assessment. It was not possible to evaluate the impact of receiving a diagnosis on the family nor on their children's symptoms' improvements and it is hoped that further qualitative work will explore the impact that this may have on the family's perception of empowerment. It is relevant to consider that a self-report measure might not capture the nuances of what is defined as clinical change and improvement in parent work, not accounting for the family's history, nor for their current relationship dynamics or difficulties.
Systemic and psychoanalytic theories seem to agree in saying that homeostatic influences and resistances can occur when working clinically with families; change in one or the other parent could affect the couple's relationship, as well as their sense of empowerment It is important to highlight that this outcome study has attempted to capture information on the symptoms of a clinical population seen in a local Mental Health Service in Northern Italy to evaluate whether these symptoms had improved after 12 months of short-term-psychodynamic psychotherapy.
The use of well-validated self-report measures was essential but felt limited to T0 and T It would have been useful to collect data in itinere , and thus draw comparisons that would shed light on how and not only if our young participants responded to the treatment. The authors recognize that self-report questionnaires are susceptible to psychological biases and can be under the influence of social desirability.
Further, the way participants were assigned to each condition of the study—namely based on their clinical presentations and profiles—prevented any randomization and no causal relationships between the variables could be inferred from this research. Despite these limitations, our results seem to demonstrate an overall effectiveness, on symptoms' reduction, of our time-limited psychodynamic psychotherapy in treating children and adolescents with psychopathological issues.
This study is rooted in the real-world experience of clinical practice and therefore may present with important strengths. Its preliminary findings contribute to the growing body of literature on the use and the effectiveness of short-term psychodynamic psychotherapy with children and adolescents for a variety of psychiatric diagnoses 20 , 67 — Mindful that an outcome study is the starting line for future research on the topic, this study's findings add to the growing evidence calling for more tailored and bespoke interventions for children and adolescents.
This is based on the view that a child's development is the product of a varied and dynamic interaction between closely-interwoven factors, including co-parenting and the child's treatment within the family The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. The authors declare that written informed consent was obtained from all patients or other parties before their participation in the study, which had obtained the prior approval of the Ethical Committee of the ULSS All authors revised and reached an agreement on the final version of the work.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The broader research project called the Lausanne Trilogue Play used as psychodiagnostic and therapeutic tool in a Neuropsychiatric Unit: an innovative clinical experience working with psychiatric children and adolescents was funded by the Italian Ministry of Health GR World Health Organization.
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Springer US. Johnston C, Chronis-Tuscano A. Families and ADHD. In: Barkley RA, editor. Parenting practices and child disruptive behavior problems in elementary school. J Clin Child Psychol. The mediating role of parenting in the relation between personality and externalizing problems in Russian children. Pers Individ Dif. Therapist success and its determinants. Arch Gen Psychiatry. The CCRT develops from early childhood experiences, but the client is unaware of it and how it developed. It is assumed that the client will have better control over behavior if he knows more about what he is doing on an unconscious level.
This knowledge is acquired by better understanding of childhood experiences Bohart and Todd, The CCRT develops out of a core response from others RO , which represents a person's predominant expectations or experiences of others' internal and external reactions to herself, and a c ore response of the self RS , which refers to a more or less coherent combination of somatic experiences, affects, actions, cognitive style, self-esteem, and self-representations.
Most people with substance abuse disorders have particularly negative expectations of others' attitudes toward them that is, the RO , although it remains unclear which came first--this response or the substance abuse disorder. Either way, the two become mutually reinforcing. Following are examples of statements that reflect the core RO of a person with a substance abuse disorder: "Everybody hates me. For many people with substance abuse disorders, alcohol or drug use is a way of self-medicating against feelings of low self-worth and low self-esteem that reflect the client's RS.
A negative RO reinforces a negative RS and can lead to the deceptive and manipulative behavior that is sometimes observed in this population. The client's RS is based on the individual's somatic experiences, actions, and perceived needs. Following are examples of statements that could reflect a client's core RS: "I'm so stupid and gullible. A third component of CCRT is a person's wish ; it reflects what the client yearns for, wishes for, or desires. The client's "wish" is largely based on individual personality style.
Those with substance abuse disorders often have a wish to continue using the substance without having to endure the consequences. Put another way, they would like to be accepted or loved or appreciated as they are, without having to give up the pleasure they get from their use Levenson et al. Many people who have substance abuse disorders have much invested in denying that they really have a problem, in portraying themselves as helpless victims, and in disclaiming their role in the behavior that has brought them into treatment.
Once therapy has been initiated, the therapist and client can work together to put the client's goals into the CCRT framework and explore the meaning, function, and consequence of her substance abuse, looking in particular at how the RO and RS have contributed to the problem. The CCRT framework also can be used to identify potential obstacles in the recovery process as the therapist and client explore the client's anticipated responses from others and from herself and discuss how these perceptions will change when she stops abusing substances.
The CCRT concept also can help clients deal with relapse, which is regarded by virtually all experts in the field as an integral and natural part of recovery. Relapse offers the client and the SE therapist the opportunity to examine how the RO and RS can serve as triggers and to devise strategies to avoid these triggers in the future. Finally, SE therapy is conducive to client participation in a self-help group such as Alcoholics Anonymous, or it can be used as a mechanism to examine a client's unwillingness to participate in these groups.
SE is the therapeutic approach used. While dependent and impulsive, Stella, a year-old cocaine-dependent woman, would be seen under many circumstances as warm and open. She appears to be the kind of person who wears her heart on her sleeve, but it is a big heart nonetheless, capable of caring for others with loyalty and compassion. In addition, she has a tenacity of spirit; despite a horrific personal history she completed her training as a medical technician and has worked in that capacity for much of the last 4 years.
Her therapist, Christopher, is a well-trained psychodynamically oriented therapist. He is an intelligent, serious, and measured person, whose well-meaning nature comes through under most circumstances despite his natural reserve. Stella has a history of polysubstance abuse, including the abuse of prescription drugs, both anxiolytics and opioids. She worked as a medical technician until she injured her back 3 months ago. At the beginning of treatment, she told Christopher that she was going to request medication from her physician for her back pain.
After her eighth session, with her reluctant agreement, Christopher informed the physician that she was in treatment for cocaine dependence. Christopher asked the physician to find a medication other than diazepam Valium for Stella's back pain. Stella began the 19th session complaining that ever since the physician found out she was a drug user, he has treated her differently. Christopher acted uncharacteristically: he offered some advice. He suggested that Stella consider telling her physician how she feels about his treatment.
The intervention strikingly altered the mood and productivity of the session. 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: that she responded so strongly because of her negative view of herself. 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: she wants to be loved and cared for but believes she will be thwarted and exploited by others because of this wish.
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. By contacting her physician, Christopher replayed a common scenario in her life: she signals that someone should take control or care for her, then resents it when they do, feeling that she is being treated like a "scumbag drug addict.
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. 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.
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. The authors concluded that SE therapy could be an effective treatment for cannabis dependence.
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 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 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. 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.
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 aware , actively 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 drinking , as 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. 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. Figure Defense Mechanisms. 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. 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. 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. 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.
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