1. Psychodynamic Psychotherapy and Addiction Claudio Costanza Addiction Clinical Psychology Service SLAM January 2014

2. Aim of presentation Psychodynamic psychotherapy of addiction, evidence and NICE guidelines Psychodynamic psychotherapy of addiction, evidence and NICE guidelines Psychodynamic models of addiction (object relation theory, attachment theory) Psychodynamic models of addiction (object relation theory, attachment theory) Other considerations: Assessment, Therapeutic relationship.. Other considerations: Assessment, Therapeutic relationship..

3. A definition of psychodynamic therapy with addiction Central principle : much distress is caused by unresolved unconscious tendencies. Central principle : much distress is caused by unresolved unconscious tendencies. Goal : Increase self-awareness and understanding of the influence of the past on present behaviour and on the quality of clients’ interactions with others. Through exploration of thoughts and feelings, free associations, memories, fantasies and dreams, and with the help of the therapist’s interpretation, this model helps clients to better understand their emotions and change their ways of relating to others as well as to substances. This will help clients to eventually feel freer to lead a more fulfilling, creative life without the help of substance Goal : Increase self-awareness and understanding of the influence of the past on present behaviour and on the quality of clients’ interactions with others. Through exploration of thoughts and feelings, free associations, memories, fantasies and dreams, and with the help of the therapist’s interpretation, this model helps clients to better understand their emotions and change their ways of relating to others as well as to substances. This will help clients to eventually feel freer to lead a more fulfilling, creative life without the help of substance

4. Psychodynamic therapy and addiction Particular attention is given to the relationship with the therapist, through which, the patient may relive situations, feelings and thoughts from their early life: The ‘transference’ Particular attention is given to the relationship with the therapist, through which, the patient may relive situations, feelings and thoughts from their early life: The ‘transference’ Although historically viewed as a long-term psychological work, this approach can also be a short-term intervention. Short-term psychodynamic counselling will have one major focus, which creates a structure and identifies a goal. Although historically viewed as a long-term psychological work, this approach can also be a short-term intervention. Short-term psychodynamic counselling will have one major focus, which creates a structure and identifies a goal.

5. Psychodynamic therapy and addiction This approach can be integrated with more drug-focused intervention such as drug counselling, group programs, therapeutic communities or NA/AA. This approach can be integrated with more drug-focused intervention such as drug counselling, group programs, therapeutic communities or NA/AA. This approach can help to better understand the therapeutic relationship and what the client may experience in recovery.

6. Review of evidence based for psychodynamic therapy with addiction Not a great deal of recent ‘evidence based’/randomised controlled trial on psychodynamic therapy with addiction exhists Not a great deal of recent ‘evidence based’/randomised controlled trial on psychodynamic therapy with addiction exhists But some research have demonstrated the effectiveness and usefulness of PT with addiction: But some research have demonstrated the effectiveness and usefulness of PT with addiction: Woody and co. (1983) and Luborsky and co. (1985) have showed that adding supportive-expressive therapy (SET) to standard drug counselling for opiates client on methadone maintenance program was beneficial to client with higher levels of psychopathology. Woody and co. (1983) and Luborsky and co. (1985) have showed that adding supportive-expressive therapy (SET) to standard drug counselling for opiates client on methadone maintenance program was beneficial to client with higher levels of psychopathology. They also showed major advancement in their lives, entered the job market and stopped using drugs

7. Review of evidence based for psychodynamic intervention with addiction Woody and co. (1995, 1998) have shown the effectiveness of SET in methadone programs. Clients required less methadone than those who received standard drug counselling and after 6 months, clients maintained their gains or showed continuing improvement Woody and co. (1995, 1998) have shown the effectiveness of SET in methadone programs. Clients required less methadone than those who received standard drug counselling and after 6 months, clients maintained their gains or showed continuing improvement Grenyer and co. (1995) compared brief drug counselling with cannabis dependency with SET (one weekly session over 16 weeks). Results showed that SET produced larger significant reduction in cannabis use, depression and anxiety Grenyer and co. (1995) compared brief drug counselling with cannabis dependency with SET (one weekly session over 16 weeks). Results showed that SET produced larger significant reduction in cannabis use, depression and anxiety Carroll and co. (1991) compared RP treatment with Interpersonal therapy (IPT) for cocaine users over 12 weeks individual sessions (N=42). Both approaches showed favourable outcome, with IPT showing higher rate of attrition. Carroll and co. (1991) compared RP treatment with Interpersonal therapy (IPT) for cocaine users over 12 weeks individual sessions (N=42). Both approaches showed favourable outcome, with IPT showing higher rate of attrition.

8. Evidence-based Some case studies also show the usefulness of psychodynamic therapy (attachment model, object relation model, supportive expressive therapy etc.) with addiction in addition to standard drug counselling interventions or group programs: Some case studies also show the usefulness of psychodynamic therapy (attachment model, object relation model, supportive expressive therapy etc.) with addiction in addition to standard drug counselling interventions or group programs: Hagman (1995) explains the relevance of using ego psychology for methadone maintenance clients Jerry (1997) demonstrated the relevance of object-relations approach in a case study of a young woman using intravenous cocaine Potik and co. (2007) shows the relevance of using object relation theory and in particular the concept of transitional object when working with methadone maintenance clients Potik and co. (2007) shows the relevance of using object relation theory and in particular the concept of transitional object when working with methadone maintenance clients Read (2002) shows the usefulness of using psychotherapy and in particular object relation model with clients on methadone maintenance program and using heroin etc. Read (2002) shows the usefulness of using psychotherapy and in particular object relation model with clients on methadone maintenance program and using heroin etc.

9. NICE and psychodynamic therapy of addiction Demonstrating effectiveness of psychodynamic therapy is complex and not always readily testable ‘in a brief manner’: time, clarity of measures, funding and possibly motivation Demonstrating effectiveness of psychodynamic therapy is complex and not always readily testable ‘in a brief manner’: time, clarity of measures, funding and possibly motivation As a result, it is difficult to find psychodynamic therapy as a recommended intervention by NICE guidelines As a result, it is difficult to find psychodynamic therapy as a recommended intervention by NICE guidelines

10. Personality Disorder and Addiction NICE ‘consider’ psychodynamic intervention only in the case of ‘co-morbidities’ (depression/anxiety) NICE ‘consider’ psychodynamic intervention only in the case of ‘co-morbidities’ (depression/anxiety) NICE does not mention PD as ‘co-morbidity’ when it is fully recognised that it is one of the major co-morbidity with addiction (Oldham, 1990; Stone, 1993; Millon, 1996, Krampe et al., 2006, Verheul, 2001,Van Den Bosh & Verheul, 2007) NICE does not mention PD as ‘co-morbidity’ when it is fully recognised that it is one of the major co-morbidity with addiction (Oldham, 1990; Stone, 1993; Millon, 1996, Krampe et al., 2006, Verheul, 2001,Van Den Bosh & Verheul, 2007) Van den Bosh & Verheul (2007) in their study on PD and addiction stresses the importance of addressing both the addiction problem and the personality disorder for the treatment to be effective Van den Bosh & Verheul (2007) in their study on PD and addiction stresses the importance of addressing both the addiction problem and the personality disorder for the treatment to be effective Many research have shown the effectiveness of psychodynamic therapy with PD: Many research have shown the effectiveness of psychodynamic therapy with PD:(Shedler 2010, Levy and Ablon 2010) Leichsenrin and Leibing (2003) have conducted a meta-analysis on the effectiveness of psychodynamic therapy with PD by reviewing studies which were published from 1974 to 2001 (N=417) and showed evidence of long-term positive effect of psychodynamic therapy with PD. Leichsenrin and Leibing (2003) have conducted a meta-analysis on the effectiveness of psychodynamic therapy with PD by reviewing studies which were published from 1974 to 2001 (N=417) and showed evidence of long-term positive effect of psychodynamic therapy with PD. Bateman A & Fonagy P (2001) have shown the usefulness of treatment of BPD with psychoanalytically oriented therapy in partial inpatient setting/mentalization based Treatment Bateman A & Fonagy P (2001) have shown the usefulness of treatment of BPD with psychoanalytically oriented therapy in partial inpatient setting/mentalization based Treatment

11. Therapeutic alliance and addiction The quality of the T/A is a significant factor for client engagement and retention in addiction treatment (Fiorentine et al., 1999; Simpson et al., 1997, 2000) or in change in drinking behaviour (Connors et al.,1997) or in drug use (Barber et al., 1999). The quality of the T/A is a significant factor for client engagement and retention in addiction treatment (Fiorentine et al., 1999; Simpson et al., 1997, 2000) or in change in drinking behaviour (Connors et al.,1997) or in drug use (Barber et al., 1999). Relevance: psychodynamic approach/model views the therapist-client relationship as central and the vehicle through which change occurs Relevance: psychodynamic approach/model views the therapist-client relationship as central and the vehicle through which change occurs

12. NICE Guidelines Importance of following NICE recommendations Importance of following NICE recommendations However, many psychological approaches can be considered when working with addiction considering the complexity of this problem (more use of micro-evidences of effectiveness of approaches with individual service users) However, many psychological approaches can be considered when working with addiction considering the complexity of this problem (more use of micro-evidences of effectiveness of approaches with individual service users) Importance of using several psychological models when dealing with addiction clients who often present with many co-morbidities (BPS) Importance of using several psychological models when dealing with addiction clients who often present with many co-morbidities (BPS) Importance of offering client ‘alternatives’ Importance of offering client ‘alternatives’ Importance of including service users' views Importance of including service users' views

13. The Orange Book (NTA, 2007) Guidelines written on behalf of the Department of Health and provide guidance on the treatment of drug misuse in the UK. They are based on current evidence and professional consensus on how to provide drug treatment for the majority of patients, in most instances Psychodynamic therapy is mentioned in the Clinical Guidelines or Orange Book. Recommended when other approaches did not work or when clinical jugement suggest that it is appropriate

14. Psychoanalytical models of addiction Various psychoanalytical models: Attachment/object relation/egopsychology etc... Models that will be discussed today: Object relation theory and addiction/Winnicot Attachment theory and addiction/Bowlby

15. Object relation theories The theory posits that a mind develops and grows in relation to others in the environment. Object relationships are initially formed during early interactions with primary care givers. These early patterns can be altered with experience, but often continue to exert a strong influence throughout life The theory posits that a mind develops and grows in relation to others in the environment. Object relationships are initially formed during early interactions with primary care givers. These early patterns can be altered with experience, but often continue to exert a strong influence throughout liferelationships

16. Object relation theory and addiction Winnicott, psychoanalyst and pediatrician (1896-1971) sees addictions as an attempts to re-find the lost object through direct physical gratification (1953, 1971) According to Winnicot there are similarities between addiction and the mother-baby relationship in the absolute dependence phase (subjective omnipotence/symbiotic mother-child relationship) Absolute dependence is the first phase during development, in which the infant is not aware of an external mother who satisfies his needs (1960). The infant sees himself and the mother as a whole. In this phase the mother ‘brings the world’ to the infant without delay which gives him a ‘moment of illusion’, a belief that his own wish creates the object of his desire which brings with it a sense of satisfaction The infant sees himself and the mother as a whole. In this phase the mother ‘brings the world’ to the infant without delay which gives him a ‘moment of illusion’, a belief that his own wish creates the object of his desire which brings with it a sense of satisfaction

17. Object relation and addiction The baby considers himself as all-powerful and the center of the mother’s existence The infant lives in a magical/imaginary world (detached from reality) in which needs are self-satisfied. His experience lacks any sense of continuity in himself or others and the time factor is missing The pleasure principle is a central characteristic in the infant’s magical and omnipotent world and all his actions are aimed towards getting satisfaction

18. Object relation and addiction Later on the child comes to realise that the mother is separate from him. The child has lost something. Later on the child comes to realise that the mother is separate from him and not within his control. The child has lost something. The child realises that he is dependent on others and vulnerable The child realises that he is dependent on others and vulnerable He loses the idea that he is independent, a realisation which creates a difficult period and brings frustration and anxiety He loses the idea that he is independent, a realisation which creates a difficult period and brings frustration and anxietyfrustration anxietyfrustration anxiety The child will need a ‘good enough’ mother to progress from the pleasure principle to the reality principle (Holding)

19. Object relation and addiction This realisation has a powerful, somewhat painful, but constructive impact on the child This realisation has a powerful, somewhat painful, but constructive impact on the child The healthy child will use the ‘transitional object’ as the ‘illusion’ of the mother and the breast to tolerate the frustration and separation anxiety (6 months and 1 year) It is a way for the child to maintain a connection to the mother while she progressively distances herself. It is the first “not-me” possession; a teddy bear, a blanket, etc. It is a ‘fantasy bond’ against anxiety and under his control

20. Object relation and addiction In a later stage of the development the child no longer needs the transitional object and it loses its meaning. He is able to make a distinction between ‘me’ and ‘not-me’, and keeping inside and outside apart and yet interrelated. He can focus his attention on learning, creativity, etc.. In a later stage of the development the child no longer needs the transitional object and it loses its meaning. He is able to make a distinction between ‘me’ and ‘not-me’, and keeping inside and outside apart and yet interrelated. He can focus his attention on learning, creativity, etc..

21. Object relation and addiction Winnicott (1971) sees addictions to substances as attempts to re-find the lost object through direct physical gratification from an external object. In that sense, addictions are similar to ‘transitional phenomena’ because they represent the mother and yet are recognised as not being the mother Unlike the child’s transitional possessions, addictions are not given up naturally because they are regressive response to an early deprivation, and an effort to regain an earlier illusory relationship with the lost object Addiction is a failure of the developmental process, tend to remain fixated and represents a denial of the separation with the lost object (Summers, 1994;Winnicott, 1971).

22. Object relation and addiction The equivalence of an absolute dependency on ‘an external mother’ is the dependency upon the drug. Many drug addicts deny their addiction and do not admit that their life had become uncontrollable. Common phrases ‘I can stop it whenever I want’ or ‘I am not addicted and can manage without drugs’ are parallel to the infants’ denial and lack of awareness of the ‘objective world’ The constant pursuit after the substance is a pursuit after pleasure and gratification and symbiosis with the lost object. A world without lack, frustration or pain, similar to the primary world of the infant. In both cases, there is a lack of awareness of the environment and centering on personal needs Conscious wish to stop using drug/alcohol addiction but unconscious drive which makes ‘users’ unable to do so

23. Attachment theory and addiction Brief review of Attachment theory Attachment model of addiction

24. Attachment theory and addiction Bowlby (1907-1990), British psychoanalyst, psychiatrist claimed that the seeking of proximity to an attachment figure in stressful situations is a basic biological need for the child to survive. Infants become attached to adults who are sensitive and responsive and who remain consistent caregivers from about 6 months oldproximity Necessity of a close, warm and caring relationship with a mother figure. Mother figure has to be stable, reliable, accessible, understanding and able to tolerate the baby’s negative feelings. Provides the reassurance and protection that will regulate internal tension in the case of distress or anxiety. This is the ‘affectional-bond’ Create a strong-enough internal security for the child to tolerate separation from the mother/explore the external world/connect with other people and become autonomous

25. Attachment theory and addiction Attachment, once formed, if interrupted, could have severe consequences on the child's emotional, intellectual and social development Role of parents is to provide opportunities for active play and exploration while maintaining boundaries that protect child from harm Parental challenge: to nurture and encourage exploration while at the same time setting boundaries and limits (Darling, 1999)

26. Attachment theory and addiction Later, Ainsworth created the concept of ‘ secure base’ (1978): it provides internal safety and enables the individual to freely explore the surrounding world (move greater distance away from caregivers, take more risks exploring environment): Caregivers are a secure base that regulate feelings of distress and anxiety Respond to the child’s needs sensitively and with consistency Attachment figure is unique and irreplaceable Proximity to attachment figure at early age is a priority When attachment bond are under stress, the infant needs the proximity and reassurance of the attachment figure Attachment to different attachment figures is possible but each relationship is specific and can not replace another one

27. Secure attachment Child is able to explore external world with interest. Show signs of missing parents during separation and greets parents actively when back and able to return to exploration Mother provides appropriate assistance, which increases the sense of internal security. It also educates the child in how to cope with the same problem in the future. Sees self as lovable and of others as trustworthy. Relatively easy to get close to others and comfortable to depend on others and having others depend on them. Positive self-image, self-efficacy, healthy interpersonal relations and a sense of well being (Collins & Read, 1990; Cummings & Cicchetti, 1990; Simpson, 1990; Sroufe, 2000; Sroufe et al., 1999).

28. Insecure attachment Child will show an inability to be comforted after separation from mother, with ambivalent expressions of attachment mixed up with anger, avoidance or detachment. He/she’ll fail to settle and take comfort in parent on reunion. Avoid exploration of the external world and will tend to cling and become dependant to an external object Unreliable/inconsistent or disengaged attention from caregiver, inability to provide model of healthy coping responses. Can be associated to child abuse or neglect for most severs cases Experience separation like an abandonment: inability to go through the cycle attachment-bonding-separation-mourning Exaggerated need for relatedness and physical presence of others (anxious- ambivalent attachment) or find difficult being close to others and trusting others (avoidant attachment) and negative image of self and/or other

29. Attachment theory and addiction Insecurely attached clients will show difficulty in self- regulating emotional distress, exhibit maladaptive coping strategies when confronted with stressful situations (Kobak & Sceery, 1988; Main, 1990; Main et al., 1985; Mikulincer et al., 1990) At greater risk to present with maladaptive behaviour (anti- social) or to develop psychological difficulties including anxiety, depression, substance abuse (Allen et al, 1996; Bowlby, 1978, 1988; Burge et al., 1997; Cole-Detke & Kobak, 1996; Rosenstein & Horowitz, 1996)

30. Attachment theory and addiction Recent research have addressed the relationship between attachment style and psychopathology (Lyddon & Sherry, 2001), with some researchers focusing on coping styles (Lopez et al., 2001; Clark et al., in press) Some research revealed a link between insecure attachment style and addiction problems and demonstrated that 66% of alcoholic inpatients could be labeled as ‘insecurely attached’ compared to 40% in the general population (Clark et al., 1996; Allen et al., 1996; Rosentein et al., 1996, Fonagy et al., 1996, Van Ijzendoorn et al., 1999 Rick & Vanheule, 2007)

31. Attachment theory and addiction Consistent with research suggesting people with substance misuse have often experienced emotional deprivation, neglect as well as physical, emotional and/or sexual abuse in childhood (Brown et al.,1999; Diaz et al., 2000; Duncan et al., 1996; El-Bassel et al., 1996; Sheridan, 1995; Dunn et al., 1994). This may also include any combination of parental alcoholism, domestic violence and family instability (Triffleman et al., 1995). Inadequate parental supervision and nurturance, inappropriate modelling of conflict and coping styles ( Gauthier et al., 1996; Sanders & Becker-Lausen, 1995).

32. Attachment theory and addiction Research also shows that they had a limited access to positive relationships and have developed a limited capacity to use supportive resources (Bays, 1990; Black, 1985, 1988; Black, Bucky, & Wilder-Padilla, 1986; deCubas & Field, 1993). Many clients attending addiction services will present with dysfunctional attachment style and difficulties in establishing supportive relationships with which to inhance own recovery.

33. Attachment theory and addiction Hofler and Kooyman, (1996) emphasised the importance of the relationship to the substance as opposed to the relationship with others: the substance is a ‘secure base’ for people having experienced traumas, neglect, deprivation and who have developed a negative self-concept and are not able to communicate the anxiety and fear associated to these experiences

34. Attachment theory and addiction Taking drugs alleviates/regulates intolerable feelings (anxiety/anger/pain/despair). Drug taking as mood regulation. It also avoids closeness with others and avoids being further hurt or rejected, specifically during the difficult period of separation- individuation/adolescence (leaving home, forming new relationships etc.)

35. Attachment theory and addiction As the use of the substance develops, it acquires the subjective value of being unique, resembling almost the specificity of the attachment figure: satisfaction of needs, safety, containment, gratification with no need of others The user will progressively more likely regulate unpleasant feelings through the use of substance and the substance will become ‘the devil they know’ with a predictable effect.

36. Attachment theory and addiction ‘Addiction can be considered an attempt at attachment transition in adolescence when there is an alternative between relationships or addiction. The attachment needs are shifted to a drug, an impersonal object, an activity, or a specific behaviour that then can become addictive.’ ‘Drug is a secure base allowing conflict-free proximity-seeking’. (Hofler and Kooyman, 1996)

37. Attachment theory and addiction According to Goodman (2010), drug and alcohol users’ ego deficit is their inability to experience, label, process, and manage their emotional life (Vulnerable Ego) According to Goodman (2010), drug and alcohol users’ ego deficit is their inability to experience, label, process, and manage their emotional life (Vulnerable Ego) They often experience the extremes of psychic numbing and emotional flooding. They can be overwhelmed by inner emptiness or a rush of powerful external effects and their substance-induced state is a retreat from a hostile external world (others) and a chaotic inner world They often experience the extremes of psychic numbing and emotional flooding. They can be overwhelmed by inner emptiness or a rush of powerful external effects and their substance-induced state is a retreat from a hostile external world (others) and a chaotic inner world As pointed out by Khantzian (1985), one's drug of choice is neither random nor accidental. Drugs are selected for their differential ability to numb, excite, calm, energize, sedate, sexualize, narcotize, and induce both ecstatic and fantasy states As pointed out by Khantzian (1985), one's drug of choice is neither random nor accidental. Drugs are selected for their differential ability to numb, excite, calm, energize, sedate, sexualize, narcotize, and induce both ecstatic and fantasy states In these alternative psychic states, the addict finds momentary surcease from the straight world In these alternative psychic states, the addict finds momentary surcease from the straight world

38. Attachment theory and addiction According to Flores (2004), addictive behaviours are misguided attempt at ‘self-repair’. According to him, deprivation of age- appropriate developmental needs (lack of availability and emotional responsiveness) leaves the substance abusers constantly searching for something ‘’out there’’ that substitute for something missing ‘’ in here’’ Attachment theory hold the position that it is impossible for individuals to completely regulate their affective state alone. Consequently, until substance abusers abandon their dysfunctional attachment styles and develop a capacity for a healthier relationship (secure attachment and mutuality), they will remain vulnerable to substitute one addiction for another

39. Other considerations when working psychodynamically in addiction Importance of a thorough assessment to identify suitability (some form of stability in lifestyle, drug/alcohol use, insight on personal responsibility, wish to know more about themselves etc.) Stepped-care model, Wanigaratne 1997 : psychotherapy Drug free/maintained CBT (RP) &counseling Reducing use/maintenance CBT/MI Stable, continue to use Behavioural approaches Chaotic lifestyle/drug use

40. The transference Assessment of the client’s developmental history to inform intervention and anticipate transferential phenomenon (which attachment style?) Particular attention given to the therapeutic relationship/transference (attachment style will tend to impose itself on the clinician) Insecurely attached client will have more difficulty to develop a positive alliance (more time is often needed, test the therapist)

41. The transference Importance of providing a secure base to allow positive alliance and narrative exploration (empathic understanding, reliability, safety, clear boundaries etc…) Client’s ambivalence which can affect transference with denial and grandiosity (I don’t need anyone!) or childlike dependency and helplessness The therapist is often seen (initially) as a helper (sometimes a saviour) but also a depriver (somebody who threatens the bond with the substance/introduces a lack) and this can lead to idealised attachment or hostile transference or disengagement

42. The transference Initially the therapist is also seen as somebody who has a ‘knowledge’ by the client, in Lacanian terms, the therapist is perceived as the ‘subject supposed to know’ (important to engage the client) In addiction clients often look for an ideal solution for their problem, a ‘quick fix’ and put the therapist in the position of a ‘little master’ (the saviour) who will ‘fix them’ like the substance Therapist must avoid the pitfall of being ‘an ideal’ with all the answers for the client otherwise he/she takes the same position as the substance=an object of instant gratification, a magical solution to pain or anxiety This can also create co-dependency and client’s guilt/anxiety of not being good enough by himself. It can also lead to disengagement/anger when the client realises that the therapist is not ‘an ideal’ (limitation of the therapist/therapy)

43. The transference Importance of the therapist taking an active position and shifting the knowledge to the client (‘Tell me what is your experience’ rather than ‘I know what is best for you’) Analyst must shift the client from a passive to an active position: desire to explore, to know (client actively trying to know why and what he can do with what is happening to him/her) The role of the therapist is to promote language and meaning rather than a ‘quick fix’ to pain or anxiety

44. The transference The bound to the substance and its function is crucial. The therapist must be aware of the triangle client-substance-therapist in the transference Lapses or craving not necessarily alarming for the psychoanalytical approach (proximity to the drug activated when the addictional bond is threatened) By maintaining the transference, the client will develop a relationship to the therapist rather than to the substance. The client will come to the therapist rather than the substance to talk and regulate anxiety or pain The client will start to use language and meaning rather than an external solution to pacify inner pain and regulate emotions

45. Finally, Importance of psychodynamic formulation with an understanding and interpretation of the client’s difficulties (internal conflicts, interpersonal conflicts etc.) identification of defences mechanisms, function of substance use etc… Importance of supervision to discuss transference but also the therapist’s counter-transference and interventions Recommended to be or to have been in psychodynamic/psychoanalytical therapy

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47. Research, books and papers Flores, PJ. (2004) Addiction as an attachment disorder. New York: Jason Aronson Flores, PJ. (2004) Addiction as an attachment disorder. New York: Jason Aronson Kaufman, E. (1989). The psychotherapy of dually diagnosed patients. Journal of Substance Abuse and Treatment, 6, 9-18 Khantzian, E.J. (1985). American Journal of Psychiatry, 142, 1259-1264 Khantzian, E.J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142, 1259-1264The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. De Rick A, Vanheule S, (2007). Attachment style in Alcoholic Inpatients. Eur Addict Res 13:101-108 De Rick A, Vanheule S, (2007). Attachment style in Alcoholic Inpatients. Eur Addict Res 13:101-108 Levy, RA.; Ablon, JS. Talk Therapy: Off the Couch and Into the Lab. Scientific American (online). 2010. Levy, RA.; Ablon, JS. Talk Therapy: Off the Couch and Into the Lab. Scientific American (online). 2010. Luborsky, L., McLellan, A. T.,Woody, G. E., Obrien, C. P., & Auerbach, A. (1985). Therapist success and its determinates. Archives of General Psychiatry, 42, 602–611. Potik D, Adelson M and Schreiber S. (2007). Drug addiction from a psychodynamic perspective: Methadone maintenance treatment as transitional phenomena. Psychology and Psychotherapy: Theory, Research and Practice, 80, 311–325 Van den Hoven, G. (2002). Toxicomania in Context. Psychoanalytical Notebooks,9, 163-170 Van den Hoven, G. (2002). Toxicomania in Context. Psychoanalytical Notebooks,9, 163-170

48. Research, books and papers Narpastek,F. (2002). Toxicomania of Yesterday and of Today. Psychoanalytical Notebooks, 9, 151-163 Narpastek,F. (2002). Toxicomania of Yesterday and of Today. Psychoanalytical Notebooks, 9, 151-163 Shedler Jonathan K.,“The Efficacy of Psychodynamic Psychotherapy,” PhD, University of Colorado Denver School of Medicine; American Psychologist, Vol. 65. No.2. Shedler Jonathan K.,“The Efficacy of Psychodynamic Psychotherapy,” PhD, University of Colorado Denver School of Medicine; American Psychologist, Vol. 65. No.2. Van Den Bosh and Vereul (2007). Patients with addiction and personality disorder : Treatment outcomes and clinical implication. Curr Opin Psychiatry, Jan, 20 (1), 67-71 Van Den Bosh and Vereul (2007). Patients with addiction and personality disorder : Treatment outcomes and clinical implication. Curr Opin Psychiatry, Jan, 20 (1), 67-71 Weegman M & Cohen R. (2002) The psychodynamic model of addiction. London: Whurr publishers Weegman M & Cohen R. (2002) The psychodynamic model of addiction. London: Whurr publishers Woody, G. E., Luborsky, L., McLellan, A. T., Obrien, C. P., Beck, A. T., Blaine, J., et al. (1983).Psychotherapy for opiate addicts: Does it help. Archives of General Psychiatry, 40, 639–645 Woody GE, Mac Lellan AT, Luborsky L and O’Brien CP (1995). Psychotherapy in community methadone programs: A validation study. American Journal of Psychiatry, 152 (9), 1302-1308 Woody GE, Mac Lellan AT, Luborsky L and O’Brien CP (1995). Psychotherapy in community methadone programs: A validation study. American Journal of Psychiatry, 152 (9), 1302-1308 Woody, G.E; McLellan, A.T; Luborsky, L; and O’Brien, C.P. (1998). Psychotherapy with opioid-dependent patients. Psychiatric times, 15(11) Woody, G.E; McLellan, A.T; Luborsky, L; and O’Brien, C.P. (1998). Psychotherapy with opioid-dependent patients. Psychiatric times, 15(11)