Chapter 23. Psychodynamics

Hallie A. Lightdale, M.D.; Avram H. Mack, M.D.; Richard J. Frances, M.D.
DOI: 10.1176/appi.books.9781585623440.352765



Psychoanalysis and psychodynamic theory are fundamental to modern psychiatric practice, including addiction treatment. Although some investigators have argued that psychodynamic treatment has only a minor role in the treatment of substance abuse (Vaillant 1995), others have shown how psychodynamic understanding can add depth to work with individuals and groups, further the rehabilitation process (Dodes and Khantzian 2004; Frances et al. 1989; Khantzian 1997), and increase the usefulness of 12-step programs (Dodes 1988). As part of a transtheoretical integrated treatment model, sophisticated understanding of psychodynamic principles can be used by the therapist to help the addicted patient recognize that he or she has a problem and then to identify what might provide effective motivation for that individual to change. This approach helps patients in actualizing their wish to change by helping them move along the continuum from contemplation of a problem, such as smoking, to contemplation of the need for change, to taking action and then maintaining abstinence.

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Table Reference Number

Sophisticated, dynamic understanding of an individual's conflicts can help motivate patients to accept that they have a problem, help patients accept a need for change, aid in treatment, and be used to maintain progress.

Psychodynamic understanding can be integrated with cognitive, behavioral, and pharmacological approaches to enhancing treatment.

More research needs to be done on how influencing the mind can affect brain function, including addictive behavior.


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Various psychodynamic models have been used to describe substance abuse behavior in the context of psychodynamic conflict. Among these models is the description of substance abuse as an example of narcissistic behavior disorder, wherein the patient uses substances to serve as a substitute idealized selfobject. This concept is associated with whom?
Another psychodynamic explanatory model for substance abuse relates to the concept of self-medication, wherein the patient uses substances to compensate for underlying conflicts. The term escape into narcosis describing this is attributed to. . .
The co-occurrence of personality disorder with substance abuse in patients is common and may make treatment for substance abuse more challenging. A substance-abusing patient who also has narcissistic personality disorder is likely to exhibit all of the following except
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