חיפוש מאמרים

Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems
Larimer, M. E., Malone, D. K., Garner, M. D., Atkins, D. C., Burlingham, B., Lonczak, H. S., & Marlatt, G. A. Jama 301.13 (2009): 1349-1357.
Objective To evaluate association of a “Housing First” intervention for chronically homeless individuals with severe alcohol problems with health care useRead More...

Objective To evaluate association of a “Housing First” intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.

Design, Setting, and Participants Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington.

Main Outcome Measures Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls.

Results Housing First participants had total costs of $8 175 922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs.

Conclusions In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

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Interventions to reduce harm associated with adolescent substance use
Toumbourou, J. W., Stockwell, T., Neighbors, C., Marlatt, G. A., Sturge, J., & Rehm, J. The Lancet 369.9570 (2007): 1391-1401.
A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse ofRead More...

A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality, and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.

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Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment
Marlatt, G. A., & Witkiewitz, K. Addictive behaviors 27.6 (2002): 867-886.
Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media.Read More...

Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media. Although several studies have demonstrated that controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, the public and institutional views of alcohol treatment still support zero-tolerance. After describing the problems with zero-tolerance and the benefits of moderate drinking, the research literature describing prevention and intervention approaches consistent with a harm reduction philosophy are presented. Literature is reviewed on universal prevention programs for young adolescents, selective and indicated prevention for college students, moderation-based self-help approaches, prevention and interventions in primary care settings, pharmacological treatments, and psychosocial approaches with moderation goals. Overall, empirical studies have demonstrated that harm reduction approaches to alcohol problems are at least as effective as abstinence-oriented approaches at reducing alcohol consumption and alcohol-related consequences. Based on these findings, we discuss the importance of individualizing alcohol prevention and intervention to accommodate the preferences and needs of the targeted person or population. In recognizing the multifaceted nature of behavior change, harm reduction efforts seek to meet the individual where he or she is at and assist that person in the direction of positive behavior change, whether that change involves abstinence, moderate drinking, or the reduction of alcohol-related harm. The limitations of harm reduction and recommendations for future research are discussed.

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Cognitive–behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action
Morgenstern, J., & Longabaugh, R. Addiction 95.10 (2000): 1475-1490.
Objective. This review examined support for the hypothesis that cognitive‐behavioral treatment (CBT) for alcohol dependence works through increasing cognitive and behavioralRead More...

Objective. This review examined support for the hypothesis that cognitive‐behavioral treatment (CBT) for alcohol dependence works through increasing cognitive and behavioral coping skills. Method. Ten studies were identified that examined the hypothesized mechanisms of action of CBT. These studies involved random assignment (or its near equivalent) of participants to CBT and at least one comparison condition.Results. Although numerous analyses of the possible causal links have been conducted to evaluate whether CBT works through increasing coping, the results indicate little support for the hypothesized mechanisms of action of CBT. Conclusions. Research has not yet established why CBT is an effective treatment for alcohol dependence. Negative findings may reflect methodological flaws of prior studies. Alternatively, findings may indicate one or more conceptual assumptions underlying CBT require revision.

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Craving to Quit: psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions
Brewer, J. A., Elwafi, H. M., & Davis, J. H. Psychology of addictive behaviors: journal of the Society of Psychologists in Addictive Behaviors 27.2 (2013): 366-379.
Humans suffer heavily from substance use disorders and other addictions. Despite much effort that has been put into understanding theRead More...

Humans suffer heavily from substance use disorders and other addictions. Despite much effort that has been put into understanding the mechanisms of the addictive process, treatment strategies have remained suboptimal over the past several decades. Mindfulness training, which is based on ancient Buddhist models of human suffering, has recently shown preliminary efficacy in treating addictions. These early models show remarkable similarity to current models of the addictive process, especially in their overlap with operant conditioning(positive and negative reinforcement). Further, they may provide explanatory power for the mechanisms of mindfulness training, including its effects on core addictive elements, such as craving, and the underlying neurobiological processes that may be active therein. In this review, using smoking as an example, we will highlight similarities between ancient and modern views of the addictive process, review studies of mindfulness training for addictions and their effects on craving and other components of this process, and discuss recent neuroimaging findings that may inform our understanding of the neural mechanisms of mindfulness training.

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Is low therapist empathy toxic?
Moyers, T. B., & Miller, W. R. Psychology of Addictive Behaviors 27.3 (2013): 878.
One of the largest determinants of client outcomes is the counselor who provides treatment. Therapists often vary widely in effectiveness,Read More...

One of the largest determinants of client outcomes is the counselor who provides treatment. Therapists often vary widely in effectiveness, even when delivering standardized manual-guided treatment. In particular, the therapeutic skill of accurate empathy originally described by Carl Rogers has been found to account for a meaningful proportion of variance in therapeutic alliance and in addiction treatment outcomes. High-empathy counselors appear to have higher success rates regardless of theoretical orientation. Low-empathy and confrontational counseling, in contrast, has been associated with higher drop-out and relapse rates, weaker therapeutic alliance, and less client change. The authors propose emphasis on empathic listening skills as an evidence-based practice in the hiring and training of counselors to improve outcomes and prevent harm in addiction treatment.

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Retraining the addicted brain: A review of hypothesized neurobiological mechanisms of mindfulness-based relapse prevention
Witkiewitz, K., Lustyk, M. K. B., & Bowen, S. Psychology of Addictive Behaviors 27.2 (2013): 351.
Addiction has generally been characterized as a chronic relapsing condition (Leshner, 1999). Several laboratory, preclinical, and clinical studies have providedRead More...

Addiction has generally been characterized as a chronic relapsing condition (Leshner, 1999). Several laboratory, preclinical, and clinical studies have provided evidence that craving and negative affect are strong predictors of the relapse process. These states, as well as the desire to avoid them, have been described as primary motives for substance use. A recently developed behavioral treatment, mindfulness-based relapse prevention (MBRP), was designed to target experiences of craving and negative affect and their roles in the relapse process. MBRP offers skills in cognitive–behavioral relapse prevention integrated with mindfulness meditation. The mindfulness practices in MBRP are intended to increase discriminative awareness, with a specific focus on acceptance of uncomfortable states or challenging situations without reacting “automatically.” A recent efficacy trial found that those randomized to MBRP, as compared with those in a control group, demonstrated significantly lower rates of substance use and greater decreases in craving following treatment. Furthermore, individuals in MBRP did not report increased craving or substance use in response to negative affect. It is important to note, areas of the brain that have been associated with craving, negative affect, and relapse have also been shown to be affected by mindfulness training. Drawing from the neuroimaging literature, we review several plausible mechanisms by which MBRP might be changing neural responses to the experiences of craving and negative affect, which subsequently may reduce risk for relapse. We hypothesize that MBRP may affect numerous brain systems and may reverse, repair, or compensate for the neuroadaptive changes associated with addiction and addictive-behavior relapse.

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Motivational Interviewing
Hettema, J., Steele, J., & Miller, W. R. Annu. Rev. Clin. Psychol. 1 (2005): 91-111.
Motivational interviewing (MI) is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolveRead More...

Motivational interviewing (MI) is a client-centered, directive therapeutic style to enhance readiness for change by helping clients explore and resolve ambivalence. An evolution of Rogers's person-centered counseling approach, MI elicits the client's own motivations for change. The rapidly growing evidence base for MI is summarized in a new meta-analysis of 72 clinical trials spanning a range of target problems. The average short-term between-group effect size of MI was 0.77, decreasing to 0.30 at follow-ups to one year. Observed effect sizes of MI were larger with ethnic minority populations, and when the practice of MI was not manual-guided. The highly variable effectiveness of MI across providers, populations, target problems, and settings suggests a need to understand and specify how MI exerts its effects. Progress toward a theory of MI is described, as is research on how clinicians develop proficiency in this method.

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Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence – The COMBINE Study: A Randomized Controlled Trial
Anton, R. F., O’Malley, S. S., Ciraulo, D. A., Cisler, R. A., Couper, D., Donovan, D. M., & Longabaugh, R. Jama 295.17 (2006): 2003-2017.
Context Alcohol dependence treatment may include medications, behavioral therapies, or both. It is unknown how combining these treatments may impact theirRead More...

Context Alcohol dependence treatment may include medications, behavioral therapies, or both. It is unknown how combining these treatments may impact their effectiveness, especially in the context of primary care and other nonspecialty settings.

Objectives To evaluate the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence and to evaluate placebo effect on overall outcome.

Design, Setting, and Participants Randomized controlled trial conducted January 2001-January 2004 among 1383 recently alcohol-abstinent volunteers (median age, 44 years) from 11 US academic sites with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of primary alcohol dependence.

Interventions Eight groups of patients received medical management with 16 weeks of naltrexone (100 mg/d) or acamprosate (3 g/d), both, and/or both placebos, with or without a combined behavioral intervention (CBI). A ninth group received CBI only (no pills). Patients were also evhttps://jamanetwork.com/journals/jama/fullarticle/202789aluated for up to 1 year after treatment.

Main Outcome Measures Percent days abstinent from alcohol and time to first heavy drinking day.

Results All groups showed substantial reduction in drinking. During treatment, patients receiving naltrexone plus medical management (n = 302), CBI plus medical management and placebos (n = 305), or both naltrexone and CBI plus medical management (n = 309) had higher percent days abstinent (80.6, 79.2, and 77.1, respectively) than the 75.1 in those receiving placebos and medical management only (n = 305), a significant naltrexone × behavioral intervention interaction (P = .009). Naltrexone also reduced risk of a heavy drinking day (hazard ratio, 0.72; 97.5% CI, 0.53-0.98; P = .02) over time, most evident in those receiving medical management but not CBI. Acamprosate showed no significant effect on drinking vs placebo, either by itself or with any combination of naltrexone, CBI, or both. During treatment, those receiving CBI without pills or medical management (n = 157) had lower percent days abstinent (66.6) than those receiving placebo plus medical management alone (n = 153) or placebo plus medical management and CBI (n = 156) (73.8 and 79.8, respectively; P<.001). One year after treatment, these between-group effects were similar but no longer significant.

Conclusions Patients receiving medical management with naltrexone, CBI, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment. Naltrexone with medical management could be delivered in health care settings, thus serving alcohol-dependent patients who might otherwise not receive treatment.

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Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users – Cochrane Systematic Review
Klimas, J., Fairgrieve, C., Tobin, H., Field, C. A., O'Gorman, C. S., Glynn, L. G., & Cullen, W. Cochrane Database of Systematic Reviews 12 (2018).
Background Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes.Read More...

Background

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

Objectives

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

Search methods

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

Selection criteria

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

Data collection and analysis

We used the standard methodological procedures expected by Cochrane.

Main results

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.

The psychosocial interventions considered in the studies were: cognitive‐behavioural coping skills training (one study), twelve‐step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol‐related harm. The results were as follows.

Comparison 1: cognitive‐behavioural coping skills training versus twelve‐step programme (one study, 41 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.

Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI ‐0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI ‐0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)

More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.

Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index‐alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

Authors' conclusions

We found low to very low‐quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment‐only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

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Drinking to regulate positive and negative emotions: a motivational model of alcohol use
Cooper, M. L., Frone, M. R., Russell, M., & Mudar, P. Journal of personality and social psychology 69.5 (1995): 990.
The present study proposed and tested a motivational model of alcohol use in which people are hypothesized to use alcoholRead More...

The present study proposed and tested a motivational model of alcohol use in which people are hypothesized to use alcohol to regulate both positive and negative emotions. Two central premises underpin this model: (a) that enhancement and coping motives for alcohol use are proximal determinants of alcohol use and abuse through which the influence of expectancies, emotions, and other individual differences are mediated and (b) that enhancement and coping motives represent phenomenologically distinct behaviors having both unique antecedents and consequences. This model was tested in 2 random samples (1 of adults, 1 of adolescents) using a combination of moderated regression and path analysis corrected for measurement error. Results revealed strong support for the hypothesized model in both samples and indicate the importance of distinguishing psychological motives for alcohol use.

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Self-Medication Hypothesis: Connecting Affective Experience and Drug Choice
Suh, J. J., Ruffins, S., Robins, C. E., Albanese, M. J., & Khantzian, E. J. Psychoanalytic psychology 25.3 (2008): 518.
According to E. J. Khantzian's (2003) self-medication hypothesis (SMH), a psychoanalytically informed theory of substance addiction that considers emotional andRead More...

According to E. J. Khantzian's (2003) self-medication hypothesis (SMH), a psychoanalytically informed theory of substance addiction that considers emotional and psychological dimensions, substance addiction functions as a compensatory means to modulate affects and self-soothe from the distressful psychological states. To manage emotional pain, dysphoria, and anxiety, substance abusers use the drug actions, both physiological and psychological effects, to achieve emotional stability. The SMH was retrospectively tested using 6 Minnesota Multiphasic Personality Inventory-2 special scales with 402 non-drug users and drug users to capture the psychological elements relevant to the SMH. Three logistic regression models were formed to predict alcohol, cocaine, and heroin "drug-of-choice" groups. Predicting variables were the Repression, Overcontrolled Hostility, Psychomotor Acceleration, Depression, Posttraumatic Stress Disorder, and Cynicism scales. Repression and, inversely, Depression scales significantly predicted the alcohol group. Psychomotor Acceleration was the only significant predictor of the cocaine group. Cynicism significantly predicted heroin preference. The results are partially consistent with the SMH. Implications of these results for understanding the relationship between affect regulation and addiction and treatment interventions are discussed.

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Psychic Retreats or Psychic Pits? Unbearable States of Mind and Technological Addiction
Schimmenti, A., & Caretti, V. Psychoanalytic Psychology 27.2 (2010): 115.
New technologies are highly interactive. They promote imaginative involvement and allow the experience of different self-states, such as those involvingRead More...

New technologies are highly interactive. They promote imaginative involvement and allow the experience of different self-states, such as those involving withdrawal or “psychic retreat”. According to Steiner, psychic retreats are areas of the mind populated by imagination and ideas which are poorly aligned with reality. Psychic retreats are not necessarily pathological in themselves—for instance, they can be used positively for counteracting anxiety or enhancing creativeness. However, with technological addiction there is a misuse of psychic retreat: here the total absorption with computer applications serves to hide painful or unbearable states of mind, and to protect the patient from overwhelming feelings through segregating self-states with a disconnection in their representations. Therefore, in clinical work with individuals suffering from technological addiction exploring the use of psychic retreats can serve as an aid to both diagnosis and treatment. Where the dysfunctional use of new technologies constitutes a temporary withdrawal from a specific painful event, this can have the function of protecting the individual from inner conflict; in the most serious cases however, technological addiction is grounded in more chronic and pathological dissociative mechanisms, and serves to prevent the mind from reactivating traumatic states connected to childhood experience of emotional neglect or abuse. While it is likely that the first condition can be positively handled with appropriate identification and treatment, the latter is much more difficult to deal with, particularly where the addictive behavior hides the weakness of the self, and psychic retreats are pervasively used to protect the patient from mental breakdown.

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The Value of Relational Psychoanalysis in the Treatment of Chronic Drug and Alcohol Use
Director, L. Psychoanalytic Dialogues 12.4 (2002): 551-579.
A view of chronic drug use that draws on central assumptions in relational theory is proposed. Namely, chronic substance useRead More...

A view of chronic drug use that draws on central assumptions in relational theory is proposed. Namely, chronic substance use is seen as being driven by conflicting and unresolved relational dynamics that derive from the early organizing relationships in a person's life. In the case of the substance user, the terms of this conflict find concrete expression in characteristic acts of drug use that serve to perpetuate it through the combined effects of reinforcement and disguise. The goal of treatment is for patient and therapist to find the components of the relational bind that are embedded in the drug use, to reformulate these forces in symbolic terms, and to revisit them in the dynamics of the transference, alongside opportunities for new exchange. Seen this way, the treatment needs of substance users can best be met by a relational model of psychoanalysis, augmented by other approaches needed to address addiction. In particular, the relational emphasis on the role of enactment as a vehicle for the expression of unsymbolized experience, and therefore the source of the phenomena to be analyzed and understood, makes this model especially well suited to substance-using people.

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Understanding Addictive Vulnerability: An Evolving Psychodynamic Perspective
Khantzian, E. J. Neuropsychoanalysis 5.1 (2003): 5-21.
In contrast to early psychoanalytic theory, which stressed pleasurable/aggressive drives and the symbolic meaning of drugs to explain their appeal,Read More...

In contrast to early psychoanalytic theory, which stressed pleasurable/aggressive drives and the symbolic meaning of drugs to explain their appeal, a modern psychodynamic perspective of substance-use disorders (SUDs) places greater emphasis on intolerable painful or confusing affects that make addictive drugs compelling. A psychotherapeutic relationship rooted in a psychodynamic approach yields valuable data on the nature of a person’s distress and deficits in psychological (ego/self) structures that predispose individuals to addiction. An evolving psychodynamic perspective, spanning 30 years, is presented wherein addictions have been considered as (1) a special adaptation, (2) an attempt to self-medicate painful or confusing emotions, (3) an overarching problem in self-regulation, and finally (4) a reflection of disorder in personality organization. This evolving perspective more likely than not should and does complement and resonate with other perspectives. A modern psychodynamic perspective of SUDs adds an important dimension to unraveling the biopsychosocial equation involved in understanding addictive vulnerability.a

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