Psychodynamic Theory and Alcoholism

Assessment and Treatment of Substance Use Disorder
Introduction
This paper uses the case study of Ms. Knapp from the book Drinking: A Love Story by the same Ms. Knapp. It is an autobiography about the author and her substance use. She reflects on the destructive aspects of her drinking problem and how she went for years believing that so long as she kept her professional life in order, her drinking problem was not really an issue. In the end, she is compelled to face the facts after almost harming her friend’s daughters while under the influence. This paper discusses how I would assess Ms. Knapp and what approach I would use to treat her—the psychodynamic approach. It discusses the underlying theory of this approach, techniques of this approach, the expected outcome, gender-based issues that should be considered as well as the limitations of this approach.
Assessment of Ms. Knapp
Ms. Knapp would certainly benefit from self-assessment, and her autobiography of her alcohol abuse serves as a type of critical self-reflection and analysis. Self-assessment is beneficial in terms of allowing the patient to identify issues that are impacting the patient (Copeland & Martin, 2004). Self-assessment allows the individual to see where strengths occur, where weaknesses, what symptoms are predominant, and how behavior is connected to the disorder. However, though self-assessment can benefit the patient and compel him or her to seek treatment, for social workers, the need for a rapid assessment instrument is crucial (Feit, Fisher, Cummings & Peery, 2015) and can reduce the risk of misdiagnosing or mistreating a patient.
As a social worker, I would assess Ms. Knapp using a rapid assessment instrument such as the Michigan Alcohol Screening Test, which consists of 24 closed yes/no questions (Selzer, Vinokur & van Rooijen, 1975). If the respondent’s answers add to a score of 5 or more, an assessment of “alcoholic” would be appropriate to deliver. For Ms. Knapp, the Michigan Alcohol Screening Test would provide an assessment of “alcoholic” rather quickly. The pain it caused her in relationships, the harm she almost brought to her friend’s daughters as a result of drinking, and her lack of having a sense of actually having a problem (such as guilt over drinking) would indicate a problem with alcohol. Her attendance at AA would, right away, signify that she had a substance use problem. Thus, this type of rapid assessment instrument serves as an ideal way for social workers to identify an issue like alcohol abuse quickly and effectively.
Evidence-Based Treatment: Psychodynamic Approach
The evidence-based treatment approach that I would utilize to treat Ms. Knapp would by the psychodynamic approach. Because there are several underlying issues driving Ms. Knapp to drink and abuse alcohol, these issues need to be brought to the fore and addressed before the problem of drinking could really be treated. Indeed, from the psychodynamic approach perspective, in treating the underlying issues the problem of alcohol abuse would effectively be treated as well because the forces compelling her to abuse alcohol would be mitigated, aired-out—so to speak—disinfected by the sunlight of awareness so that they would no longer be the problems lurking in her unconsciousness that they currently are.
As Dodes and Dodes (2017) note, the psychodynamic approach creates a balance between a too microscopic approach to the patient and a too macroscopic approach: it places the patient at the center and looks at the experience of the patient, the environment, the underlying issues, and the motivational factors that are driving the patient’s thoughts, impulses, perspective formation, awareness, and behavior. The psychodynamic approach is rooted in the work of Freud, who launched the field of psychoanalysis, which developed in many different directions of the century that has passed since then. It would be an appropriate evidence-based treatment approach for Ms. Knapp, who is in need of having the underlying issues of her conscious behavior analyzed and explained.
Theory Undergirding the Psychodynamic Approach
Undergirding the psychodynamic approach is psychodynamic theory, which explains behavior and personality in terms of conscious and unconscious compulsions, desires, and forces (Khantzian, 2014). This particular theory holds that there is tension between the conscious mind and the unconscious mind; that the unconscious mind is where trauma typically lingers. The conscious mind is unable to process the trauma, the negative feelings, the overwhelming experiences, and the environment in which one lives—so it is all suppressed into the inner being. It is repressed and buried in the unconscious while the conscious mind strives to go about the daily duties and activities that the individual must engage in. However, because the trauma or the negative issues have not be adequately or effectively dealt with, they remain like an unwanted guest—an unwelcome specter that continues to haunt and drive the individual’s impulses. Coping mechanisms—like substance use—are typical symptoms of some trauma lingering within the unconscious that has to be explored, exposed and adequately addressed in order for the individual to at last come to some form of peace.
Freud (1915) developed psychodynamic theory throughout his career, evaluating the relationship between the Id, Ego and Superego, also known as the unconscious, the pre-conscious or subconscious and the conscious parts of the mind. Freud believed that the goal of human behavior was the achievement of pleasure and the avoidance of pain at all cost. The Ego was like the surface level motivator; the Id and the Superego contended with the will and the mind below the surface. The conscious mind rose up out of the surface and projected out into the world. For Freud (1915), the Conscious region consisted of that of which one is aware; the Preconscious region was that which one could be prompted to access if properly compelled; and the Unconscious region consisted of feelings, beliefs, impulses and instincts that are not accessible directly via the Consciousness. The aim of the approach is to help the patient to uncover the beliefs and ideas hidden deep in the Unconscious.
Techniques of the Approach
The technique of the psychodynamic approach involves assisting the patient in talking through prior experiences and allowing the unconscious mind to unfold so that the patient can better understand why he or she is having a particular set of problems. One of the goals of this approach is to help the patient to see patterns in their thoughts and emotions that can allow them to develop a better understanding of themselves, of who they are, and what is going on in their inner self. The technique involves beginning as far back as the patient’s childhood and looking at issues that developed during this particularly formative period of the person’s life.
Through asking the patient questions about his or her life, childhood, adolescence and adulthood, the patient begins to put the puzzle pieces of personality together. The counselor is rather minimally involved in explaining the personality of the patient to the patient; rather, the patient is the one who ultimately locates meaning and explains it to the counselor. The counselor’s aim is simply to prod and to get the patient to probe more deeply and fully into the unconscious to uncover what elements of experience and past thoughts, ideas or beliefs have been hiding there to cause the patient to see the self and the world the way he or she currently does.
There is no set schedule or routine with this approach. Instead the technique is based on the idea of free association (Khantzian, 2014). Sessions can be open-ended, rather intense at times, and begun by having the patient simply discuss whatever is on the mind. Thus, sessions begin with the consciousness and only through repetition of concepts does the patient, with the help of the therapist, begin to see patterns in thought emanating from the unconscious. Following these patterns down the rabbit hole, so to speak, is essentially the purpose of the psychodynamic approach. Revelation is the end-goal: the picture of the true self is the aim.
Formal techniques that have been applied include dream analysis, free association and the Rorschach test, in which the patient looks at inkblots and describes what he or she sees. This is supposed to offer a window into the unconscious ideas that sit below the surface. It is a method that can be used to introduce the conscious mind to the unconscious by way of the pre-conscious so that there a more unified person or whole person can emerge. The Freudian slip method is also an option, as it focuses on slips of the tongue that indicate that an underlying passion or feeling that is only revealed to the conscious mind by way of accident.
How Techniques Would be Utilized with Ms. Knapp
For Ms. Knapp, the technique would include posing a variety of open-ended questions and probing her background in a way that compels her to think about and talk about her past, her past relationships, her feelings surrounding her father, her family, her work, her relationships with men, and so on. As she talks, the goal would be to get her to realize that her actions are connected to her past—her experiences, feelings, and thoughts that have been locked in her unconscious and have been begging for release. Her drinking would be seen by her, inevitably, as a way of avoiding the issues that she has needed to deal with since being a young girl and seeing the bond with her father.
By asking Ms. Knapp about her childhood, she would begin to uncover an awareness of herself and why she was drawn to her father, who also had a similar kind of double life to that which she herself developed over time: professionally and publicly keeping it together while privately falling apart because of drinking.
As the main goals of the psychodynamic process are self-awareness and a better understanding of emotions and beliefs, stemming from childhood and impacting life as an adult, it would be important to allow Ms. Knapp to spend time reflecting on her childhood, her bond with her father, her connection to him, their felt kinship, and any other emotions or beliefs that might arise from these reflections. The therapist could suggest that Ms. Knapp discuss her relationships with Julian and Michael and discuss why she is torn between the two men. Though Michael loves her and gives her tenderness, she still feels like she wants to make Julian happy, though all Julian ever wanted from her was to see her change into someone she was not. Talking about these feelings and locating the root of her motivations in her childhood and in particularly in her relationship with her father would help her to see what is going on within herself and why she has developed her drinking problem.
Gender-Based Issues
The gender issue in psychodynamic theory is rooted in what Freud believed to be a sex instinct that is the ultimate motivation of all behavior. Freud viewed that children develop sexual feelings for their parents from a young age and that, because these feelings are deemed inappropriate, they are shoved down into a box within the Unconscious zone. For young boys, they develop an Oedipal complex—love for their mother. For young girls, they develop an Elektra complex—love for their fathers.
Freud believed that the Elektra complex stems from feelings of inadequacy—a young girl feels she lacks what her father has (a masculine gender). She becomes jealous of the mother, whom she views as a rival for her father’s attention. Her desire to have her father eventually is replaced with a desire to have a baby as she develops a female superego.
When working with a woman who has substance use issues, the gender-based issues that should be considered are that there are likely to be unconscious motivations that she will need to explore in order to understand herself more fully. This need is assisted by the psychodynamic approach, which can give room to the woman patient as she reflects on her childhood and considers her relationship with her father more fully. This relationship is likely to be very impactful on her psyche and in order for her to comprehend some of her issues or her substance use, it may be necessary for her to see herself anew and see, particularly, how her adult views have been shaped by the views and beliefs she acquired as a young girl.
Expected Outcome of Treatment
The expected outcome of this treatment would be that Ms. Knapp more fully comes to understand herself and the beliefs and ideas that were formed inside of her from her childhood onward. She begins to see how her present, destructive course through substance abuse is rooted in the destructive relationships she has had. Her relationship with Julian, for example, in which he wanted her to become something she was not was an echo of the destructive bond she felt for her father, whose own double life was the beginning of the self-destructive urge and process in her own. By seeing her compulsion to please Julian in the light of these ideas, she would see that her drinking was an attempt to cover up this destructive impulse—the impulse of her superego to melt into nothing so that her unconscious desire to please a man could be asserted. By realizing the destructive aspect of this impulse, she would be better prepared to recognize its approach and ward it off whenever it reared its head.
Limitations of the Psychodynamic Approach
The ideas of gender and sex that were generated in the psychodynamic approach were largely the result of the times in which Freud was working. Freud was emerging from an era in which sexuality had largely been repressed overall by Victorian, polite society. Sex, therefore, was viewed as something that had been pushed down within the self and not allowed free expression. It was natural that Freud would focus on the repression of sexuality as a motivating force in the early 20th century. However, there has not been a great deal of evidence since then to suggest that gender ideas such as the Oedipal complex or the Elektra complex are scientifically reasonable or based on empirical fact. Rather, gender differences have been seen in young children from as young as age 1, far earlier than when Freud suspected that the initial complexes begin. This indicates that Freud was interpreting childhood development incorrectly, at least with regard to the focus on the sex instinct and its place in the development of the superego and the unconscious.
Likewise, the psychodynamic approach has been criticized by behavioral theorists who suggest that just because a patient becomes aware of internal thoughts and motivations does not mean that the patient is any more likely to gain control over a problem that is plaguing the patient’s life. To gain control, behavioral norms have to change. To that end, cognitive behavioral therapy (CBT) has been proposed as an alternative treatment. Instead of focusing on the why, CBT focuses on the what—i.e., what can the patient do to address the problems that the patient is having. CBT doesn’t spend much time trying to figure out the reasons for the patient’s problems—in this case, why the patient is an alcoholic. Instead, the CBT therapist identifies the fact that alcoholism is bad and identifies with the patient better behaviors and goals that the patient can work towards achieving with the goal being to normalize these other behaviors so that they become the new habit and the old, bad habit is replaced. CBT, in other words, is viewed as a means of addressing the patient’s problems by getting the patient to engage in a new, better behavior. The psychodynamic approach is criticized for being limited in terms of what it can accomplish behaviorally speaking, as it focuses primarily on cognitive impressions.
Conclusion
In conclusion, Ms. Knapp could be assessed using the rapid assessment instrument, such as the Michigan Alcohol Screening Test. This would show that Ms. Knapp was an alcoholic. I would use the psychodynamic approach to treat her, which would be based on getting Ms. Knapp to discuss her past so as to allow her unconscious beliefs and motivations to emerge. By better understanding these, Ms. Knapp would begin to see herself more clearly and fully and be empowered to take control of her own life.

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