Psychodynamic Psychotherapy and Addiction Claudio Costanza Addiction Clinical Psychology Service...

Psychodynamic Psychodynamic Psychotherapy and AddictionPsychotherapy and Addiction

Claudio CostanzaClaudio CostanzaAddiction Clinical Psychology Addiction Clinical Psychology

ServiceServiceSLAMSLAM

January 2014January 2014

Aim of presentation

Psychodynamic psychotherapy of addiction, Psychodynamic psychotherapy of addiction, evidence and NICE guidelinesevidence and NICE guidelines

Psychodynamic models of addiction (object Psychodynamic models of addiction (object relation theory, attachment theory)relation theory, attachment theory)

Other considerations: Assessment, Other considerations: Assessment, Therapeutic relationship ..Therapeutic relationship ..

A definition of psychodynamic therapy with addiction

Central principleCentral principle : much distress is caused by unresolved : much distress is caused by unresolved unconscious tendencies. unconscious tendencies.

GoalGoal : Increase self-awareness and understanding of the : Increase self-awareness and understanding of the influence of the past on present behaviour and on the influence of the past on present behaviour and on the quality of clients’ interactions with others. Through quality of clients’ interactions with others. Through exploration of thoughts and feelings, free associations, exploration of thoughts and feelings, free associations, memories, fantasies and dreams, and with the help of the memories, fantasies and dreams, and with the help of the therapist’s interpretation, this model therapist’s interpretation, this model helps clients helps clients to better to better understand their emotions and change their ways of understand their emotions and change their ways of relating to others as well as to substances. This will help relating to others as well as to substances. This will help clients to eventually feel freer to lead a more fulfilling, clients to eventually feel freer to lead a more fulfilling, creative life without the help of substancecreative life without the help of substance

Psychodynamic therapy and addiction

Particular attention is given to the relationship Particular attention is given to the relationship with the therapist, through which, the patient may with the therapist, through which, the patient may relive situations, feelings and thoughts from their relive situations, feelings and thoughts from their early life: The ‘early life: The ‘transference’ transference’

Although historically viewed as a long-term Although historically viewed as a long-term psychological work, this approach can also be a psychological work, this approach can also be a short-term intervention. Short-term short-term intervention. Short-term psychodynamic psychodynamic counselling counselling will have one major will have one major focus, which creates a structure and identifies a focus, which creates a structure and identifies a goal. goal.

Psychodynamic therapy and addiction

This approach can be integrated with more This approach can be integrated with more drug-focused intervention such as drug drug-focused intervention such as drug counselling, group programs, therapeutic counselling, group programs, therapeutic communities or NA/AA.communities or NA/AA.

This approach can help to better understand the therapeutic relationship and what the client may experience in recovery.

Review of evidence based for psychodynamic therapy with addiction

Not a great deal of recent ‘evidence based’/randomised Not a great deal of recent ‘evidence based’/randomised controlled trial on psychodynamic therapy with addiction controlled trial on psychodynamic therapy with addiction exhistsexhists

But some research have demonstrated the effectiveness But some research have demonstrated the effectiveness and usefulness of PT with addiction: and usefulness of PT with addiction:

Woody and co. (1983) and Luborsky and co. (1985) have Woody and co. (1983) and Luborsky and co. (1985) have showed that adding supportive-expressive therapy (SET) showed that adding supportive-expressive therapy (SET) to standard drug counselling for opiates client on to standard drug counselling for opiates client on methadone maintenance program was beneficial to client methadone maintenance program was beneficial to client with higher levels of psychopathology. with higher levels of psychopathology. They also showed major advancement in their lives, entered the job market and stopped using drugs

Review of evidence based for psychodynamic intervention with addiction

Woody Woody and coand co. (1995, 1998) have shown the effectiveness of . (1995, 1998) have shown the effectiveness of SET in methadone programs. Clients required less methadone SET in methadone programs. Clients required less methadone than those who received standard drug counselling and after 6 than those who received standard drug counselling and after 6 months, clients maintained their gains or showed continuing months, clients maintained their gains or showed continuing improvement improvement

Grenyer Grenyer and coand co. (1995) compared brief drug counselling with . (1995) compared brief drug counselling with cannabis dependency with SET (one weekly session over 16 cannabis dependency with SET (one weekly session over 16 weeks). Results showed that SET produced larger significant weeks). Results showed that SET produced larger significant reduction in cannabis use, depression and anxiety reduction in cannabis use, depression and anxiety

Carroll Carroll and co.and co. (1991) compared RP treatment with (1991) compared RP treatment with Interpersonal therapy (IPT) for cocaine users over 12 weeks Interpersonal therapy (IPT) for cocaine users over 12 weeks individual sessions (N=42). Both approaches showed individual sessions (N=42). Both approaches showed favourable outcome, with IPT showing higher rate of favourable outcome, with IPT showing higher rate of attrition. attrition.

Evidence-based Some case studies also show the usefulness of psychodynamic therapy Some case studies also show the usefulness of psychodynamic therapy

(attachment model, object relation model, supportive expressive (attachment model, object relation model, supportive expressive therapy etc.) with addiction in addition to standard drug counselling therapy etc.) with addiction in addition to standard drug counselling interventions or group programs: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 Potik and co. (2007) shows the relevance of using object relation theory and in particular the concept of transitional object when theory and in particular the concept of transitional object when working with methadone maintenance clients working with methadone maintenance clients

Read (2002) shows the usefulness of using psychotherapy and in Read (2002) shows the usefulness of using psychotherapy and in particular object relation model with clients on methadone particular object relation model with clients on methadone maintenance program and using heroin etc.maintenance program and using heroin etc.

NICE and psychodynamic therapy of addiction

Demonstrating effectiveness of psychodynamic Demonstrating effectiveness of psychodynamic therapy is complex and not always readily testable therapy is complex and not always readily testable ‘in a brief manner’: time, clarity of measures, ‘in a brief manner’: time, clarity of measures, funding and possibly motivation funding and possibly motivation

As a result, it is difficult to find psychodynamic As a result, it is difficult to find psychodynamic therapy as a recommended intervention by NICE therapy as a recommended intervention by NICE guidelinesguidelines

Personality Disorder and Addiction

NICE ‘consider’ psychodynamic intervention only in the case of ‘co-morbidities’ NICE ‘consider’ psychodynamic intervention only in the case of ‘co-morbidities’ (depression/anxiety)(depression/anxiety)

NICE does not mention PD as ‘co-morbidity’ when it is fully recognised that it is one of the 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 major co-morbidity with addiction (Oldham, 1990; Stone, 1993; Millon, 1996, Krampe et al., 2006, Verheul, 2001,Van Den Bosh & Verheul, 2007)al., 2006, Verheul, 2001,Van Den Bosh & Verheul, 2007)

Van den Bosh & Verheul (2007) in their study on PD and addiction stresses the importance 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 of addressing both the addiction problem and the personality disorder for the treatment to be effectiveeffective

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 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 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 2001 (N=417) and showed evidence of long-term positive effect of psychodynamic therapy with PD. with PD.

Bateman A & Fonagy P (2001) have shown the usefulness of treatment of BPD with Bateman A & Fonagy P (2001) have shown the usefulness of treatment of BPD with psychoanalytically oriented therapy in partial inpatient setting/mentalization based Treatmentpsychoanalytically oriented therapy in partial inpatient setting/mentalization based Treatment

Therapeutic alliance and addiction

The quality of the T/A is a significant factor for The quality of the T/A is a significant factor for client engagement and retention in addiction client engagement and retention in addiction treatment treatment (Fiorentine (Fiorentine et al.,et al., 1999; Simpson 1999; Simpson et al.,et al., 1997, 2000) or 1997, 2000) or in change in drinking behaviour (Connors in change in drinking behaviour (Connors et al.,et al.,1997) or in drug use 1997) or in drug use (Barber (Barber et al.,et al., 1999). 1999).

Relevance: psychodynamic approach/model views Relevance: psychodynamic approach/model views the therapist-client relationship as central and the the therapist-client relationship as central and the vehicle through which change occursvehicle through which change occurs

NICE Guidelines

Importance of following NICE recommendations Importance of following NICE recommendations

However, many psychological approaches can be considered when However, many psychological approaches can be considered when working with addiction considering the complexity of this problem working with addiction considering the complexity of this problem (more use of micro-evidences of effectiveness of approaches with (more use of micro-evidences of effectiveness of approaches with individual service users)individual service users)

Importance of using several psychological models when dealing with Importance of using several psychological models when dealing with addiction clients who often present with many co-morbidities (BPS)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' viewsImportance of including service users' views

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

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

Object relation theories

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

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 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 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 ‘moment of illusion’, a belief that his own wish creates the object of his desire which brings with it a sense of satisfactiondesire which brings with it a sense of satisfaction

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


Later on the child comes to realise that the mother is Later on the child comes to realise that the mother is separate from himseparate from him and not within his control. The child has . The child has lost something. lost something.

The child realises that he is dependent on others and The child realises that he is dependent on others and vulnerablevulnerable

He loses the idea that he is independent, a realisation which He loses the idea that he is independent, a realisation which creates a difficult period and brings creates a difficult period and brings frustration frustration and anxiety and anxiety

The child will need a ‘good enough’ mother to progress from the pleasure principle to the reality principle (Holding)


This realisation has a powerful, somewhat painful, but This realisation has a powerful, somewhat painful, but constructive impact on the child 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


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

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).

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

Attachment theory and addiction

Brief review of Attachment theory

Attachment model of 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 old

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


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)


Later, Ainsworth created the concept of ‘secure base’ (1978): itprovides 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

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).

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


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)

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)

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).


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.


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


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.)


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.


‘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)


According to Goodman (2010), drug and alcohol users’ ego deficit is According to Goodman (2010), drug and alcohol users’ ego deficit is their inability to experience, label, process, and manage their their inability to experience, label, process, and manage their emotional life (Vulnerable Ego)emotional life (Vulnerable Ego)

They often experience the extremes of psychic numbing and They often experience the extremes of psychic numbing and emotional flooding. They can be overwhelmed by inner emptiness or a emotional flooding. They can be overwhelmed by inner emptiness or a rush of powerful external effects and their substance-induced state is 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 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 As pointed out by Khantzian (1985), one's drug of choice is neither random nor accidental. Drugs are selected for their differential ability random nor accidental. Drugs are selected for their differential ability to numb, excite, calm, energize, sedate, sexualize, narcotize, and to numb, excite, calm, energize, sedate, sexualize, narcotize, and induce both ecstatic and fantasy statesinduce both ecstatic and fantasy states

In these alternative psychic states, the addict finds momentary In these alternative psychic states, the addict finds momentary surcease from the straight worldsurcease from the straight world

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

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 :psychotherapyDrug free/maintained

CBT (RP) &counselingReducing use/maintenance

CBT/MI Stable, continue to use

Behavioural approaches Chaotic lifestyle/drug use

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)

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

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)

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

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

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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