Summary

Psychoanalytic theory has a lot to offer addictions counselors when it comes to gaining an understanding of the etiology of substance use disorders for some clients.This is especially true from the perspective of the more contemporary psychoanalytic models (e.g. the self-medication hypothesis and Attachment Theory), which provide ways in which to conceptualize substance use disorder risk based upon a prior history of trauma or insecure attachments to others. While psychoanalytically oriented therapists such as Keller (2003) find that unconscious processes often play a role in relapse, generally, psychoanalytic-oriented therapy, which helps clients gain insight into their motivations and behavior, may not be as useful to clients in the early stages of recovery. Anna Freuds contributions in describing defense mechanisms are as relevant today as they were back in 1936 in describing ways in which people with substance use disorders may avoid the harsh realities of the pain caused by substance abuse by means of rationalization, repression and denial. Given the high incidence of trauma within the population of people with SUDs it’s imperative for counselors to be aware of ways to provide trauma-informed care to their clients.

Boxed Item 2.3 Avoiding Re-traumatization

As described in this section, it’s important that we avoid re-traumatizing clients by allowing them to work at their own pace. This is true especially when working with combat veterans, who often have been taught through their military training to focus on the mission and to make sure that everyone in the platoon or group comes back alive.Veterans are often hesitant or fearful to talk with non-combat veterans about their experiences overseas, so it’s important to establish trust and a working therapeutic alliance. Veterans will share traumatic experiences when they’re ready and when they feel they can trust you. An example of this was with a veteran who served in the US Army during the worst fighting in the Viet Nam War. One day, after several weeks of having this veteran in counseling for alcohol and prescription opioid use disorders, he called and asked if I was near a fax machine. I said and I was, and gave him the fax number. He proceeded to fax me a 20-page handwritten account of an incident which occurred during his time in Viet Nam in which a fellow soldier had stepped on a landmine within a few yards of where he was standing. He recounted the sound of the mine exploding, the soldier’s cry, the smoke, the blood, the smell of the smoke as well as his own feelings of horror, and survivor guilt, all in great detail. We met the next day to talk about the traumatic experience but what was most important was that by faxing this information first, it was his way of wanting to make sure I was not going to judge him.