Utilization of the therapeutic relationship to address active substance use when working with patients with severe mental disorders

In any psychotherapy differences in the communicative process between therapists and patients may cause significant difficulties in understanding. Patients with serious psychiatric difficulties who also misuse substances... [ view full abstract ]

In any psychotherapy differences in the communicative process between therapists and patients may cause significant difficulties in understanding. Patients with serious psychiatric difficulties who also misuse substances present additional levels of communicative and therapeutic complexity. Not all models of psychotherapy readily adapt to the issues raised when patients also actively abuse substances. Additionally, treatment models for mental disturbance and substance misuse are incompatible or contradictory. Variable and shifting mood and self states with concomitant impaired comprehension interfere with attempts to communicate in coherent ways that extend beyond periods of acute intoxication. Attempting to solve problems by substance use rather than verbalization and engagement inhibit change and maintain counterproductive and self-destructive patterns. Attempts to understand by transference or mentalization may be insufficient and make it difficult to establish reasonable levels of understanding and assess the effects of treatment. Focusing primarily upon cessation of substance use may divert our attentions away from other important concerns and suppress their emergence.

Many suggest that the interference introduced by substance use makes it necessary to refer patients to treatments primarily designed for substance use before initiating psychotherapeutic work on mental functioning. However, complications from additional referrals often result in patients falling through the cracks of the treatment system.

Elements of a transference based system of treatment focused upon the therapeutic relationship will be presented that facilitate productive engagement and understanding when working with patients with severe mental disorders and concurrent substance use problems. The emphasis will be upon the successful resolution of complicated clinical encounters in which we learn that denied or previously undisclosed substance use has been ongoing or when patients attend in intoxicated states. The focus on the therapeutic relationship allows the material to be adapted readily to a variety of different psychotherapeutic approaches. Clinical examples from the presenter’s practice will be discussed.