Relationships, Emotions, and Defenses Among Patients with Substance Use Disorders, Assessed with Karolinska Psychodynamic Profile: Possibilities to use Intensive Short-Term Dynamic Psychotherapy in Substance Abuse Treatment

ABSTRACT

Substance use disorders (SUDs) are connected to emotional and relational difficulties. Intensive Short-Term Dynamic Psychotherapy (ISTDP) aims at supporting emotion regulation and relational capacity through confronting the patient’s defenses. The authors assessed relational capacity, emotion regulation, and defenses in nine patients with severe SUD and a history of childhood maltreatment, using the semistructured method Karolinska Psychodynamic Profile. All participants had difficulties in handling interpersonal dependence and separations. Functioning in other areas varied. ISTDP could be useful in substance abuse treatment. Thorough assessment before starting ISTDP is however recommended so that treatment is planned according to the patients’ level of functioning.

KEYWORDS:

• Intensive Short-Term Dynamic Psychotherapy (ISTDP)
• Karolinska Psychodynamic Profile (KAPP)
• emotion regulation
• relationships
• assessment
• substance abuse treatment

Research has shown an association between emotional difficulties (Dingle, da Costa Neves, Alhadad, & Hides, 2018; Mandavia, Robinson, Bradley, Ressler, & Powers, 2016; Wilcox, Pommy, & Bryon, 2016) as well as relational difficulties (Aleman, 2007a; Director, 2002; Larkin, Wood, & Griffiths, 2006) and substance use disorders (SUDs). There is a connection between SUD and affective conditions such as depression and anxiety (Besenius, Beirne, Grogan, & Clark-Carter, 2013; Fröjd, Ranta, Kaltiala-Heino, & Marttunen, 2011). Moreover, patients with SUD might experience alexithymia, which means difficulties in identifying, describing, and expressing emotions (Aleman, 2007a; Ghorbani, 2017; Thorberg, 2009). Negative emotions might fuel self-destructiveness and trigger relapse and therefore need to be identified and handled (Flanagan, 2013; Luoma, Kohlenberg, Hayes, & Fletcher, 2012; VanDerhei, Rojahn, Stuewig, & McKnight, 2014). Accordingly, emotion regulation and relational difficulties need to be targeted in assessment and treatment (Dingle et al., 2018; Doumas, Blasey, & Mitchell, 2007; Vinci, Schumacher, & Coffey, 2015; Wilcox et al., 2016). Regulation means the capacity to evaluate emotions, influence how and when they are expressed, and alternate them (Gross, 2014).

Disturbing emotions and relational difficulties might be mitigated by defense mechanisms. Defenses are cognitive, emotional, and interpersonal strategies that keep overwhelming emotions from awareness (Coughlin, 2016). Defenses thus mitigate anxiety but simultaneously exclude adaptive emotion regulation and thereby hinder symptom reduction. Defenses might be classified as primitive or mature (Kernberg, 1992; Perry & Bond, 2012). When primitive defenses are habitual, emotional and relational development is hindered (Kernberg, 1992; Ramos, 2004). Turning against the self is one example of a primitive defense that mitigates emotions while increasing suffering. In turning against the self, aggression toward others is not permitted because aggression is connected to painful experiences of loss of love. Instead anger is turned toward oneself, for example, in form of self-contempt or physical self-attacks (McWilliams, 2011; Perry & Bond, 2012). Splitting is another primitive defense in which intense positive and negative emotional reactions, and contradictory experiences of self and others, are separated and thus become difficult to identify and handle. Primitive defenses tend to occur in individuals with SUD, and the patients’ defenses need to be assessed so that treatment can be planned according to the needs and capacities of each patient (Aleman, 2007b; Beveridge, 2008; Director, 2002; Evren et al., 2012).

Emotions, relationships, and defenses are central to current psychodynamic psychotherapy, such as Intensive Short-Term Dynamic Psychotherapy (ISTDP) (Diener, Hilsenroth, & Weinberger, 2007; Gross, 2014). The word short term might be somewhat misleading because the number of sessions in ISTDP varies according to the severity of the patients’ difficulties, even though more than 40 sessions seldom are provided (Town, Abbass, Stride, & Bernier, 2017). In ISTDP it is assumed that unsatisfactory attachment leads to maladaptive emotional regulation because emotions connected to loss of love or punishment during childhood become connected to anxiety (Della Selva & Malan, 2006). The patient avoids the disturbing emotions. Anxiety signals that the person is becoming aware of the emotion. Because the patient is not in contact with her or his emotions, relationships become unfulfilling or problematic. The ISTDP therapist supports the patient to identify and regulate emotions and reflect on emotional and relational needs. Another assumption is that emotions involve experiential, physiological, perceptional, and behavioral components (Coughlin, 2016; Frederickson, 2013). ISTDP therapists use specific interventions to initiate emotional reactions and explore the patient’s subjective, perceptional, and bodily emotional expressions, as well as behavioral tendencies (Coughlin, 2016; Feldman Barrett, 2016). Such interventions involve invitation of feeling, supporting self-observing capacity, and confrontation of defenses (Frederickson, 2013). When the patient experiences disturbing emotions in the clinical setting, without having to face negative consequences, adaptive regulation strategies might develop, and symptoms and anxiety become mitigated or relieved.

The literature indicates that interest in ISTDP is increasing. According to a study by Ajilchi, Nejati, Town, Wilson and Abbass (2016), patients with depression who were treated with ISTDP had decreased levels of depressive symptoms at end of treatment and at 12-months follow-up. Their executive functions also increased (Ajilchi et al., 2016). Randomized controlled trials concerning depression showed that ISTDP was connected to partial or complete remission 6 months after treatment, and also to increased social-cognitive capacity (Ajilchi, Kisely, Nejati, & Frederickson, 2018; Town et al., 2017). Moreover, a meta-analysis of 15 studies showed that ISTDP is cost effective (Abbass & Katzman, 2013). Such beneficial results seem to be connected to ISTDP being a structured method (Abbas & Town, 2013) and structured methods have been recommended for patients in substance abuse treatment (Socialstyrelsen, 2014). ISTDP for patients with SUDs have been mentioned when ISTDP is presented (Della Selva & Malan, 2006; Town et al., 2017), but studies concerning ISTDP and SUD have not yet been published.

ISTDP, with its focus on emotions, relationships, and defenses, could reasonably be a valuable contribution to the treatment of patients with SUD. It should however be noted that in ISTDP, impartial assessment is not commonplace because the diagnostic evaluation specific to ISTDP, the extended trial therapy, is seen as sufficient for assessing the patient’s level of functioning (Ajilchi et al., 2016; Della Selva & Malan, 2006; Frederickson, 2013). Psychodynamic assessment of patients with SUDs has however been described as difficult (Weinryb, Busch, Gustavsson, Saxon, & Skarbrandt, 1998), and it has been recommended that various assessment methods should be used (Aleman, 2007b). Karolinska Psychodynamic Profile (KAPP) is an interview and assessment method that covers the patients’ emotional and relational functioning as well as defenses (Weinryb & Rössel, 1991). It is founded upon object relation theory and provides researchers and clinicians working in the psychodynamic tradition a method that permits valid and reliable psychodynamic assessment of mental functioning. KAPP involves a semistructured interview that takes about 2 hours, with eighteen subscales that cover levels of functioning. The subscales are assessed according to a 5-point ordinal scale (Weinryb & Rössel, 1991). Level 1 (normal functioning, including normal neurotic modes of functioning), Level 2 (considerable difficulties), and 3 (severe difficulties). Intermediate levels are also used, which that there are five points on the scale. The assessment results in a profile that shows the patient’s functions and thus acknowledges difficulties as well as strengths.

A tentative suggestion is that ISTDP might be a valuable addition in the treatment of patients with SUDs. We however submit that increased knowledge about emotional and relational needs as well as defenses among patients with SUD is necessary. Accordingly, the aim of this study is to assess relational capacity, emotion regulation, and defenses among patients in substance abuse treatment, using KAPP. Based on the KAPP results, we reflect on the possibility to use ISTDP in substance abuse treatment.

Method

Procedure and participants

Participants were recruited through information sheets distributed at an outpatient clinic in the Swedish public health and social care system, aiming at individuals with complex SUD and psychosocial difficulties. Interested patients could contact the interviewer or leave their name and phone number at the reception and be contacted.

An information session was arranged and each patient was informed that she or he was free to discontinue participation or refrain from answering questions that were perceived as uncomfortable. They were also informed that participation was separated from treatment and that data would be anonymized. Inclusion criteria were (1) previous complex SUD, (2), stable abstinence at the time of the study, and (3) established treatment contact. At this first meeting, the participants were interviewed about living conditions, employment, alcohol and drug use, and relationships, according to Addiction Severity Index (Socialstyrelsen, 2009).

Nine individuals, two female and seven male, age 25–44 years, participated. The gender distribution is representative for this clinical population (Montanari, Serafini, Maffli, Busch, & Kontogeorgiou, 2011). Four participants were in employment, two were students at secondary school level, two were unemployed, and one was on permanent sick leave. All participants had been through traumatic childhood experiences. At least one of their parents had a criminal lifestyle and/or severe psychological difficulties, eight of them had at least one parent with severe SUD, and seven of them had been exposed to physical and/or sexual abuse. The participants had started using substances during their teenage years and had previously met diagnostic criteria for poly substance dependence according to (the Diagnostic and statistical manual of mental disorders (4th edition)) (American Psychiatric Association, 1995). One participant had used opiates, one amphetamine, and one alcohol. The others had used a variety of substances including alcohol, amphetamines, cannabis, cocaine, (metylendioximetamfetamin), and benzodiazepines. They thus represent a clinical population with severe difficulties.

Their treatment included weekly supportive contact with a social worker or a nurse, and contact with a psychiatrist concerning medication and treatment planning. Some participants also had weekly meetings with a nurse who distributed medication. They had been patients at the treatment unit for one year up to 3 years. The interviews were thus performed while the participants were in treatment.

Instrument

The participants were interviewed using the KAPP. Results from subscales 1, 2, and 3 address interpersonal relationships, subscale 8 addresses alexithymic traits and emotions, and subscale 18 addresses defense strategies that affect personality organization are presented. Subscale 18 is based on the assessment or personality organization according to Kernberg (1975, 1992). Interpersonal relationships include capacity for reciprocal relationships (subscale 1), capacity to handle dependence and autonomy and tolerate separation (subscale 2), and strivings for power and control in relationships (subscale 3). Alexithymic traits (subscale 8) concern ability to identify, experience, and handle emotions. Subscale 18 concerns personality organization, which is assessed as neurotic personality organization (NPO) level 1, borderline personality organization (BPO) level 2, or psychotic personality organization (PPO) level 3. Assessment of subscale 18 is based on reality testing, stability of self, and object representations and whether defenses are mature or primitive (Kernberg, 1975, 1992; Weinryb & Rössel, 1991). The KAPP also includes subscales describing personality functioning such as frustration tolerance and impulse control, body image, sexual functioning, and social functioning. Results from these subscales are not presented here because the focus is on relationships, emotions, and defenses.

Interviews were performed at the treatment unit by the first author who is a researcher in clinical psychology and a licensed psychologist with experience from substance abuse treatment, educated in the KAPP by the method’s originator. The audio-recorded interviews were 120 to 180 minutes. In line with the method, the interviews were performed in one sitting. The participants were informed that the interviews would last at least 2 hours, and it was underlined that they were free to take a pause during the interview. Moreover, after about one hour, the interviewer asked each participant if she or he needed a pause. Three participants asked for a short pause, the others wanted to continue. After the interviews, some participants were tired. No one however found the interviews emotionally overwhelming. The participants were informed that they could contact the interviewer if they found any topic bothersome, or if they wanted to discuss something further. No participants however contacted the interviewer. Both authors listened to the interviews twice, and those parts that concerned relationships, emotions, and defenses were transcribed verbatim, including pauses and cadence, by the second author.

Analysis

A qualitative analysis, theoretically guided by object relation theory as presented in the KAPP (Weinryb & Rössel, 1991), aiming at assessing relational functioning, alexithymic traits, and defenses, was performed. Each author made an initial assessment separately. Thereafter, we scrutinized the interviews and the assessments together and reached a final assessment. In some cases the initial assessment changed after the mutual reflection, for example concerning alexithymic traits. Grade 3 means that the patient lacks capacity to differentiate emotional states and rather describes global experiences or states of arousal. Grade 2 means that the patient can differentiate between emotions but describe them without specific details. Grade 1 means that the patient uses words that convey what she or he actually experienced. Moreover, facial expressions and gestures are in line with the reported emotions. In some cases, participants were initially rated as 2.5 or 2. When the interview data was discussed, we however reached the conclusion that the participant had capacity to express emotions even though verbal expressions were not detailed. In such cases the rating was changed to 2 or 1.5. In rare cases, it was difficult to reach a conclusion. In those cases, the lower point was chosen. This is in accordance with recommendations not to pathologize patients (Weinryb & Rössel, 1991). The results were thereafter related to the view of emotions, relationships, and defenses in ISTDP. This means that the analysis was close to the interview data and simultaneously guided by theory.

Ethical considerations

The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. To ensure anonymity, individual characteristics of each participant are not described. It would have been methodologically adequate to present individual characteristics and follow each participant in the presentation of the results. Methodological and ethical considerations however have to be balanced, and in this case the integrity of the participants was prioritized. In Table 1, the numerical assessment of each participant is presented without connection to individual characteristics such as gender or age. Thereby, the KAPP profiles are presented, while protecting the participants’ integrity.

Table 1. KAPP scores.

	Part 1	Part 2	Part 3	Part 4	Part 5	Part 6	Part 7	Part 8	Part 9
Subscale 1 Intimacy and reciprocity	2.5	2.5	1.5	1.5	2.5	2	2	2	1.5
Subscale 2 Dependence and separation	2.5	2	2	2	2.5	2.5	2	2	2
Subscale 3 Controlling personality traits	2	1	2	2	2.5	3	1.5	2	2
Subscale 8 Alexithymic traits and emotions	2.5	2	1.5	2.5	2.5	2.5	2	2	1.5
Subscale 18 Personality organization, including assessment of defenses	2.5	2.5	1	1.5	2	2	2	2	1

Results

In Table 1, the KAPP scores are presented. Thereafter, we will present results from the qualitative analysis. Numerical values clarify the profile of each participant and show similarities and differences between participants. The alexithymia and personality organization subscales, for example, show considerable variation whereas the dependence and separation subscale shows similar levels of functioning.

Interpersonal relationships

When the participants described their relationships they related that they felt insecure, inferior, and anxious to “fit in.” To counteract this, they could strive to support others and thereby feel accepted. In other situations, they avoided others, thereby shielding themselves from the risk of being excluded. The participants understood their lifelong difficulties with relationships as connected to traumatic childhood experiences, as described in the following quote:

My explanation is my father, my childhood. To me a conflict means … that my father is devilish, beats me up, tries to kill me … that’s my experience. When I was three or four … he grabbed me by my feet, held me upside down and just dropped me to the floor. He was a monster. It’s logical that I am the way I am. This horror during conflicts … I die!

Some participants described attention needs that could be tiresome to others. Even though these participants were aware of their attention needs they found it difficult to hold them back. One participant described his attention needs, self-contempt, and tendency to avoid others with the following words:

I am tiresome. I’m too much, and demanding during discussions/…/I sense that I’m nice, but I’m incapable of reading others, their needs and wishes. My capacity to understand what others think is incredibly low. What is demanded from me in this context? I get caught up in myself. And instead I might withdraw./…/In relationships my self-hate is confirmed since I perceive myself as causing difficulties.

All our participants expressed that experiences of nonreciprocity and withdrawal could lead to loneliness. Nevertheless, the participants were grateful for the few authentic relationships they had experienced throughout life. Some participants even sensed that without these relationships they would not have survived. Some participants expressed that they could long for intimate relationships just because they had experienced such relationships earlier in life. The main concern for all our participants was difficulties in enduring separations and losses, and they all had a fear of being abandoned, which shows in the numerical levels on the subscale concerning dependence and separation.

Seven participants had difficulties with controlling traits. One participant who was active in Narcotics Anonymous (NA) for example tended to establish relationships to young women who were new in NA and these relationships was based on a power imbalance, which he expresses in the following humoristic way:

I’m the knight in shiny armors who saves the newcomers. I see this look in her eyes, a frightened individual. Her eyes express grief and I’m the one who confirms this. Oh, I’m gonna save you/…/I’m supporting this helpless individual. Superman. A woman tied to the railroad tracks. Who holds the power? (laughs)

This participant, and others, described a tendency to shift between superiority and inferiority. In relation to the young women, he was in a superior position whereas he felt inferior in virtually all other situations.

All participants suffered from their relational difficulties and sensed that their substance misuse had ruined their relationships. Some participants asked themselves what it really meant to love somebody; they longed for and simultaneously wondered if they ever could have a reciprocal relationship.

Alexithymic traits

Difficulties to identify, regulate, and express emotions were considerable in seven participants. Throughout the interviews, these difficulties became obvious, for example when the participants shielded themselves from emotions through using generalized expressions. One participant described that he had taken substances when he “wanted to not give a damn and just run away.” He also related that he had “a clump of unsorted feelings inside, often a sense of resignation, that triggered substance abuse.” This participant was aware of his difficulties in identifying emotions such as angry or sad. He described himself as a “witness” to his life, which indicates that his avoidance of emotions hindered self-understanding and agency. Difficulties in emotion regulation are also visible in the following dialogue between another participant and the interviewer;

P:

It’s hard to give examples, it [emotions] often shows afterwards. If I try to remember them now, I will get caught in them. Therefore I … shield myself.

I:

Do you think this influences what you would like to tell me?

P:

I’m honest, but avoid emotional parts. I don’t think it’s good to plunge into things, this is more of an assessment. I don’t think it’s good to “dig” in emotions.

The participants were aware that avoiding emotions was no solution and related that they tended to switch between emotional outbursts and emotional avoidance.

Also positive emotions could be difficult to describe. All participants had a sense of being unworthy. Therefore it was difficult for them to allow themselves to feel joy. One participant, who described a lifelong contempt for himself and his body, had however found an activity in which he could experience and express positive emotions as well as self-compassion; dancing. During dance classes he could actually like himself and his body:

Dancing made this possible. Wow! Great we talked about this! My body showed me a way back to myself, after that confusing period … my body showed me that I’m good. I can appreciate myself, even more than before. That’s a comforting thought.

Defenses

In the analysis it came forth that all participants used the defense turning against the self. This was for example visible when one participant spoke about her experiences after her grandmother had passed away. She spent a considerable amount of time cleaning and emptying her grandmother’s apartment and felt abandoned by her relatives. She also needed to study for an upcoming exam. Her anxiety increased, but she could not identify her actual feelings, “I panicked. I felt I was forgotten. I just wanted to scream; ‘Hello! I’m here… and I suffer.’” She related that she needed time to mourn her grandmother who had meant a lot to her. Her relatives did not ask how she felt, and she couldn’t express it. In the interview, it came forth that she felt sad and angry. Anger toward others was however threatening and therefore instead directed toward herself. She blamed herself for not being able to clean and study and sensed that she was unworthy. When the self-blame became unbearable she mitigated them with alcohol. This example shows how self-attacks might be calming but simultaneously they invoke difficulties and fuel misuse. Another participant used the following words to describe how even minor shortcomings or self-doubt fuelled self-attacks, from self-blame to violent self-harm, which in turn were mitigated by substances:

There’s probably no limit to my self-hate. I blame myself for everything and perceive myself as a big failure compared to others. When I see the future, I only see shortcomings./…/There’s this void inside that I try to fill with alcohol and drugs, but I don’t succeed. When I was younger, I could sit by a computer all day, constantly read or play the guitar or eat candy, watch TV or have sex all the time. Engage in something two hundred percent, to fill the void. Or use substances. Then I became violent. Banged my head to the wall or destroyed my apartment.

Splitting was prominent among seven participants. Accordingly, they were assessed as having borderline personality organization, or an intermediate stage between borderline and psychotic organization. They shifted between states of severe hopelessness and self-hate to states of self-idealization. Thereby, they felt fragmented and lacked a sense of wholeness. One participant expressed that ”I don’t know who or what I am.” Another one could perceive that he was more than one person:

Like night and day. Two different persons who replace each other. Like a split personality. When I’m alone I can have conversations with myself. I talk out loud, accuse myself and defend myself, for example when I’m in the shower. I almost become three persons, two are talking and one is listening. I exist somewhere in between, the observer. My experience of the world varies…

Two participants could handle ambivalence, perceive themselves and others as nuanced persons, and reflect on contradictions. They were thus assessed with NPO. The following quote is from a participant with NPO who at the time of the interview was studying. In the quote, she reflects on her previous identity as a drug user, and whether she should be open with this to her classmates, or not. This quote shows the capacity to experience ambivalence and reflect over oneself.

On one hand I don’t want others to know too much about me, they might perceive me as weak. On the other hand I want to be open and perceived as strong. Some days I feel strong ’cause I’ve been through so much, other days I feel weak, especially in social contexts. Weak is not the proper word, rather scared, of not belonging.

Affect isolation and intellectualization were identified in the two participants with NPO. Although the participants with BPO were scared of heir emotions, those with NPO wished to approach their emotions and understand their emotional difficulties and themselves, “I think everything one does is rooted in one’s childhood in some way. One should really immerse in this…. I think that’s where everything starts. The choices we make, what we do, and how we feel.”

Discussion

This study suggests that the participants had considerable or severe difficulties with interpersonal relationships, and seven of them predominantly used primitive defenses. The defenses mitigated conflicts momentarily. In the long run the defenses however hindered self-observing capacity and influenced the interaction with others negatively. The participants expressed fear of abandonment and separation, and self-attacks were described. These results are in line with previous studies that have found that SUD is connected to relational difficulties, self-punishment, and a sense of being unworthy (Aleman, 2007a; Skinner & Veilleux, 2016). The importance of identifying and handling the defense turning against the self has been emphasized in previous studies of psychotherapy treatment outcome, and it has been shown that this defense complicate recovery and maintains aggression toward the self, especially among patients with borderline pathology (Geiser, Imbierowicz, Conrad, Wegener, & Liedtke, 2005; Kuhn, 2014; Presniak, Olson, & Macgregor, 2010).

Based on the results from this study, we propose that the defense mechanism turning against the self needs to be acknowledged when working with patients with severe SUD. It seems important to perceive self-attacks as strivings to solve emotional and relational suffering. We hypothesize that ISTDP could support patients to terminate self-attacks by increasing their capacity to understand underlying emotions, including aggression. For our participants, emotional difficulties complicated their self-observing capacity. This is common among individuals with severe SUD, and such difficulties might be understood as connected to lack of emotional support during childhood (Afifi, Henriksen, Asmundson, Gordon, & Sareen, 2012). Insufficient emotional support during childhood also has a negative influence on self-percpetion (Schore, 1994). Our participants had grown up with parents with considerable difficulties themselves. It had been difficult for the participants to develop the capacity for emotion regulation and a coherent self-perception.

All our participants had a fragile sense of self-worth and seven of them had a noncoherent perception of themselves and others, due to splitting, and were accordingly assessed with BPO. Emotional awareness and a sense of self-coherence are prerequisites for understanding others. Our participants’ difficulties in self-perception and emotion regulation impaired their capacity to establish and maintain interpersonal relationships. Psychotherapy as well as self-help groups such as NA might support emotional awareness and self-understanding (Orzeck & Rokach, 2003). Patients with SUD tend to avoid negative emotions and experiences of shortcomings (Orzeck & Rokach, 2003; Punzi & Tidefors, 2014). ISTDP strives to support patients to handle emotional suffering and shortcomings through identifying and expressing emotions that have been avoided (Frederickson, 2013). It should however be acknowledged that for patients with a nonoherent self, disturbing emotions easily become overwhelming. Therefore, ISTDP therapists should not ask these patients about current emotions, which is normally done in ISTDP, but rather use the graded approach. This means that the therapist asks questions about past emotional experiences and reactions, thereby supporting self-observing capacity as a step toward identification and regulation of emotions. In the graded approach, the therapist explores emotions until the patient’s anxiety is expressed in muscular tension on cognitive/perceptual distortions. The therapist shifts between exploring emotions and regulate anxiety, thereby supporting the patient to identify and tolerate emotions, making defenses redundant (Frederickson, 2013). It should be noted that seven participants in this study had BPO. Patients with non-coherent self-perceptions, for example patients with BPO, who enter ISTDP need a restructuring phase in which splitting and other primitive defenses are counteracted, before the graded approach (Davanloo, 1987; Kuhn, 2014). Moreover, patients with multiple diagnoses, and patients who have experienced sexual abuse during childhood, might have considerable difficulties in overcoming dysfunctional defenses and therefore need long-term psychotherapy (Perry & Bond, 2012). Accordingly, it should be noted that some patients should not be recommended ISTDP but other treatment interventions.

It should also be noted that the KAPP and ISTDP represent somewhat different psychodynamic perspectives. In the KAPP, nondifferentiated emotions are assessed as alexithymic traits whereas in ISTDP nondifferentiated emotions are seen as defensive strategies. In clinical work with patients with SUD, varying assessment and treatment approaches need to be integrated (Aleman, 2007b; Cosci & Fava, 2011; Johansen, Tavakoli, Bjelland, & Lumley, 2017). We suggest that the thorough assessment of defenses in ISTDP, and the broad and comparably open KAPP-interview, together contribute knowledge about the needs and capacities of each individual; knowledge that is important for the treatment process. We therefore suggest that if ISTDP is used with patients with SUD, it is beneficially combined with another psychodynamic assessment method, such as the KAPP. If any treatment is initiated without prior assessment there is a risk of triggering overwhelming emotions that in turn could trigger relapse.

It should also be acknowledged that each individual has a unique temperament and thereby a unique pattern of emotion regulation (Gross, 2014). Such patterns are relatively stable and thus influence treatment and recovery. Accordingly, assessment of character traits might support understanding of the patient’s strengths as well as difficulties. Neuropsychological functioning also influences emotion regulation. Dysfunctional regulatory mechanisms in the prefrontal cortex (PFC), for example, decrease the capacity to resolve everyday issues, especially when much information is to be processed simultaneously. Substance abuse is associated with structural and functional differences in the PFC and subcortical areas (Motzkin, Baskin-Sommers, Newman, Kiehl, & Koenigs, 2014; Wilcox et al., 2016). In conclusion, SUDs neuropsychological and cognitive functions that furthermore may be impaired before the onset of SUD, and any treatment needs to consider this complexity.

Finally, we would like to acknowledge that our participants spoke about overwhelming and traumatic experiences. Their candor demands us to approach their experiences with sensibility. It is important to pay attention to their overwhelming difficulties. Simultaneously we do not want to pathologize them. In this study, strengths and capacities came forth. Six of the participants for example worked or studied despite their difficulties. The participants’ efforts and capacities should be kept in mind even though their difficulties have been in focus here.

Concluding reflections and implications for treatment

The KAPP-interviews showed that the participants had difficulties with relationships, especially separation and fear of abandonment, and with identifying and regulating emotions. The majority of them used primitive defenses. This supports the assumption within ISTDP that emotions and relationships are crucial for the origin and maintenance of psychological difficulties. Simultaneously, the results show that individuals with SUD are heterogeneous. Accordingly, treatment must be nuanced and adapted to the individual. It therefore seems relevant to carry out assessment before starting any treatment, including ISTDP. ISTDP therapists should consider that the graded approach with a preparing restructuring phase might be relevant for those who have complex SUD and BPO. It should also be noted that this study concerns psychodynamic concepts, assessment, and treatment. Psychodynamic treatment is not the solution to everyone. Other treatment methods, interventions, and perspectives should be considered in clinical practice.

One question for future research is whether a KAPP assessment before a usual ISTDP assessment and treatment would improve treatment results. It would be interesting to follow one group of patients with SUD that undergoes ISTDP treatment without a foregoing assessment and another group that was interviewed with KAPP, or another psychodynamic assessment method before ISTDP treatment so that treatment could be planned according to their specific functioning and personality organization.

Limitations

In ISTDP it is assumed that psychological difficulties may disappear or be reduced if emotions and relational needs are acknowledged, and defenses counteracted. As clinicians and researchers we however have to ask ourselves if this is necessarily the case. ISTDP and the KAPP have a limited focus on interpersonal relationships. It is possible that expressive artistic activities and sense of belonging that go beyond interpersonal relationships are important for recovery (Torgerson, 2018), as illustrated by the participant who engaged in dancing. Such expressive and transpersonal experiences need to be further considered and studied.

The participants in this study were motivated to share their personal experiences. Many patients with SUDs do not have the motivation or the capacity to talk about their experiences. Therefore little is known about this group. Another limitation is that the interviews were audio-recorded. Smiles, crossing of arms or avoidance of eye contact might be signs of avoiding emotional closeness. Such nonverbal signs could however not be analyzed. Finally, questions of gender have not been focused, and should be acknowledged in future studies.

Acknowledgments

We would like to thank Alexander Wilczek for his support during the preparation of this article.

Disclosure statement

No potential conflict of interest was reported by the author.