Active substance use, including marijuana consumption, can be problematic for psychodynamic and other uncovering types of psychotherapeutic treatments such as Intensive Short-Term Dynamic Psychotherapy (ISTDP). 

My perspective is that of an outpatient psychotherapist, where clients see me for an hour or two per week and then go back to their lives. Working with clients in a residential or partial hospitalization context could have very different implications and falls outside the scope of my practice.

There could be psychodynamically oriented psychotherapists who do effective psychodynamic work with client’s who are actively using substances, but I am not one of them. More on why I take this position later.

Client’s that are in the throws of an active addiction can still benefit from seeing me for psychotherapy, but the sessions will be supportive, geared towards behavioral changes, and finding non-substance related ways of managing anxiety. This way of working precludes an in-depth approach aimed at resolving the engine of the client’s difficulties, but it is the only approach possible when a client is actively abusing substances.

I evaluate clients’ readiness for uncovering psychotherapy on a case by case basis. In some cases, minor marijuana or alcohol consumption does not interfere with a psychodynamic treatment. Smoking a joint once a week or consuming a couple of glasses of wine a few nights per week is typically not problematic. 

More often than not, however, I find that active substance use greatly interferes with uncovering and exploratory psychotherapeutic work. More than 2 alcoholic drinks on a given evening raises a red flag and will prompt me to closely monitor the client’s relationship to substances and whether or not these habits are likely to impede psychotherapeutic progress. 

Why active substance use interferes with psychodynamic treatment

The first problem with active substance use is that therapeutic gains simply do not stick. Insights and therapeutic movement may occur in a given session, but if the client goes back to his or her life and consumes substances in excess, those very insights are often obliterated and the therapeutic movement stopped in its tracks. Therefore, the therapeutic gains do not generalize to the rest of the client’s life — the client takes a step forward and two steps backward. 

Second, I am flying blind diagnostically — I do not know which symptoms may be brought on by the substance, nor do I really know what is coming from the client, and what client responses and communications are influenced by the effects of the substance. 

Third, uncovering work while the client has not kicked the substance use habit can trigger more severe substance abuse, which can create safety issues. 

Lastly, in uncovering work I want to help the client uncover the emotional conflicts that drive the client’s difficulties, and substance use covers up and patches over the very conflicts that need to be uncovered, resulting in the client and myself working at cross-purposes. The treatment is sabotaged by the client who is actively using substances. 

For these reasons, I let people who struggle with substance use know in my initial 30-minute free meet-and-greet that in order to optimize the therapy and  give the treatment a chance to really take off the ground and be successful, that as an experiment, they try to abstain from all drugs and alcohol for six weeks only, and to come in after six weeks and just be honest with me about whether or not they managed to do so.

I usually say that whether the client does or does not manage to abstain, we will know something important about the client and the role of alcohol (or whichever the drug is) in his or her life. If they do not manage to abstain, supportive and behavioral therapy is still an option, and when and if they manage to gain six weeks of sobriety under their belt, more in-depth psychotherapy can take place. 

If after six weeks the client reports they succeeded in staying clean, I am usually confident that substance use is not a primary diagnostic concern and we proceed with uncovering work.

Some clients think my approach is based on moralistic thinking. This is not the case. It is technical — certain therapeutic goals are simply not possible to reach when certain behaviors impede and undermine the path required to reach those goals. It’s cause and effect, not right or wrong.

Author: Johannes Kieding

I have a passion for practicing ISTDP informed psychotherapy and I enjoy writing about it. For more information and what I do, visit my website: www.johanneskieding.com