Theoretical Perspectives for Working with AOD Clients: Choosing Your Best Psychotherapy Match

Plenty of theories could be discussed in relation to the most and least appropriate to guide program development for clients who are addicted to alcohol and other drugs (AOD). A clinician does a disservice to clients by blindly pursuing every client’s issues through the dogma attached to a specific, single theory. In order for clinicians to provide sound services, they have to obtain as much knowledge about as many theoretical perspectives as possible. While many different theories are not well suited for AOD clients, it is valuable to understand theories and their relationship to psychotherapy approaches. For the least appropriate theory, this article will discuss Sigmund Freud’s psychoanalytical theory of personality along with Rollo May’s theory.  Again, to say that these two theories have no place in AOD psychotherapy would be misleading.  Although there are many more appropriate theories, it is vital to have an understanding of all of them. This paper will also discuss James Prochaska’s Transtheoretical Stages of Change and Carl Rogers’ theory of personality as the most appropriate for people who experience AOD addiction.

Please be aware that this article will be a very limited, focused discussion. There is no way that this effort could ever speak at the level intended to indicate that it has fully obtained the knowledge required to implement all of the therapeutic activities within each of the theories.  Both personal and professional beliefs, along with some of the theorists’ original perspectives, will be included.

The first step is to define theory and how that plays into therapy. Sometimes it seems that they could be one in the same; however, theory is considered as a perspective about human behavior and therapy is the clinical activity applied in relation to changing human behavior.

Freud’s theories and his writings have both fascinated and caused great debates. While Freud’s work specifically pertaining to the Ego, Id, and Superego are somewhat understandable, it would take a large amount of dedicated time to comprehend his overall body of work. The same statements could be made regarding Rollo May’s work regarding Existential Psychology. May’s point that existentialism is not a system of therapy, but an attitude toward therapy, could be applied to whatever therapy one brings to his or her therapeutic session. Freud and May’s work, while interesting, seems to be the least pliable when working therapeutically with AOD addicts.

Freud’s Theory of Personality

Freud’s theory of personality is very complex, specifically structures concerning the persistent functional units of the id, ego, and superego. From Freud’s perspective, the basic dynamic forces motivating personality were Eros (life and sex) and Thanatos (death and aggression) (1963).  These are instincts expressed in fantasies, desires, feelings, thoughts, and actions. It is his belief that people constantly desire immediate gratification—mainly, sex and aggression. This natural impulse results in social conflicts due to social rules regarding appropriate behaviors. Without some type of internal control—which Freud identifies as defense mechanisms—our society would result in chaos. Due to our defense mechanisms, we are constantly unaware of our desire to rape, ravage, and be savages.

Defenses keep people out of danger and punishment. They also keep the person from experiencing anxiety and guilt over the constant desire to break social rules. The properly-operating defense system keeps the person unconscious of his or her existence. The heart of the Freudian personality is the person’s unconscious conflict surrounding the sexual and aggressive impulses, social rules established to control these instincts and the person’s defense mechanisms’ attempt to control the impulses in order to minimize guilt and anxiety. Some safe impulses are gratified occasionally, however. The reason for a normal personality, compared to an abnormal or neurotic, lies somewhere in the malfunctioning defense mechanism. According to Freud, that neurosis occurs when the unconscious conflicts become too intense and painful, and the reluctant defense mechanisms become too restrictive. The stage of life in which the conflict begins to happen—such as oral, anal, phallic, or genital—is critical in determining the personality.

The oral stage spans from birth to about eighteen months and focuses on oral pleasures. The child’s greatest pleasure is to suck on a satisfying object, which could be a breast. Freud would consider this oral, sucking stage as “sexual” and the child is dependent on the parent to satisfy this intense, urgent sexual gratification. The parent’s response to this need determines the child’s personality. Depriving or over-indulging the baby could result in the child not maturing to the next stage properly. There’s no winning here; by not providing enough oral satisfaction to the baby, it may remain fixated at the oral stage in constant search for that object which was in short supply. Too much oral satisfaction could result in the baby remaining in the oral stage, continuously in search of satisfaction and gratification.

The anal stage spans eighteen months to three years and centers on the pleasures of the anus.  Before this stage, the child could relax his anus muscles and “go” at will; now the child must begin to be in control. As in the oral stage, a too demanding or overindulgent parent can cause personality problems in the anal stage. The main problems in this stage are power struggles such as sleeping, eating, and dressing. Individuals who had demanding parents, resulting in the child holding on or clinching his or her anus, could end up as a person who may hold onto their money. Contrarily, a parent who allowed the child to go whenever the pressure was felt could have a grown child that lets things go, like money, being prompt, or details.

The male genitalia stage, or phallic stage, was generalized to women. During the ages three to six both sexes are very interested in their own genitals. They are also interested in the opposite sex and their genitals. The main consideration is not the genital area itself, but the object of their sexual desire. The boy desires the mother and is scared of his father’s seemingly competitive spirit. The boy constantly fears that his father will end the competition by cutting off the boy’s penis. In the phallic stage, girls resent their mothers for not giving them a penis. Freud’s main point about this stage is the parent’s response to the child; just like the prior stages, overindulgence could result in vanity and over rejection.

The important thing about the stages is that we are more vulnerable if our conflicts and fixations occurred earlier in life. When a fixation occurs early on, the person would be more dependent on more immature defenses for dealing with anxiety. Also, the more intense our conflicts are earlier in life, the more vulnerable we are in coping with adult stress and conflicts. When an individual is confronted with an event such as a sexual affair, there is a stimulus to an impulse, which they have been trying to control since childhood. The unconscious reacts to the current event as if it were a repetition of a childhood experience. The result could be a number of reactions due to their entire defensive system being out of balance. Their system has operated as a delicate balance of keeping impulses and anxiety at a safe level; at this point the person is willing to spend any amount of energy to keep these impulses from coming into consciousness (Freud, 1963).

Freud’s Therapy

Freud’s therapeutic process of making the unconscious conscious comes directly from past events. Responding to the environment in a healthier way requires a consciousness of how our responses derive from the unconscious, that is, conscious rising. Freud would work toward free association in therapy sessions; the patients would let their minds go without any defenses, thereby exposing their instincts. It is still very scary for patients to allow raw instincts into consciousness, because they have been dangerous to expose. After several years of controlling these instincts, it takes more than just Freud’s suggestions to “let yourself go.” With the therapist’s help, the patient has to raise his/her consciousness in order to bring relief. Forming a working alliance helps the patient face possible terror in recalling detailed dreams and childhood memories.

Freud’s approach does not work with every behavioral problem. Those who cannot regress or come back from this process are less appropriate patients. Inappropriate candidates might include schizophrenics, manic-depressive types, or borderline personalities. There are four basic procedures to psychoanalysis: confrontation, clarification, interpretation, and working through (Freud 1963). These are attempted when analyzing the patient’s resistance to free-associating and the transference, the unconscious redirection of feelings from one person to another, that emerges as the patient regresses.

The Therapeutic Relationship

Although this article identifies Freudian theory as least appropriate for AOD clients, Freud’s analysis of the therapeutic relationship is vital for therapists to understand. He believes that the working relationship between patient and therapist needs to be non-neurotic, rational, and realistic. This type of relationship is mandatory before therapy can result in any gains. The trust between the patient and therapist allows the negative transference reactions to be dealt with appropriately during psychoanalysis.

When there is not a therapeutic relationship, transference comes into play. The patient experiences feelings toward the therapist that actually apply to significant people in the patient’s past, and most times, those past feelings, impulses, and displacements are shifted to the therapist.  The past conflicts are not resolved, but are relived through the current relationship with the therapist. Unfortunately for the patient, this process remains unconscious. The therapist’s job is to remain balanced between caring and depriving enough to work through this, while allowing the patient’s transference to react. Therapists must also be aware of their own unconscious process, or counter transference. The therapist must be healthy enough to separate what is unconsciously coming from the patient and him/herself. This requires that the therapist receive about five years of psychoanalysis.

Does it Work with AOD Addicts?

The answer to that question depends on who is asked. A true psychoanalyst would say it works very well with just about everyone. It might be common for professional therapist to dabble in this theory and somewhat enjoy it, but not consider it to be much help by itself. The main problem with Freud’s approach is the same as any other theoretical approach: how to measure success and what it actually looks like. Because Freudian theory states that the unconscious has to become conscious, it takes a long time to be trained and to work through the process. The time required to go through this process would never work in today’s AOD treatment facility.

The approach is also risky. Freud would seem to always connect sexual aggression to every problem. More broadly, psychoanalysis is too subjective and unscientific; it cannot be linked to observable behavior to be objectively measured and validated. However, Freud’s work has stood the test of time and continues to be taught in colleges and universities. While it is problematic to use some of his approaches, AOD therapists deal with transference issues all the time.

Rollo May’s Theory of Personality 

There are obvious differences between Freud and May, beginning with their training and education. Freud was trained in Europe and earned a MD. May on the other hand was trained in the US as a theologian and clinical psychologist. No evidence suggests that Freud ever suffered from the neuroses he treated in others. May seemed to have suffered personally as well physically, which influenced his theory. Having come down with TB and being confined in a sanatorium for two years would seem to impact most people. May’s own existential struggles contributed to his writings. Although I am stating that this theory would be inappropriate for AOD clients, I think his own suffering could be compared to the recovering alcoholic becoming a professional counselor. Although it does not take the suffering from a disease to be able to treat it, it could help during the therapeutic process having been where your clients have been.

May’s definition of existentialism centers on the existing person and emphasizes the human being as he is emerging, or becoming (May 1977). Existentialists do not see the theoretical perspective as a structure resulting in a specific therapy; rather, existentialism is an attitude toward therapy (May 1977). Existentialists do not agree with the term personality as related to a fixed set of traits located within an individual. May also goes beyond the individual’s inner dimensions and connects the individual to their world, rejecting dualism, which assumes a split between the mind and body, experience, and environment.

To understand the person, one has to understand to the person’s world. According to May (1977), we all live in three levels of the world: us in relation to the biological and physical aspects of our world (being in nature), the world of persons socially (being with others), and in our own world (being for oneself). Each of our personalities exists differently at each level. During the process of creating a healthy existence, each of us attempts to pick the best way to be in nature, with others, and for ourselves. Existentialists believe the best choice is to be authentic and that being honest and open allows us to be spontaneous with others and ourselves. We do not have to fear that we portray something we are not; being authentic ensures that when people care for us they truly are caring for us, and not something we are acting out falsely. This will allow for healthy relationships because we can trust that everyone else is authentic and not saying something because they think it is what we want to hear.

According to existentialists, pathology happens when people are not authentic, that is, lying to oneself and others. Lying is an attempt to avoid nonbeing, or death. This is similar to the person who could not come to terms with the passing of her mother after spending the last eight years of her life in a nursing home with Alzheimer’s disease. When she finally died, the daughter wanted to bring charges against the home, due to her belief that her mother was in good health. Somehow, she believed the nursing home was at fault. Reading and trying to understand May’s position would help the daughter understand that she was avoiding and lying to herself and others.

May’s Therapy

Of course, if lying is the problem, the solution is becoming honest. Therapy has to focus on everything that is missed by lying to oneself and others, along with how lies close off everything to being, or living. The first part of May’s therapy greatly encourages the authentic relationship with the therapist. While Freud would encourage the patient to begin speaking about whatever comes to mind, May’s session would encourage the patient to be whatever he or she wants to be.  Patients should express freely and honestly whatever they are experiencing presently. The therapist should try to understand the world of the patient without imposing any theoretical or personal preconceptions. Most of the therapist’s feedback clarifies the patient’s own language.

The Therapeutic Relationship

Freud would remain somewhat aloof with his patients focusing on transference issues. May, however, encouraged the therapist to understand the patient’s world or being in the world.  Without understanding this, any theoretical or technical understandings are worthless. By engaging the patient in an authentic discussion, the patient becomes aware of the ways in which he/she avoids an encounter.

Does it Work with AOD Addicts?

Who knows? Since it is not a technique, it would be hard to measure success. Existentialists would not participate in reducing people into statistical experiences. Also, being in the world with others and trying to measure individual’s experiences as they relate to each other would be quite difficult. As with Freud, some things within May’s theory could fit nicely in an AOD program. Therapists should have a way of thinking about therapy, as May puts it. However, as it related to AODs, Carl Rogers’ way of thinking fits better.

Most Appropriate For AOD Services

The two theories that will be discussed as being most appropriate for this population are Carl Rogers’ theory of personality and James Prochaska’s Transtheoretical Stages of Change. Carl Rogers laid the groundwork for motivational interviewing (MI), a therapeutic process of increasing motivation for change.

Carl Rogers’ Theory of Personality

Carl Rogers’ main idea about humanity is that every one of us has one ultimate motivating force, self-actualization. He defines self-actualization as the inherent tendency of the organism to develop all its capacities in ways that serve to maintain or enhance the organism (Rogers 1959).  According to Rogers we are born with a positive valuing process that enhances and maintains those positive things in our lives and we value negatively those experiences that stagnate our growing potential. These internal processes are part of our inherent design, and we trust that they intend to serve us well. Rogers (1959) concludes that our world is made up of our own making (our reality) and that, in order for others to understand our reality, they must attempt to place themselves in our frame of reference. Once we understand ourselves, we seek positive regard for that self from others. People learn to need to feel loved, prized, and accepted and these feelings become so positive that they turn into the most important thing in becoming a person.

For instance, if a parent provides a child’s behavior with a positive reflection, then the child views that interaction positively and sees how positive he is. If the parent responds negatively to a behavior, then the child views the loving relationship with the parent as weakening. Before long, as the child grows, he sees himself through the lens of how others regard them. This results in having a condition of worth, as those outside the self see the person as worthy.

Someone with maladjusted conditions of worth is threatening to one’s self. Everyone deserves full self-actualization, becoming a whole person, and if our behavior is conflicted between the self we like and the self we dislike, then we have a divided personality, resulting in dysfunction (Rogers 1959).

Rogers’ Therapy and the Therapeutic Relationship

The most important ingredient for therapy, according to Rogers, is the therapeutic relationship.  As stated earlier, Rogers’ therapy and his beliefs about the therapist’s relationship with clients are the foundation of motivational interviewing’s techniques. He uses terms such as unconditional positive regard (e.g., showing complete support and acceptance), empathy, and genuineness. The therapeutic relationship offers empathy and genuineness as a means to allow the patient to achieve self-actualization. The emphasis on genuineness also recalls the previous section on existentialism, which also have similar connections with Roger’s ideas.

If the therapist does not succeed in these relationship issues, Rogers’ therapy falls apart.  Because of his theory of personality and people seek self-actualization, if the therapy session’s atmosphere does not provide unconditional positive regard for the client, then harm will continue.

Does it Work with AOD Addicts?

How could being empathetic and genuine with clients not work? It surprises me how little empathy many AOD “professionals” have for their clients. Historically, this field has held the belief in the necessity of breaking a person down to the lowest levels and then building them back up with, unfortunately, the same techniques used to break them down. Other health professions would never attempt this strategy. If someone walked into a hospital with a mild heart problem, the clinician would not wait until a massive heart attack before taking the problem seriously.

James Prochaska’s Theory of Personality Change

What I really like about Prochaska’s transtheoretical model is that it started with a comparative analysis of all of the main theories and psychotherapies in an effort to seek what each had to offer. It is an integrative theory. Prochaska created five criteria for the model. First he wanted a sophisticated integration that respects both the fundamental diversity and essential unity of psychotherapy systems. Second, the model should emphasize empiricism by measurable variables and then validated. The third criterion was to account for how people change without therapy, due to the fact that many people with clinical disorders are able to change without the help of professionals. Fourth, the model should prove successful in generalizing to a broad range of human problems. Finally, the transtheoretical model should encourage psychotherapists to be innovators, rather than simply borrowing from other systems (Prochaska 2003).

Stages of Change

Five stages of change have been conceptualized for a variety of problem behaviors. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance.  One of many reasons for using Prochaska’s model in an AOD program is its natural connection with the Twelve Steps of Alcoholics Anonymous (AA). While there will be a discussion of this therapy later, some of the Twelve Steps of AA will be listed below to show how they would fit with the stage.

Precontemplation

This is the stage in which people do not intend to take action in the foreseeable future, usually, the next six months. People may be in this stage because they are uninformed or under-informed about the consequences of their behavior. Or, they may have tried and failed to change a number of times and have become demoralized about their ability to change. Both groups tend to avoid reading, talking or thinking about their high-risk behaviors. Other theories often categorize them as resistant, unmotivated or not ready for treatment. The fact is that traditional therapeutic programs are often not designed for individuals in the precontemplation stage and typical treatment services are not matched to their needs.

Contemplation

Contemplation is the stage in which people intend to change in the next six months. They are more aware of the pros of changing but are also acutely aware of the cons. This balance between the costs and benefits of changing can produce profound ambivalence, which can keep people stuck in this stage for a long time. Those finding themselves in this stage are characterized as chronic contemplators or behavioral procrastinators. These people are also not ready for traditional action-oriented programs and could account for many treatment dropouts.

Preparation

This is the stage in which people intend to take action in the immediate future, usually measured as the next month. They have typically taken some significant action in the past year. These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach. These are the people that should be recruited for action-oriented programs, such as smoking cessation, weight loss, or exercise programs.

Action

Action is the stage in which people have made specific and overt modifications in their life-styles within the past six months. Since action is observable, traditional therapy often equates action with behavior change. In the Transtheoretical Model, however, action is only one of five stages. Not all modifications of behavior count as action in this model. People must attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease. In smoking, for example, reduction in the number of cigarettes was counted as action, or switching to low tar and nicotine cigarettes. According to the model the consensus is clear: only total abstinence counts. The Action stage is also the stage where vigilance against relapse is critical.

Maintenance

Maintenance is the stage in which people work to prevent relapse but do not apply change processes as frequently as in the action stage. They are less tempted to relapse and increasingly more confident that they can continue their change.

Prochaska’s Therapy

In Prochaska’s therapy there is an attempt to combine the process of change and the stage. Once the stage of change is identified in a client, then the process of change is applied. Prochaska has specific recommendations for the process of change during each stage. For instance, if a client was in the precontemplation or contemplation stage, then the therapist would attempt to raise the client’s consciousness. Helping the client become more aware of the problem and get some emotional relief would move the person into the next stage. Environmental reevaluation and self-reevaluation are used in the contemplation stage specifically. As clients become more aware of the problem, they are more open to reevaluating beliefs. The preparation stage utilizes self-liberation due to the client’s readiness for change. They need to know that they have autonomy to change their lives, which is associated with self-efficacy. The action and maintenance stages use contingency management, counterconditioning, and stimulus control.

The Therapeutic Relationship

The transtheoretical psychotherapist is an expert having all of the answers, rather an expert about change. Because some of Prochaska’s research studied how people changed without seeking professional services, the therapeutic relationship is based on the assumption that people have the capability to change. According to Prochaska, the relationship with the client depends on the client’s current stage of change. For example, the relationship with Precontemplators should be that of a nurturing parent who allows for independence. Contemplators would benefit from the therapist taking a Socratic or teacher position, in which the therapist would encourage insight into the problem’s conditions. Working with clients in the preparation stage is like coaching a specific game plan. A consultation relationship would be used for the maintenance stage. This is another reason to use some of the skills of motivational interviewing.

Does it Work with AOD Addicts?

Yes, and with others as well. Over twenty years of data collection document the success of using this approach. The Centers for Disease Control and Prevention, American Lung Association, and World Health Organization use it, along with many others. One of the most important data from this research is developing interventions that match the client’s stage of change. One of the reasons that clients may drop out of treatment prior to completion, usually within the first week, is the treatment intervention not matching the client’s stage of change. Unfortunately, many treatment facilities operate under the assumption that any client entering treatment services is in the action stage, which is a problematic approach to treatment. One of the good things about using this theory is that, once the client’s stage of change is identified, there are plenty of opportunities to use many theoretical-based approaches. This theory does not force the therapist into an inflexible idea of the problem or its solution(s).

Conclusion

There are a variety of transtheoretical approaches that could have been discussed, both supportive and less than supportive for addicted individuals. Of the many positive attributes of Prochaska’s theory, it allows for a variety of other theoretical approaches. Adaptability to the client’s needs seems to be an important criterion for evaluating theories. Finding and working within a theoretical framework is not mandatory to be an effective therapist. However, lacking basic knowledge related to the historical and theoretical context of professional therapy is part of the responsibility of providing effective and professional services. It is vital for professional AOD workers to move beyond what might be required theoretical studies in college courses and drill down into other theories that best match your own clinical approaches, as well as what is best for sound clinical services.

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