Can the cultures of addiction and psychoanalysis mix? A psychiatric center's experience with integrated treatment uncovers obstacles.

Treating addiction in an open, psychodynamically oriented hospital setting provides challenges that may suggest the need for a paradigm shift in how professionals treat addiction in other settings, as well. The challenge of integrating psychiatric and addiction treatment exists in many settings, as the health field strives toward establishing wraparound, interdisciplinary, and seamless systems of care. Several areas of conflict in this move toward integration offer a conceptual framework suggesting a more modern approach to treating comorbid disorders, which was arrived at through this writer's efforts to establish a substance abuse service in a psychoanalytically oriented hospital treatment center. These areas include exploring similarities and differences between mental health and addiction treatment and developing a clear understanding of role-specific authority in implementing an interdisciplinary treatment model.

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An "open setting," as defined by this hospital's mission statement, is on the one hand characterized by the absence of seclusion rooms, restraints, and locked doors, and on the other by the assumption that life and its interactions are worth ongoing examination.

The Austen Riggs Center, located in the picturesque Berkshire Mountains of western Massachusetts, has been traditionally known as a long-term treatment facility with roots dating to the days of rest homes, socialized therapeutic work programs, and sanitariums of the early 20th century. The center blends in with the local architecture of "cottages" and centuries-old colonial homes lining the town's main street. Patients participate in various levels of care in which they hold ultimate responsibility for their own safety under the scrutiny inherent in active therapeutic community group life. Many patients have cars and jobs and attend school.

The most prominent aspect of treatment is psychoanalytic therapy offered four times per week; all patients attend regardless of level of care. Other services are provided by social workers, medical staff, psychiatric nurses, psychopharmacologists, substance abuse professionals, and an activities staff that offers a clinical-free zone where patients can become students of woodworking, weaving, pottery, theater, photography, and horticulture. The center operates a Montessori school in which patients are able to take part through volunteering or paid internships and an active work program.

Within a short walk of the center, the village offers various shops and restaurants, with many cultural events nearby. This environment includes bars and a modest offering of nightlife catering to the local population and an influx of summer tourists. While the setting's openness might at first seem to be a drunkard's dream, its challenges are an integral part of treatment--there is little effort to shelter patients from the "people, places, and things" with which they ultimately will have to deal. One can literally walk the same distance to a nightclub or to an AA meeting. All patient experiences are grist for the mill of ongoing examined living. This arrangement is not for everyone, and in fact many prospective clients with an active substance abuse problem are referred to addiction-specific treatment facilities in order to establish a viable period of sobriety before admission is considered.

Shedding old stereotypes

As an institution with traditions incorporating many of the tenets of psychodynamic treatment, the center has had its share of conflict in developing a substance abuse service element. The center has been in operation for more than 75 years but has had specialized substance abuse counselors for only the past 10 years. The traditional psychoanalytic tendency was to view addictions as highly defended symptoms meant to obtain pleasure or relieve tension from pathology of underlying origin. The thought was that once the conflict was uncovered and solved through the analytic process, the substance abuse then would resolve as a symptom no longer needed, allowing the real work to begin.

But the changing demographics of the population seeking treatment at the center (or anywhere else for that matter) strongly suggest that dual diagnosis is the norm rather than the exception, and that development of an addictive disorder can occur in varied forms, most often within the context of other Axis I and II diagnoses. Truly, the dually diagnosed no longer are seen as a "special population."

The growing concern for containing healthcare costs and the resulting competition for limited resources have erected obstacles to a truly integrated model of treatment under an interdisciplinary staff. The impact of the 12-Step fellowship has challenged the psychoanalytic tradition's view by suggesting that recovery occurs best through one recovering person helping another (rather than solely through developing a transference/countertransference relationship between patient and therapist).

These traditions of self-help also provided the groundwork for a growing field of substance abuse treatment as the disease model began to take hold through the advocacy of the medical community. As a wide range of services proliferated, the self-help community was tapped for its most vital resource: people who had gained experience working with others with substance abuse problems.

Changing demographics as well as regulatory agencies' influence required that the center begin to assess substance abuse more consistently. With the support of center administration, particularly the nursing staff, the center in 1994 established a substance abuse services committee in an attempt to begin the integration of psychodynamic and addiction treatment models. A certified substance abuse counselor was promoted from the nursing staff to manage the committee, which implemented procedures and made recommendations to therapists.

Conflicts and disagreements among staff at the center arose out of the different traditions and roots of addiction and psychodynamic treatment. While the psychoanalytic view held that symptoms were manifestations of deeper pathology requiring interpretation in order for the patient to recover, addiction treatment tended to view addictive behavior as something to be managed prior to being understood. This is in keeping with the roots of psychoanalytic treatment lying within an ambiguous, Freudian entity called the unconscious, while the roots of addictions treatment grew primarily out of fundamentalist religious groups and the penal system, with the problem of addictions disposed of clearly and authoritatively. These two fields were coming from different places, but through integration of care now found that their conflicts had been brought under one roof.

As a field, we have a long way to go to begin to achieve real integration--a culture that shares common authority, language, sense of purpose, and clarity of role in which there are mutual understanding and respect for the traditions of both mental health treatment and substance abuse treatment. We remain, as always, a work in progress.

Getting started

The beginnings of a substance abuse service at the Austen Riggs Center took place informally in the early 1990s. Several clinicians from different fields, nicknamed "the lunch bunch," began sharing their lunch hour and mutual concerns over a patient population presenting with increasingly more severe and deep-rooted substance abuse problems that were not being sufficiently addressed. Few of these clinicians had previous experience in substance abuse-specific treatment settings. Out of these meetings, often characterized by heated debates on the interrelatedness of substance abuse and other psychiatric illnesses, the clinicians began to suggest interventions to the psychotherapy staff.

Other disciplines at the center, as well as patients, were asked to view the substance abuse service as part of the center's consultative model for treatment, thereby minimizing the potential for this important aspect of treatment to be split off. In this way, the service's interventions were intended not to resemble those in the boutique-like model of behavioral healthcare that treats comorbid diagnoses in a sequential or serial fashion.

Documentation was developed to reflect the explicit authorization of substance abuse service interventions from staff and treatment teams. A range of services, including weekly individual and group counseling, was conceptualized (with patient input), developed, and integrated into the treatment plan. Short-term "seminars" or focused learning groups cofacilitated by the substance abuse service and related clinical staff were established to reflect the community's needs. Incidents of substance abuse, drug sharing, underage drinking, and related problems were addressed through the already established framework of examined living, specialized community meetings, and task (or peer/staff small support) groups designed to inform patients of their impact upon others and the community.

Resolving conflicts

While all this might suggest that the process went smoothly, the integration of the substance abuse service at the center transpired slowly and painfully, and not without sizeable moments of contention. Clinicians from different backgrounds and orientations have negotiated, struggled, argued, and analyzed the intricacies of the conflict between the fields of addiction treatment and psychoanalysis from numerous dimensions for the better part of the past decade. Many of these debates specifically occurred between the substance abuse service and clinicians of other disciplines who had little experience and training in the area of addictions, but who had strong feelings about them.

Staff conflicts often were resolved at the level of the interdisciplinary team meeting, which included the patient in the discussion. Often these meetings concluded with a feeling of mutual respect among the various disciplines and patients. Through this positive process, staff continues to learn to articulate the subtleties of and distinctions between mental health and chemical dependency.

The idea of integrating substance abuse services at the center continues to nurture the development of skills that incorporate the psychodynamic aspects of addiction with the realization of behavioral change. The center has acquired an ability to adopt more objective and workable treatment alliances among staff groups and with patients. It is clear that this makes sense given today's integrated nature of dual diagnosis treatment, as opposed to a past scenario in which patients could disown and split off aspects of their experiences between competing agencies or between clinicians of different disciplines within a single healthcare system.

Joel D. Sturz, MEd, CADAC II, is a former Coordinator of Substance Abuse Services at the Austen Riggs Center in Massachusetts. He currently works as a consultant. To send comments to the author and editors, please e-mail [e-mail].

by Joel D. Sturz, MEd, CADAC II

RELATED ARTICLE: A Case That Demonstrates the Integration Challenge

"Karen" was admitted to the Austen Riggs Center's residential treatment program after being hospitalized numerous times for short-term evaluation, stabilization, and medication review. A graduate student whose academic pursuits had been interrupted several times because of poor grades and apparent difficulties with professors and fellow students, Karen had a known substance abuse history that included regular use of cocaine and alcohol. She had not been treated specifically for substance abuse in the past, although she had several psychiatric diagnoses that included bipolar disorder and PTSD. Her family sought her admission to the residential program, with the expectation that the length of stay might be several months.

During the first few days of her treatment, Karen was assessed by a substance abuse counselor in accordance with protocol for all newly admitted patients. It was noted that in addition to her own extensive history of abusing multiple substances, she was the child of an alcoholic father who had been capable of violent outbursts as well as sexual innuendo during Karen's early years.

At an initial team meeting, the substance abuse counselor noted that Karen had selected cocaine as her preferred drug. This, combined with alcohol use, may have intrinsically re-created an experience of rapid movement from exhilaration to despair, which resonated for the patient in terms of likely past physical and sexual abuse. The counselor suggested that the psychotherapist calibrate his interventions carefully so as not to undermine efforts toward Karen's establishing a firm support system by which to maintain abstinence.

From the counselor's perspective, Karen was vulnerable and predisposed to relapse if she were encouraged prematurely to process events and memories pertaining to the likelihood of her having experienced incest. Focus, therefore, would be best exercised toward encouraging behavioral change by facilitating Karen's attention to activities of daily life, including attendance at symptom-focused (substance abuse) groups. In addition, the counselor believed she should begin attending local meetings of AA and NA in order to receive further education and support.

With an integral component of her treatment program consisting of intensive psychodynamic psychotherapy several times per week, Karen soon found herself amid a highly charged clinical conflict between her therapist (who represented stern paternal authority) and her counselor (who represented a more empathetic maternal figure). Several relapses occurred, which contributed to a sense of anxiety from staff. This anxiety was "held" by the substance abuse service, which the rest of the staff saw as responsible for managing the patient's substance abuse-related behavior. As the institution turned to the substance abuse service for insight and responsibility, the service, as might be expected, felt scapegoated and misunderstood in terms of its efforts, thereby establishing a confusing and destructive rift within the institution.

In the end, Karen, who was relatively high-functioning, motivated, and intelligent, was able to make substantial progress toward health, but primarily because of her own ability to integrate her own experiences.