Using Both Lenses: Academic/Evidence-Based and Psychodynamic

Disclaimer: nothing in this content should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care.

One way to think about clinical work in addiction counseling is through the lens of academic and evidence-based practices. And another way is to use the lens of psychodynamic approaches.

Below, find a simplified way to begin thinking about the two approaches. Personally, I like memorizing material like this. Because in that way I have a reliable framework that’s easy to access and holds the basics as a starting place.

Example 1: Academic and evidence-based. Around 30 years ago we had a patient in our 9-12 month residential treatment program who was middle aged and did quite well. Their adaptation to the house concepts and rules was positive. And they had a really constructive and collaborative style of being in group therapy and individual counseling. But what stood out most was their recent history with cancer. A few years before entering the program they had a rather serious case of cancer and they seemed to beat it. But they were concerned it might come back, given that it was only a couple of years ago. In addition to routine clinical assistance we individualized their care and helped them with their fear, grief, a whole range of personal relapse justifications, and other kinds of clinical tools and supports as I’m sure you can imagine. The person completed the program, accepted our continuing care recommendations for outpatient continuing care, and was committed to continuing to work a personal program of recovery in their chosen mutual-aid fellowship.

Example 2: Psychodynamic. A few years later that person returned to the long-term residential program having had a serious and prolonged chemical use relapse that stretched on for at least a couple of years. Once they stabilized we asked about their cancer. How had they done? Did the cancer stay in remission? How were they doing now with regard to hope, and things like that? Did their cancer prognosis worsen and was that why they returned to using? When we asked these questions the patient was completely confused and didn’t know what we were talking about. After going back and forth with them for several minutes (they were very collaborative, but just had no clue what we were talking about) we finally flat-out said we were asking and concerned because their cancer had been a very memorable center-piece of their work in treatment during their previous stay. The patient then sheepishly laughed while seeming somewhat embarrassed and taken a bit off-guard. That’s when they explained that while they were listening to us they started to realize they had used “the cancer story” during their previous stay. And how they had forgotten they had used that story with us the last time they were here for treatment. And that they in fact never had cancer and sometimes used that story. And they said they wanted to apologize for having used “the cancer story” with us, since we seemed so nice.

Conclusion: When watching and listening, consider also adopting a psychodynamic lens, as an added way of knowing. For example, consider the following probes of our thinking as clinicians:

How could it be that what I observe is actually a symptom?
How could it be that their presenting symptoms are actually a form of communication?
And if I consider their communication to be a general defense strategy writ-large, what understanding can I gain?

Only after their initially completed residential stay with a good prognosis, eventual non-adherence to continuing care and mutual-aid, a full and prolonged relapse, and later return to our setting with them taking a different stance with us, did we come to begin to understand that:

Their positive participation in their first treatment was a manifestation of their coping strategies, and did not constitute change-work.
Their presenting symptoms were false, and functioned as a way of asking for help that we never understood.
Their communication had been a way of hiding.

But what’s really compelling to me is that:

These three takeaways were taught to us by the patient during their second stay
This other way of thinking did not constitute a clinically-derived, clinically-presumed, and clinically judgmental method or approach on our part (as some would claim the psychodynamic approach is full of)
And our academic and evidence-based approach during the first stay was seriously off the mark and far too shallow.

What can we take away from this kind of story? The working clinician can hold both the academic/evidence-based method and the psychodynamic method lightly, and not put them in tension. And the working clinician can consciously, mindfully, and intentionally oscillate between the use of these two lenses in the clinical moment and during the longer clinical process. And be informed by both, perhaps, rather than exclude and miss what the other approach might suggest or provide.

For those that might be interested, here’s a much fuller resource that discusses the multi-factorial production of whatever manifests in any addiction counseling moment. It considers the following factors: