Psychodynamic therapy for substance use: what the evidence shows

Psychodynamic therapy is a talking therapy that looks at the patterns behind a person's feelings, relationships and ways of coping, including patterns that may sit partly outside everyday awareness. In addiction care it is used less often than approaches such as cognitive behavioral therapy, and its research base is smaller. This page explains how it works, what a course of sessions can look like, and what a recent meta-analysis found when it was compared with other psychological treatments.

Counseling and psychotherapy of various kinds are the most common treatments for substance use disorders, according to the National Institute on Drug Abuse (NIDA), and they are delivered by licensed mental health professionals.

What psychodynamic therapy is

A Greater Manchester Mental Health NHS Foundation Trust information page describes psychodynamic psychotherapy as a talking therapy built on the understanding that people are shaped by their relationships and experiences with others. It says these processes can be both conscious and unconscious, which can produce known and hidden feelings, wishes and thoughts connected to present and past difficulties. Painful feelings can lead to ways of defending against distress, and the therapy aims to understand and work on coping habits that no longer serve a person well.

How it works in outline

The Manchester page explains that the work happens through a safe and trusting relationship with the therapist. Patterns of feeling, relating and behaving are expected to show up in that relationship too, and they can then be looked at in the room. During assessment, the person and therapist agree a particular problem area to be the focus of the therapy.

Writers in the psychodynamic tradition have proposed many ideas about the causes of addiction and about what happens during treatment. The authors of the 2023 meta-analysis discussed below point out that most of those theories lack solid methodological evidence, and that only in recent decades have psychodynamic researchers tried to measure their work against modern standards. Confident explanations of "why" addiction develops deserve that caution.

What sessions can look like

According to the same NHS trust page, a person usually meets the therapist at a regular, agreed time each week. The person brings their own concerns, and there is space to explore what is on their mind. The therapist tries to understand what is said and to talk in a helpful way, but the page states that the therapist's role is not normally to give advice or suggest a course of action.

It also notes that feelings sometimes involve the therapist, which can feel difficult or risky at first, and that problems are expected to ease through facing and understanding them, even when that is uncomfortable. In that service the therapy usually lasts between two and six months, with the length agreed at the start or at a mid-point review. Other services and settings may use different lengths.

What the research says

A 2023 meta-analysis by Zuccon and colleagues in the Journal of Personalized Medicine compared psychodynamic therapy with other psychological treatments for substance use disorders. The authors examined 2,223 articles from several databases and found 21 eligible studies, of which 16 had enough data to combine. They looked at three outcomes: substance use, participation in treatment, and other symptoms.

• Alcohol: no differences between treatments on any of the three outcomes.
• Cocaine: no significant differences on substance use or participation; there was too little data on other symptoms.
• Opioids: small but significant differences in participation, favoring non-psychodynamic treatments, and no significant results on the other outcomes.

The authors concluded that psychodynamic interventions were as effective as other psychological treatments for these addictions. Read carefully, that means similar results to other treatments, and the comparison groups in the included studies ranged from counseling and cognitive behavioral treatment to treatment as usual. It does not show that psychodynamic therapy outperforms them. One long follow-up study at two and a half years found a larger reduction in consumption with non-dynamic treatments than with supportive-expressive therapy (a short-term psychoanalytic form), and in another trial both approaches were followed by increased opiate use over time.

The authors link the general equivalence to the "common factors" idea, that a good working relationship matters more than the specific technique. They also report that most of the included trials combined psychological treatment with medical or medication treatment, and that people in this population often have more than one diagnosis.

Limits and who it may not suit

The meta-analysis has stated limits: it was restricted to English-language papers and searched unpublished literature only superficially, and the authors call for more rigorous work before firm conclusions. Because many studies paired therapy with medication, the effect of the therapy alone is hard to separate. People weighing medications used in treatment can discuss how therapy and medication fit together with a clinician.

The Manchester page says a person who likes structure or direction may not find this the first-choice therapy, since the therapist does not usually advise or direct. Someone who wants homework, skills practice or a step-by-step plan may prefer a more structured approach such as relapse prevention. When depression, anxiety or other conditions are present alongside substance use, the page on co-occurring conditions covers that situation. The relationship-centered interpersonal therapy is a more structured, time-limited cousin worth comparing.

Questions to ask a clinician

• Is this therapy a good fit for my situation, or would a more structured approach suit me better?
• How many sessions are planned, and how will we decide whether it is helping?
• How will it be coordinated with any medication or other treatment I am receiving?
• What training and supervision do you have in psychodynamic work with substance use?