A 28-year-old unmarried male, graduated and working as a software engineer in an urban setting, presented with alcohol, cannabis and tobacco use in dependence pattern and a history of recreational use of hallucinogen and stimulants in the past. He was on pharmacotherapy for substance use and comorbid bipolar affective disorder. He was referred for psychotherapy in view of distress in interpersonal relationships and mood disturbances.
Assessment Phase
The initial interaction between the therapist and the patient tried to clarify the patient’s motivation for consultation.
Therapist: Is there anything you would like to understand about your diagnoses or treatment? (Assessment question)
Patient: Yes. I want to know if I will have to completely let go of substances or can I use it occasionally in the future? If I stop using substances, will I feel lonelier? Will it make matters worse because I do not want to lose my friends? Substances help me to relax and connect with my friends.
As seen above, the patient appeared to use substances to enhance his relational experiences and therefore seemed ambivalent about the goal of abstinence. Further discussion helped to understand the interpersonal context in which these concerns presented. A harm reduction goal was set. After obtaining preliminary information on the general functioning of the patient, the therapist introduced personality impairments as potential vulnerability underlying his substance use.
Therapist: One of the reasons people continue to use substances even when they see it is harmful is because they tend to behave in certain repetitive ways that make substances necessary for them to function. For example, to feel more accepted and desirable in a social group, they might take substances. Would you be willing to explore if these could be a possibility for you?
The levels of personality functioning scale (LPFS) was administered. Assessment responses were continually linked to patient’s real-life contexts. Other measures like the drug abstinence self-efficacy scale (DASE) (McKiernan et al., 2011), the difficulties in emotion regulation scale (DERS) (Gratz & Roemer, 2004) and the inventory of interpersonal problems (IIP) (Barkham et al., 1996) complemented the personality functioning formulation.
Severe impairments in identity and moderate impairment in empathy and intimacy were noted. Difficulties were noted on all domains of emotion regulation. Interpersonal functioning was suggestive of an overaccommodating and non-assertive style. High risk situations for substance use were identified as withdrawals and craving, social interactions and positive and negative affect.
Formulation: The formulation (Fig. 1) was co-constructed by the therapist-patient dyad as substance use resulting from impaired personality functioning specifically the identity and intimacy domains. Poor emotion regulation and an internalizing temperament were identified as the mediating mechanisms through which the patient’s personality emerged in interpersonal contexts.
Therapy Targets
On the identity domain, impairment in the sense of self, the emotional range and regulation were targets while on the intimacy domain, the impairments in the desire and capacity for closeness and the depth and duration of connection. Difficulty tolerating differing perspectives was targeted on the empathy domain.
Personality targets were further refined as enhancing emotional functioning: awareness and clarity of one’s emotions, reducing impulsive behavior during negative emotional states and learning adaptive emotion regulation strategies. The over-accommodating and non-assertive interpersonal styles were addressed through healthy expression of needs.
Harm reduction approaches were used for substance use management while mood symptoms were targeted through behavior activation (Cuijpers et al., 2007) and medications.
Phases in Therapy
The initial phase addressed harm reduction and behavior activation. Motivational interviewing principles (Miller & Rollnick, 2012) were used to address patient’s concerns of losing friendships. Relapse prevention strategies (Larimer et al., 1999) were used to address risk of relapse.
In the middle phase, techniques from DBT and emotional schema therapy (EST) (Leahy et al., 2011) were used to improve emotion regulation while dual focused schema strategies helped to modify interpersonal patterns. Therapeutic alliance was maintained by addressing ruptures early therapy and motivation through periodic assessments and a focus on the balance between change and sustain talk.
In the final phases, the patient was encouraged to build a lifestyle incompatible with drugs i.e. a non-substance identity. Any opportunity was seen as a potential avenue to capitalize on treatment gains.
Outcome: At termination patient showed improvement in personality functioning, emotion regulation and interpersonal problems. The patient reported improvement in number of abstinence days, amount of use, self-efficacy, better understanding of internal states like emotions and needs in interpersonal contexts, improved relationships with family and peers, began exploring potential romantic relationships which he had been previously avoiding and greater satisfaction at workplace.
Treatment Structure: The duration of therapy was 3 months with 15 sessions. Sessions were more frequent in the initial phase of therapy. A blended format i.e, online and in-person session was used to ensure engagement as the patient was not able to attend all sessions in person due to other commitments.