Substance abuse is a serious social, economic, and health burden that not only impacts the concerned stakeholders but also the society that surrounds them. The domain of substance abuse includes abuse of alcohol, addiction to narcotics (such as heroin, marijuana, ecstatic drugs) and abuse of tobacco [1]. The major symptoms of substance abuse include an increase in the episodes of cravings, the reduction in the period in reverting to abuse after therapy, and increased frequency of abuse [2]. The negative outcomes of substance abuse include increased incidences of emergency visits, accidental injuries, family and domestic violence, and psychopathic disorders. Since there are different facets and symptoms of substance abuse, the condition is jointly referred to as “Substance Use Disorders” (SUDs). The prevalence and complications of SUDs have significantly increased during the past two decades. Moreover, individuals presenting with SUD also exhibit comorbid psychopathic disorders. Hence, the management of SUD imposes significant challenges across healthcare professionals [2].

Although different pharmacological and non-pharmacological interventions are used to treat comorbid substance use and psychopathic disorders, non-compliance with the therapeutic interventions remains the major challenge for managing the respective disorders [3]. Amongst non-pharmacological interventions, psychotherapy approaches such as Cognitive Behavioral Therapy (CBT) and Rational, Emotional, Behavioral Therapy (REBT) have gained popularity amongst psychologists and clients for managing SUD. On the contrary, psychoanalysis approaches (another form of psychotherapy) is largely perceived to be ineffective in managing SUD. Although different psychotherapy interventions are recommended for managing SUDs, there is inconclusive evidence regarding their effectiveness based on the type and the severity of abuse. Likewise, various authors have argued that therapists should play an active role in ensuring the compliance of clients with the respective psychotherapy intervention. The hallmark of psychotherapy interventions are the counseling sessions [4]. During these sessions, the therapists try to unfold the cause-and-effect relationship regarding the genesis of psychopathic disorders in their clients.

Moreover, these sessions aim to improve health outcomes in clients by developing coping skills in them. It is contended that most of the SUDs and psychopathic disorders are triggered by overwhelming events either in the past or present. The complications of these disorders increase due to the inability of the concerned stakeholders to cope with the respective event. Although counseling is the core of most of the psychotherapy approaches, it is more pertinent in the case of psychoanalysis. For this reason, psychoanalytic approaches are integrated with other forms of psychotherapy. In psychoanalysis, the therapist prompts their client to share the overwhelming events through transference and countertransference [5].

Studies suggest that substance use behavior is stringently driven by specific psychosocial factors that might be extrinsic or intrinsic to an individual [4]. Hence, the therapeutic modalities for managing SUD should be tailored to address those extrinsic or intrinsic attributes that motivate an individual for substance abuse. Therefore, the current therapeutic modalities for managing SUD are emphasizing on personcentric care. In this regard, psychotherapy approaches are often used alone or in combination with other therapeutic interventions for managing SUDs [4]. It is contended that almost all psychotherapy approaches aim to improve coping across concerned stakeholders in a person-centric manner. For example, the United Kingdom National Guidelines for managing substance abuse recommends that pharmacological interventions should be initially administered for reducing the severity of substance abuse. The same guidelines suggest that non-pharmacological interventions such as Alcoholics Anonymous should be extended to the concerned individuals once their severity of substance use subsides or reduces [6]. Therefore, the UK National Guidelines voices for pharmacotherapy in preference to psychotherapy or other non-pharmacological interventions for managing substance abuse. However, the reality is that individuals affected with substance abuse often ignore or does not comply with the therapeutic interventions recommended for treating substance use behavior.

Most of the individuals presenting with SUD often exhibit underlying psychopathic disorders. The presence of psychopathic disorders is acknowledged as one of the major causes that predispose the risk of SUD across at-risk individuals. Psychopathic disorders such as Major Depressive Disorder (MDD) or anxiety disorder are often comorbid with SUD [2]. It is contended that most individuals abuse substances to overcome the overwhelming events that prompt the development of different psychopathic disorders in them. On the contrary, evidence suggests that SUD could also predispose the risk of developing or increasing the complications of different psychopathic disorders across the concerned stakeholders [4]. Theoretically, if the underlying psychopathic disorder remains unaddressed, the respective individual would continue to abuse substances to overcome the overwhelming events that prompted the genesis of psychopathic disorder in him or her. As a result, the UK National Guidelines for managing substance use has been challenged by various authors [4]. Therefore, the psychologists and the psychiatrists should reserve the right to choose the non-pharmacological and pharmacological interventions and their timing of administration based on the attributes of the underpinning psychopathic disorder.

Different studies have suggested that individuals presenting with SUD often exhibit Major Depressive Disorder (MDD). The respective individuals tend to abuse substances to overcome either the depressive episodes or the events that prompt such episodes. As a result, various studies have highlighted the importance of psychotherapy in managing SUD as well as comorbid MDD and versa-versa. Although various forms of psychotherapy are witnessed and recommended across clinical settings, there are a lot of apprehensions regarding their effectiveness amongst the healthcare professionals and their respective clients. The major psychotherapy approaches that are recommended across clinical settings include psychoanalysis, psychoanalytic psychotherapy, rational behavior therapy, family therapy, Adlerian therapy, cognitive behavioral therapy, and family therapy [4].

The major hallmark of psychotherapy approaches are the counseling sessions. During these sessions, the therapist aims to develop an effective therapeutic relationship with the client through discussion and dialogue [4]. It is speculated that an effective therapeutic relationship would prompt the client to share their apprehensions or the overwhelming events that prompted the genesis of substance abuse and psychopathic disorders in them. Therefore, psychotherapy aims to help the clients to overcome the overwhelming events that prompt substance abuse or psychopathic disorders in them. However, there are only a few studies that have explored the effectiveness of different psychotherapy interventions in managing comorbid MDD and SUD. For example, psychoanalytic psychotherapy exhibit greater effect sizes than cognitive behavioral therapy for managing comorbid SUD and MDD (73 versus 62, p<0.05). CBT was found to be more effective than short-term psychodynamic psychotherapy in managing patients presenting with comorbid substance abuse and MDD. In this regard, psychoanalytic psychotherapy has generated a lot of interests in managing individuals presenting with SUDs [2].

Psychoanalysis speculates that the development of an individual is driven by behavioral, psychological, and cognitive attributes that enable them to confront various conscious and unconscious events by helping them to overcome the conflicts, anxiety, and the emotional distress associated with such events. It is contended that psychoanalysis is effective in understanding the mental distress of addicted individuals and the reasons for their substance abuse behavior. As a result, psychoanalysis helps an individual to untangle the overwhelming thoughts that caused emotional distress and compelled him or her towards substance abuse. Hence, psychoanalysis aims to inculcate the desired changes that would help the client to abstain from substance abuse. Psychoanalysis considers that there are different steps through which such changes could be incorporated (Figure 1).

Figure 1: Functions impaired assessed with ECAS.

Although psychoanalysis is considered effective in managing various psychopathic disorders, it is often associated with slow outcomes. As psychoanalysis approaches are lengthy and timeconsuming, they are perceived to be less effective compared to other psychotherapy interventions. Likewise, it is also necessary to identify the overwhelming events that trigger substance abuse and the genesis of psychopathic disorder in clients. Unless the causes or reasons for the same remain cryptic, the therapist would not be able to tailor the therapeutic interventions for their clients. As a result, the chances of relapse or the complications of the disorder could increase in the respective client. Hence, therapists should be convinced regarding the effectiveness of psychoanalysis in managing SUD and comorbid psychopathic disorders. However, the lack of well-designed and crosssectional studies has limited the use of psychoanalytic approaches in managing SUD and comorbid psychopathic disorders. This study explored one main research question “Whether the perception of psychologists on psychoanalysis approaches to limit or facilitate their use in managing Substance Use Disorders?” However, secondary research questions were also explored to back the main research question. The study provided conclusive and comprehensive evidence regarding the benefits and limitations of psychoanalysis in managing SUD. Based on the dissemination of this study, a set of recommendations are framed that could help psychologists for managing comorbid SUD and MDD.

Study design and sampling `

A mixed-methodology approach implemented to conduct the present study. Both primary and secondary sources were accessed to collect the relevant data. The primary data was compared with the secondary data to draw conclusive evidence while addressing the research questions. The integration of primary and secondary data ensured that the findings were reliable and reproducible. The primary data for this study was obtained based on a prospective and crosssectional study design involving practicing psychologists (n=20). The psychologists (n=20) who participated in this study were selected through a snowball sampling. The psychologists were requested to share their perceptions and views on psychotherapy approaches including psychoanalytic approaches on a 10-point Likert scale. Each participating psychologist was also requested to share the outcomes of at least two cases where they used psychoanalytic psychotherapy or psychoanalysis as one of the psychotherapeutic regimes in at least one out of those two cases. A total of 40 cases (n=40) were finally selected for conducting the primary data analysis. The participant psychologists were requested to share their views regarding the history, progression, and outcomes of the respective cases that were reported by them. The respective participants were further requested to substantiate their claims by providing the electronic or other forms of documented health records of the patients. However, the participating psychologists were assured that the identity of them and their patients would remain confidential during and after the completion of the research. The cases (n=40) were randomly selected based on age, socioeconomic status, type of abuse, a number of substances used, the severity of abuse, abstinence from abuse, frequency of abuse and demographic background. The effectiveness of any psychotherapy approach was measured based on two end-points; the period of abstinence from abuse and the frequency of abuse.

Power analysis

The present study was assumed to have a power of 0.7 which suggests that the overall findings would be reproducible in 70 out of 100 such studies. The power of this study was intentionally kept low compared to the standards that are generally considered for clinical trials (0.7 versus 0.8) because studies involving qualitative parameters are often confounded by subjective bias.

Data collection

Collection of primary data: The primary data were obtained from the participating psychologists through semi-structured interviews. The questions that were explored through the semi-structured interviews were both narrative and objective. The narrative questions explored the subjective responses of the participant psychologists on the attributes of psychoanalysis, while the objective questions assessed patient-related data based on health outcomes. The narrative responses formed the basis of qualitative data while the objective responses formed the basis of quantitative data for this study. The respective individuals were interviewed through a face-to-face manner, and the interview transcripts were recorded (based on their informed consent) over the digital media.

The semi-structured questionnaire explored different parameters such as their perception on the effectiveness of psychoanalysis in managing substance abuse behavior in comparison to other forms of psychotherapy, the facilitators and barriers that are associated with psychotherapy, the effectiveness of psychotherapy approaches from the perspective of the type and the severity of substance abused, the impact of underlying psychopathic disorders (such as MDD) in influencing the prognosis of SUD, and the role of age, socioeconomic status, demography and ethnicity of the patients in influencing the therapeutic outcomes and the severity or the type of abuse. The end-points such as abstinence from abuse and episodes of cravings of the respective patients were obtained from the verbatim of the participating psychologists who were responsible for managing their clinical condition. However, neither the patients nor their family members were directly approached for the proposed study.

Collection of secondary data

The secondary data for the present study include evidence-based literature in the form of systematic reviews, meta-analysis, cohort trials, and randomized-controlled trials. The secondary data was appraised based on the statistical findings as reported by the respective authors in their studies. The secondary data was also critiqued to identify the relevant variables that could influence the dependent variables that are planned for the present study. The dependent variables were chosen to explore the effectiveness of psychotherapy during contemplation and pre-contemplation phases as well as during the maintenance phase. The studies that were selected for obtaining the necessary secondary data include [1-7].

Data analysis

The inferential statistics that were undertaken include statistical tests of comparison (such as the t-tests and chi-square tests), correlation analysis (such as the Pearson’s and Spearman’s correlation coefficient), and logistic regression analysis. Two separate stepwise regression models were explored with Episodes of Cravings (ECRA) and the Period of Abstinence (POA) as the two dependent variables. However, the independent variables for both the regression models include age, socioeconomic status, the severity of abuse, demographic background, mental health status, type of abuse, number of substances used, and other treatment modalities across the study participants. The two regression models that were evaluated in this study were as follows:

a. Model 1

POA=B1+B2*AGE+B3*SES+B4* SOA+B5* DB+B6 * MHS+B7* TOA+B8*OTM

b. Model 2

ECRA=B1+B2*AGE+B3*SES+B4* SOA+B5* DB+B6 * MHS+B7* TOA+B8*OTM

Each regression model was appraised from three perspectives; p-value of the ANOVA related to the model, the coefficient of determination (R²) and the adjusted coefficient of determination (adjusted-R²) of the regressions, and the p-value of the y-intercept of the regression. The research questions for this study were interpreted based on the acceptance or the rejection of the null (H0) and the alternative hypothesis (H1) respectively. The respective hypothesis was explored at the 0.05 level of statistical significance (p=0.05).

Qualitative analysis

Figure 2 reflected that most of the participating psychologists (n=14) perceived psychoanalysis to be less effective (perceived efficacy score<5) in managing SUD.

Figure 2: Perception of the effectiveness of psychoanalysis in managing substance abuse.

Figure 3 reflected that most of the participating psychologists (n=9) perceived that psychoanalysis help to implement a person-centric approach. The psychologists perceive that understanding the root cause of abuse through a person-centric approach (that is widely acknowledged as the principles of transference and counter transferance) would help them to design tailor-made therapy in mitigating substance abuse.

Figure 3: Perception of the barriers that limit the effectiveness of psychoanalysis in managing substance abuse.

Figure 4 reflected that most psychologists believed that the effects of psychoanalysis are not immediate (n=11). Moreover, the responses of psychoanalysis are often unpredictable and dependent on the intrinsic features of those affected. The responses from the participants also suggest that the benefits of psychoanalysis are perceived primarily in the long-term. However, the interesting finding in Figure 3 was that the incidence of relapse of substance abuse was perceived by only 5% (n=1) of the psychologists. Such findings implicate that psychoanalysis might be effective in reducing the rate of relapse of abuse in the concerned stakeholders may be over the long-term.

Figure 4: Reflected the efficacy of psychoanalysis based on the type of abuse.

Figure 5 reflected that most of the participating psychologists (n=17, 85%) that the efficacy of psychoanalysis differed based on the type of abuse. Substance abuse is triggered by different factors that act on the reward-punishment pathway of the brain. Therefore, some substances are abused from the perspective of euphoria while others are abused to overcome psychopathic states or emotional stress. On the contrary, certain substances are also abused from the perspective of addiction or habit-formation that could have stemmed from pharmacological or non-pharmacological needs in the concerned stakeholders. Hence, it is not unlikely that the efficacy of psychoanalysis would differ based on the substance abused. Therefore, the next question explored the perception of psychologists on psychoanalysis based on the types of substance abused.

Figure 5: Reflects the effectiveness of psychoanalysis on mitigating abuse of cigarette smoking.

Figure 6 reflected that most of the participating psychologists (n=12, 60%) did not perceive psychoanalysis to be effective in mitigating the risk of smoking. Such findings are not unlikely because smoking is often abused from the perspective of recreational purposes rather than the presence of underlying psychopathic disorder. Studies also suggest that the habit-forming and addictive properties of cigarette smoke for recreational purposes is one of the highest amongst different substances that are abused for the same category of mood elevation or behavioral adjustments.

Figure 6: Reflects the effectiveness of psychoanalysis on mitigating abuse of alcohol.

Figure 7 reflected that most of the participating psychologists (n=13, 65%) perceived psychoanalysis to be effective in mitigating alcohol abuse. Such findings are not unlikely because alcohol is often abused from the perspective of underlying psychopathic disorders such as depression, anxious depression, major depressive disorder, obsessive-compulsive disorder, PTSD, and bipolar disorder. Studies also suggest that the habit-forming and addictive properties of alcohol mitigate stress and help concerned stakeholders to abstain from the thoughts of the overwhelming that caused emotional distress or prompted the psychopathic disorder. Pharmacologically, alcohol activates GABA receptors to cause sedation in the end users. Such behavioral states might be desirable for the concerned stakeholders who abuse alcohol to abstain from the recurrent or overwhelming thoughts. On the other hand, studies have provided conclusive evidence regarding the positive association between major depressive disorder or depression and substance abuse disorders (primarily alcoholism). These findings could help to speculate that psychoanalysis might be effective in mitigating alcohol abuse by helping the respective individuals to overcome their episodes of depression or other psychopathic disorders.

Figure 7: Reflects the effectiveness of psychoanalysis on mitigating abuse of other substances (marijuana, LSD, smokeless tobacco, pain-killers, and sedatives).

Figure 8 reflected that most of the participating psychologists (n=12, 60%) perceived psychoanalysis to be partially effective in mitigating the abuse of other substances (marijuana, LSD, smokeless tobacco, pain-killers, and sedatives). Such findings are not unlikely, because marijuana, LSD, smokeless tobacco, pain-killers, and sedatives are often abused from the perspective of recreational as well as from the presence of underlying psychopathic disorder. Studies also suggest that the habit-forming and addictive properties of marijuana, LSD, smokeless tobacco, pain-killers, and sedatives for recreational or mood elevation purposes are some of the highest amongst different substances that are abused for the same.

Figure 8: Effectiveness of psychoanalysis based on the severity of abuse.

Figure 9 reflected that the participating psychologists were divided (n=10 each, 50%) on the effectiveness of psychoanalysis based on the severity of abuse. This means that 50% of the participants perceived that the severity of abuse does make a difference in adopting psychoanalysis as a therapeutic modality for treating substance abuse.

Figure 9: Perception of the efficacy of psychoanalysis based on socioeconomic, demographic, age, ethnicity, and underpinning factor dependence of the affected individuals.

Figure 10 provided conclusive evidence regarding the effectiveness of psychoanalysis based on the severity of abuse of different substances separately. The figure reflected that most of the participating psychologists perceived that the severity of alcohol abuse do not deteriorate the effectiveness of psychoanalysis. In other words, these findings reflect that psychoanalysis was perceived as an effective therapeutic modality for managing alcohol abuse.

Figure 10: Effectiveness of psychoanalysis based on the severity of abuse of different substances separately.

Q6. Whether the effectiveness of psychoanalysis-based therapy depends upon the age, socioeconomic status, the demographic and ethnic background of the concerned stakeholders?

Figure 11 reflected that most of the participating psychologists perceived that the effectiveness of psychoanalysis is not dependent on the socioeconomic or ethnicity of the concerned stakeholders. On the contrary, most of the participating psychologists perceived that demography and age and factor dependence are some of the variables that modulated or confounded the effects of psychoanalysis in mitigating substance abuse.

Figure 11: Perception of the efficacy of psychoanalysis based on socioeconomic, demographic, age, ethnicity, and underpinning factor dependence of the affected individuals.

Figure 12 reflected that most of the participating psychologists (n=8, 50%) did not differentiate between the efficacy of psychoanalysis with other psychotherapeutic modalities in managing substance abuse.

Figure 12: Perception of the efficacy of psychoanalysis compared to other psychotherapy modalities in managing substance abuse.

Figure 13 reflected that most of the participating psychologists (n=7, 50%) perceived that psychoanalysis was as comparable to the harm reduction strategy in mitigating substance abuse. However, they also felt that psychoanalysis was more effective than Cognitive Behavioral Therapy (CBT) in mitigating substance abuse across concerned stakeholders. Such findings are in line with evidence-based literature which reflects that psychotherapies such as harm reduction therapy are more effective than cognitive behavioral therapy in mitigating substance abuse. Hence, it could be interpolated that psychoanalysis could be more effective than cognitive behavioral therapy in mitigating substance abuse.

Figure 13: Perception of the efficacy of different psychotherapy modalities in managing substance abuse.

Figure 14 reflected that the immediate effect of psychoanalysis and other types of psychotherapy is to convert into other forms of addiction (either from the substance or from work) or exhibition of aggressive behavior. Such findings are also in-line with the evidence-based literature. The aggressive behavior might stem from the withdrawal symptoms of the concerned stakeholders over the respective substance for which psychoanalysis was administered, or it might be due to the resilience and conflict of the respective individuals in adopting with the coping behavior. On the contrary, individuals who exhibit dependence on alternative sources of addiction may exhibit positive or negative coping. Positive coping could include the engagement of the respective individual in value-added or rewarding jobs, while negative coping may induce the individual to become addicted to other substances. The long-term effects of psychoanalysis are perceived by the participating psychologists as improved coping on the overwhelming or distressing thoughts.

Figure 14: Perceived clinical effects of psychotherapy.

Quantitative analysis

Descriptive statistics: The descriptive statistics (Table 1) that were considered for the respective study participants include age in years (AGE), socioeconomic status as a function of family and self-income (SOCIOECO), severity of abuse based on the frequency of abuse per day multiplied by the number of months before psychotherapy was initiated (SEVEBEF), severity of abuse based on the frequency of abuse per day multiplied by the number of months after psychotherapy was initiated (SEVREDUC), period of abstinence based on the number of days refrained between second episode of abuse before the initiation of psychoanalysis (PERABSB), period of abstinence based on the number of days refrained between second episode of abuse after the initiation of psychoanalysis (PERABSA), the presence of depression (DEPRESS), type of abuse (ABUSETY, smoking=1, alcohol=2, others=3), type of psychotherapy administered (PSYOTH), Period of psychotherapy before perceived benefits on health outcomes of the respective individuals (PERTHERAP).

Table 1: Descriptive statistics on the cases (n=40).

The descriptive statistics did reflect that there were differences in terms of abstinence or severity of abuse based on the type of psychotherapy administered. The descriptive statistics also reflected that the effects of different types of psychotherapy on abstinence or severity of abuse could have been modulated by underlying psychopathic disorders or by the type of abuse in the concerned stakeholders. However, inferential statistics such as the regression analysis and ANOVA were undertaken to interpret the descriptive statistics.

Tables 2a, 2b, and 2c reflected that period of abstinence were significantly influenced as a holistic function of PERTHERAP, ETHNICITY, AGE, ABUSETYPE, DEPRESS, GENDER, SOCIOECO, and PSYOTH (p=0.035). However, depression remained a significant and independent predictor for the period of abstinence in the respective stakeholders (p=0.007). The next regression model was constructed with the severity of abuse as the dependent variable.

Table 2a: Model Summary for the period of abstinence as the dependent variable.

Table 2b: ANOVA^a for a period of abstinence as the dependent variable.

Table 2c: Coefficients for the regression Model with a period of abstinence as the dependent variable.

Tables 3a, 3b, and 3c reflected that severity of abuse reduction were also significantly influenced as a holistic function of PERTHERAP, ETHNICITY, AGE, ABUSETYPE, DEPRESS, GENDER, SOCIOECO, and PSYOTH (p=0.013). However, depression remained a significant and independent predictor for the severity of abuse reduction in the respective stakeholders (p=0.006). Based on the regression models, ANOVA was undertaken to explore the variables that were significantly influenced by psychoanalysis in comparison to other types of psychotherapy (Table 4).

Table 3a: Model Summary with Severity of abuse reduction as the dependent variable.

Table 3b: ANOVA for the Model Summary with Severity of abuse reduction as the dependent variable.

Table 3c: Coefficients for the regression model with the Severity of abuse reduction as the dependent variable.

Table 4: ANOVA comparing psychoanalysis with other psychotherapies on different variables that were considered in this study.

The ANOVA analysis reflected that psychoanalysis significantly differed in terms of the period of therapy (p<0.05). However, such speculations are an understatement regarding the beneficial effects of psychoanalysis or other forms of psychotherapy in managing substance abuse. Therefore, a subset analysis (Tables 5a, 5b, 5c, and 5d) was conducted in individuals presenting with depression and substance abuse who received either psychoanalysis or another type of psychotherapies.

Table 5a: Group Statistics comparing severity reduction in abuse in individuals with depression between psychoanalysis-treated and other types of psychotherapy-treated individuals.

Table 5b: Independent Samples Test comparing severity reduction in abuse in individuals with depression between psychoanalysis-treated and other types of psychotherapy-treated individuals.

Table 5c: Group Statistics comparing the increase in the period of abstinence from substance abuse in individuals with depression between psychoanalysis-treated and other types of psychotherapy-treated individuals.

Table 5d: Independent Samples Test comparing the increase in the period of abstinence from substance abuse in individuals with depression between psychoanalysis-treated and other types of psychotherapy-treated individuals.

Tables 5a and 5b reflected that psychoanalysis-treated individuals with MDD exhibited significantly higher reductions in the severity of abuse compared to their counterparts who received treatment through other psychotherapy modalities and were also affected with MDD (p=0.047).

Tables 5c and 5d further reflected that psychoanalysis-treated individuals with underlying MDD exhibited a significantly greater period of abstinence from substance abuse compared to their counterparts who received treatment through other psychotherapy modalities who also had underlying MDD (p=0.047).

This study showed that the perception of psychologists on psychoanalysis limit their implementation in clinical settings. In most instances, the therapeutic modality is considered to be time-consuming and slow with respect to health outcomes. As a result, psychologists often prefer Rational Behavioral Therapy (RBT) or Cognitive Behavioral Therapy (CBT) for managing SUD. Such therapeutic modalities are associated with fast response and less time-consuming compared to psychoanalysis. However, studies suggest that psychoanalytic psychotherapy produce larger effect sizes compared to CBT (0.73 versus 0.65) in SUD-affected individuals. It is contended that REBT or CBT is more effective across individuals who are able to identify the overwhelming events and their needs to overcome such events.

On the contrary, psychoanalysis is effective in individuals who reveal the overwhelming events that prompted their abuse or psychopathic disorder through transference or countertransference. Hence, it is not surprising that psychoanalytic approaches are considered slow. The present study also highlighted that psychoanalysis was effective in identifying the root cause of substance abuse or psychopathic disorder through a person-centric approach. Hence, person-centric approach practiced through transference, countertransference, and therapeutic relationship might be considered as the hallmark of psychoanalytic approaches. For the same reasons, psychoanalysis is often perceived to be patient-dependent and unpredictable as per this study. Such speculations were substantiated by the fact that the efficacy of psychoanalysis was perceived to be different based on the type of abuse. This study further endorsed the statement that the perception of psychologists varies over the effectiveness of psychoanalysis based on the type of substance abused.

The present study showed that the prognosis of SUD is dependent or confounded by various factors apart from the therapeutic interventions. The major factors that confound the prognosis of SUD include clientcentric attributes (socioeconomic status, demographic status, age, and ethnicity), the type of substance abused, the duration of abuse, and the severity of abuse. Hence, it is not unlikely that a specific psychotherapy approach would exhibit different outcomes across patients abusing a similar substance. Therefore, psychoanalytic approaches might be more effective in specific category of clients while other psychotherapy approaches might be more beneficial across other categories.

The study showed that there should not be any sacrosanct perception that psychoanalysis is less or more effective than other forms of psychotherapy. For example, an individual who do not disclose the reason for their abuse or psychopathic disorder might respond to other forms of psychotherapy in the short-term. Under such circumstances, the respective psychotherapy approach is often perceived to be more effective. However, the same individual could exhibit high rates of relapse either for SUD or for the psychopathic disorder or both over the long-term. In such instances, the respective psychotherapy approach should not be considered effective only based on fast response.

On the contrary, psychoanalytic approaches might take time to respond but could be beneficial in mitigating the risk of relapse for the referred disorders over the long-term. Hence, psychoanalytic approaches should not be considered less effective only from the perspective of slow response. Nevertheless, short-term psychoanalytic approaches (such as psychoanalytic psychotherapy) are used in practice settings to manage SUD. However, their efficacy is either comparable to or lesser than CBT in managing SUD over the short term.

Different authors have highlighted the limitations of REBT and CBT in improving outcomes across SUD patients. For example, one study showed that such interventions were primarily effective in managing substance during the maintenance phases of therapy. Moreover, Rosenthal [8] highlighted that the number of drop-outs was more for cognitive therapy and pharmacological-based interventions for substance abuse compared to psychoanalysis-based approaches. On the contrary, psychoanalytic-based approaches were considered to be more effective during the contemplation and pre-contemplation phases of psychotherapy. Nevertheless, the theoretical framework and principles underpinning psychoanalytic approaches provide grounded support for their effectiveness in managing various types of abuse during the precontemplation and contemplation phases as well as during the action and maintenance phases. Psychoanalytic approaches are based on the speculation that unless the cause and root of substance abuse remain unaddressed, it would be difficult to improve health outcomes across concerned stakeholders. Psychoanalysis helps to achieve deeper selfinsights such as self-awareness, unconscious desires, motivations, and conflicts that are not visible. Studies suggest that psychoanalysis help avoid repetition of self-harming and unhelpful behaviors. Sigmund Freud showed that the transfer of the relationship between the clinician and patient is essential for improving health outcomes in the respective stakeholders.

Although the philosophy of psychoanalytic psychotherapy in managing addictive disorders is promising, there is a lack of conclusive evidence over such speculations. Taylor et al. [2] highlighted that the lack of evidence was primarily due to the implementation of nonrandomized study designs. On the other hand, higher and lower effect sizes also confounded the findings of previous studies that explored the effectiveness of short-term and long-term psychoanalytic approaches in managing substance use disorders. Verma and Vijaykrishnan [4] stated: “establishing the efficacy and effectiveness of psychoanalytic psychotherapy would require the standards of control that are more difficult to maintain in long-term and open-ended therapies”. The authors further contended that the inclusion of psychoanalytic approaches in non-psychoanalytic interventions significantly improved prognosis in individuals exhibiting a history of substance abuse. Yalisove [6] mandated modifications in traditional psychoanalytic approaches that include initial phases of therapy which is more supportive and didactic followed by a more traditional mode of psychoanalysis with the therapist playing an active role in the rehabilitation process could justify the effectiveness of “Alcoholics Anonymous” initiatives.

The present article reflected that psychoanalytic psychotherapy is effective in managing AUD and MDD. Perhaps, psychoanalysis helps to mitigate alcohol abuse behavior by reducing the episodes of MDD. This study further implicated that psychoanalysis approaches could help to mitigate SUD because individuals who abused substances other than alcohol (such as marijuana, opiates, pain killers, and LSD) tend to benefit from psychoanalytic psychotherapy. On the contrary, the major issue that stemmed in this study was the low acceptance of psychoanalytic psychotherapy across healthcare professionals. Psychologists often perceived psychoanalysis approaches to be less effective than other forms of psychotherapy because it is time-consuming and the clients show a slow response. On the contrary, the supporters of psychoanalytic approaches contend that the inability of the therapist to effectively engage with the client during the counseling sessions gives rise to such perceptions. Counseling is an important prerequisite for any forms of psychotherapy, and it is even more important while administering psychoanalytic approaches.

In most counseling sessions, the client feels detached from the therapist because the therapist often exhibits resilience in complying with stereotypes. However, studies suggest that there is no sacrosanct protocol for administering correct counseling. Effective counseling could be considered as that approach where the therapist is able to overcome his or her stereotype and aligns with the client in a person-centric manner. Unless the respective professional is able to develop a trustworthy and therapeutic relationship with the client, it is difficult to identify the reasons that prompt him or her to abuse substances. Perhaps, that could be the basic reason why most healthcare professionals perceive that psychoanalytic psychotherapy is less effective in comparison to other modes of psychotherapy. In most instances, the clients feel that the therapist is pursuing a relation with them only from a professional perspective. However, clients want their voice and feelings should be acknowledged by the therapist before planning therapeutic interventions.

In instances where the therapist undertook effective counseling sessions, the psychotherapy approach was perceived to be effective and vice-versa. The present study also reflected that time constraint is a major limitation for the low acceptance of psychoanalytic psychotherapy amongst psychologists. To recall, psychoanalytic psychotherapy differs from traditional psychoanalysis in terms of the frequency of counseling sessions. However, most of the practicing psychologists fail to understand the demarcation between traditional psychoanalysis and psychoanalytic psychotherapy. Prochaska et al. [1] showed that changes associated with experiential, cognitive, and psychoanalytic approaches are more helpful during the contemplation and pre-contemplation phases, while those involving behavioral and existential processes are effective during the action and maintenance phases of psychotherapy.

The author concluded that modifications to the traditional psychoanalysis approach are mandated for treating individuals presenting with addiction to alcohol. The initial phase of such treatment should focus on supportive and didactic approaches, while the later stages should involve the traditional psychoanalysis-based treatment where the therapist should become an active player in the therapeutic channel rather than being passive. During this phase, forestalling of transference and making the concerned individuals participate in social programs intended for substance abstinence (such as Alcohol Anonymous) should be the major endeavor for psychoanalysis-based psychotherapy. Yalisove [6] reported that individuals presenting with a history of addiction derived significant benefits from modified psychoanalysis–based therapy in two out of three studies that were considered for the analysis.

The findings of Yalisove [6] supported the findings because both authors reflected that engaging an individual in the psychotherapy sessions actively through active engagement of the therapist help to identify the root cause of addiction. One of the reasons why psychoanalysis-based therapy was less effective over the short-term as speculated could be attributed to the inability of the therapists to identify the root cause of addiction in the concerned individuals during the initial phases of treatment. Incorporating a supportive and didactic approach might prompt the concerned individuals to reflect upon the overwhelming events in the past or present that predisposed them to different forms of addiction.

One of the key attributes of psychoanalytic psychotherapy is the transference relationship between the therapist and their respective patient. The psychodynamic sessions are generally conducted at a frequency of once or twice a week. However, the total duration of therapy might differ from one patient to another. The duration of the sessions per patient-therapist interaction is generally brief and involves a focused or predetermined goal. On the contrary, the psychoanalytic sessions are longer than the psychodynamic sessions. The psychoanalytic sessions typically happen to reference your three to five times per week and are more exploratory. The transference relationship between the therapist and the patient becomes stronger and intensive with the increase and frequency of such sessions. The frequency of psychoanalytic or psychotherapy sessions supported. To recall, the respective individual in the study experienced less distress by attending the psychoanalytic sessions four times per week. This study reflected that psychoanalysis could pave the platform for planning therapeutic interventions during the action and maintenance phases of substance abuse and also during the contemplation and pre-contemplation phases. Hence, the finding of this study similarly challenged the UK National guidelines for mitigating substance abuse in the concerned patients. The present study provided a conclusive evidence for developing the consensus statement “psychoanalysis should be considered as an effective and viable option for managing comorbid AUD and MDD.”

The study design ensured that the findings were reliable and reproducible. Moreover, this is the first study that integrated the subjective responses with the objective end-points with respect to the implementation of psychotherapy approaches in clinical settings. However, some of the limitations of the study include the lack of experimental rigor for minimizing the confounding effects of demography, ethnicity, and socioeconomic status. As a result, the chances of experimental bias might not be totally ruled out of the study. Since the psychologists provided qualitative responses, the study might have suffered from a certain degree of subjective bias. Since the present study did not report the outcomes of the client based on effect sizes, it could erode the stereotype of psychologists for perceiving the effectiveness of a therapeutic regime.

There are different explanations of addiction and the behavioral dimensions associated with addiction. These attributes help to understand the behavioral aspects of addiction and psychological interventions that are required to overcome such behaviors. The major treatment challenges for SUD are the cravings associated with denial and withdrawal. Psychoanalysis should be regarded and implemented as an aid to enable and kindle coping skills for individuals presenting with a history of substance abuse.

Future studies should compare psychoanalysis with other psychotherapy approaches for managing SUD either alone or in the presence of MDD through well-designed and case-controlled studies. Moreover, such studies should incorporate reliability analysis for considering the variables and the sample size that would be necessary to answer the research questions comprehensively. Finally, future studies should be blinded to assess the client-related outcomes. Such a study design would minimize the chances of subjective and experimental bias in the studies. Finally, future studies should report the outcomes in clients as effect sizes too for complying with the stereotypes of psychologists that they often use for interpreting the effectiveness of a therapeutic regime.

Roadmap for Psychoanalytic Practice

The recommendations that stemmed from the present study are as follows:

i. Psychologists should consider psychoanalytic psychotherapy for identifying the cause of AUD and MDD.

ii. They should treat the underlying psychopathic disorder either in association or independent to SUD.

iii. Standardized screening tools should be used during the counseling sessions to identify the underlying psychopathic disorder if the principles of transference and countertransference fail to surface the same.

iv. Psychoanalytic psychotherapy might be used interchangeably with other psychotherapy approaches for managing comorbid SUD and MDD.

v. Psychoanalytic psychotherapy might be considered both as a short-term and long-term therapeutic modality either alone or in combination with other therapeutic interventions.

vi. Pharmacological interventions should be considered as an adjunct therapy to psychoanalytic approaches if the client exhibits risk of self-harm.

1. Prochaska JO, DiClemente CC, Norcross JC (1992) In search of how people change. Applications to addictive behaviors. Am Psychol 47: 1102-1114
2. Taylor D, Carlyle J, McPherson S, Rost F, Thomas R, et al. (2012) Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression. BMC Psychiatry 12: 60
3. Leichsenring F, Rabung S (2011) Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. Br J Psychiatry 199: 15-22
4. Verma M, Vijayakrishnan A (2018) Psychoanalytic psychotherapy in addictive disorders. Indian J Psychiatry 60: S485-S489
5. Blomberg J, Lazar A, Sandell R (2001) Long-Term Outcome of Long-Term Psychoanalytically Oriented Therapies: First Findings of the Stockholm Outcome of Psychotherapy and Psychoanalysis Study. Psychother Res 11: 361-382
6. Yalisove DL (1989) Psychoanalytic approaches to alcoholism and addiction: Treatment and research. Psychol Addict Behav 3: 107-113
7. de Maat S, de Jonghe F, Schoevers R, Dekker J (2009) The Effectiveness of Long-Term Psychoanalytic Therapy: A Systematic Review of Empirical Studies. Harv Rev Psychiatry 17: 1-23
8. Rosenthal RJ (2008) Psicoterapiapsicodinâmica e o tratamento do jogopatológico. Rev Bras Psiquiatr 30: 41-50