Rodrigo Barahona (2005): The Psychoanalytic Meaning of Notices of Non-compliance in the Psychotherapy of Opiate Addiction

This study assesses the psychodynamic meanings of the issuing of notices of non-compliance (NONs) to patients by their therapists in the psychotherapy of individuals with opiate addiction during methadone maintenance. Also assessed was the impact of these meanings, as well as quantity of NONs, on the Therapeutic Alliance. Implications for the theoretical differences between the concepts of Therapeutic Alliance and Transference were also inferred from the results.

Forty participants completed the Working Alliance Inventory adapted from Horvath and Greenberg (1986) at two times, approximately three months apart. Change in the WAI was correlated with the number of NONs received. Eighteen of these participants were also interviewed using a short, semi-structured, open-ended interview enquiring about the psychodynamic meanings of the NONs. The interviews were analyzed using a form of content analysis, with the aim of uncovering unconscious and conscious patterns relating to the meaning of the NONs for the therapeutic relationship. From this analysis, dynamic inferences were made at two levels: the first level used categories derived from Luborsky’s CCRT. The second combined an elaboration of Luborsky’s conceptualization of wishes with Kernberg’s patterns of internalized self and object representations, as well as Vaillant’s hierarchy of defenses.

The general findings of this study were two: First, there was a trend associating the number of NONs received over three months and a decrease in the alliance levels. This was analyzed in particular in association to the subscales of the Working Alliance Inventory. The result of the analysis of the subscales suggested that the effect of the NONs may have been more associated to a decrease in the bond and the goal subscales. Second, two subtypes of patients were identified in the interviews: one group felt contained by receipt of NONs, the other larger group felt abused. Using the information gathered from the Alliance Interviews as well as the Framework Analysis developed by the researcher for this purpose, it was possible to determine that these groups exhibited differences in wishes, defenses, and patterns of internalized self and object representations.

The results of this study have potential implications for the broader field of limit-setting in the psychotherapy of opiate addiction, as well as for the theoretical distinctions between Therapeutic Alliance and the psychoanalytic concept of Transference. Many questions were raised by the results, and attempts at shedding light on them were discussed with reference to the literature, while staying close to the actual data obtained from the research subjects. Some of the issues that were discussed were the possible influence (on the results) of: the patient’s subjective character; the psychodynamics of addiction; possible unconscious enactments between patient and therapist; the therapist’s possible unconscious resistance; the limitations of the research methods. Implications for the future handling of limits in the psychotherapy of patients suffering from opiate-addiction, with a special emphasis on the importance of supervision were also discussed.