The use of medications in detoxification and the treatment of substance use disorders is not new. Widespread access to medications like naloxone, naltrexone, and buprenorphine, while still controversial, has a made a real and positive difference for families and communities. When it comes to solving the puzzle of alcohol detox, medication and psychotherapy may be the right choice.
Alcohol detox can be life threatening
Alcohol misuse and dependence is an urgent health issue. For example, Johnson and Koch (2023) reported that “severe withdrawal [from alcohol] is followed by the development of seizures or delirium tremens in up to 20% of hospitalized patients” (p. 3). Additionally, 29% of people who were “detoxified on an inpatient hospital service” (p. 2) had died at eight-year follow-up.
Brian Johnson, the lead author of this preliminary research report, has written extensively on the integration of medication assisted detoxification/treatment, neuroscience, and psychoanalysis. Termed neuropsychoanalysis, this approach “uses the psychoanalytic sensibility that every patient is their own experiment. There are no attempts to prescribe behaviors or outcomes, referred to as “analytic neutrality,” which makes the patient the center of initiative, and also facilitates observation of illness. With this approach [we have] learned from patients how to optimally treat alcoholics in need of detoxification” (p. 2).
Simply put, this approach to alcohol detoxification treats patients as individuals, does not force anyone into a pre-determined course of action, and allows for ‘watchful waiting’ on the part of the clinician during during the treatment process.
Medication + psychodynamic psychotherapy
In this study, Johnson and Koch (2023) report on the use of valproate and chlordiazepoxide (instead of benzodiazepines) for alcohol detoxification. They assert that this can be done safely in an outpatient environment. The protocol outlined in the paper also requires a sober support person to attend intake, and commit to overseeing administration of disulfiram each day for one year after detoxification. Participation in AA was encouraged (not required), and patients were seen twice a week for transference-focused psychotherapy. In some, when navigating alcohol detox, medication and psychotherapy may be the right choice.
But what kind of psychotherapy? Johnson and Koch explain:
“One way to conceptualize schools of psychotherapy is that the cognitive behavioral therapist wants to deliver expert recovery skills, the contingency management therapist chooses goals that are rewarded if the patient proves that they have met those goals, while the psychoanalyst ideally contributes nothing except helping the patient to do their own good thinking about having alcoholism, and what to do about it. We regard motivational interviewing as a version of the psychoanalytic approach that confines interpretations to only clarification and confrontation; rebranded as “reflexive listening,” and “double-sided reflection.” The psychoanalytic goal to initiate no ideas but rather interpret the patient’s free associations makes it ideal for collecting systematic observations about the nature of addictive illness” (p. 6).
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