PSYCHOTHERAPY

Analiză a principalelor tipuri de psihoterapie folosite în tratamentul dependenţei de droguri

 General view regarding the different types of psychotherapy used for the treatment of drug addiction

First published: 16 aprilie 2021

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/Psih.64.1.2021.4780

Abstract

The detailed, accurate national and international situation regarding drug addiction will always have some weaknesses points. The dependence to different drugs, in correlation with factors related to culture, mentality, self-control, habits or low self-esteem, could explain this behavior of searching a balance that some people do not find in their private life. The therapeutic approach is complex and consists of a harmonious combination of pharmacological therapy with psychotherapy in order to avoid relapses and shape the addictive personality. The compliance is essential in achieving therapeutic goals; it depends not only on the patient’s behavior, but also on the therapist's abilities, on family, psychosocial and cultural factors. The long-term prognosis and the evolution of the addicted behavior are individualized especially by the degree of involvement of the patient and his sociofamilial entourage in obtaining the best possible therapeutic compliance. Thus, the aim of this paper is to underline the main important types of psychotherapies that can be used for drug addiction and their framing in the general therapeutic management.

Keywords
addiction, psychotherapy, therapeutic management

Rezumat

Situaţia detaliată, exactă, la nivel naţional şi internaţional referitoare la dependenţa de droguri va avea întotdeauna unele puncte nevralgice. Consumul de diferite droguri, în  corelaţie cu factori ce ţin de  cultură, mentalitate, autocontrol, obiceiuri sau stimă de sine scăzută, ar putea explica  acest comportament, de căutare a unui echilibru, pe care unele persoane nu îl găsesc în intimitatea lor. Abordul terapeutic este complex şi constă dintr-o îmbinare armonioasă a terapiei farmacologice cu psihoterapia, pentru a putea combate recidivele şi a modela personalitatea adictivă. Complianţa terapeutică este esenţială în atingerea obiectivelor, ea depinzând nu numai de comportamentul pacientului, dar şi de terapeut, familie, precum şi de factorii psihosociali şi culturali. Prognosticul îndelungat şi evoluţia adicţiilor se individualizează mai ales prin gradul de implicare a pacientului şi a anturajului său sociofamilial în obţinerea unei complianţe terapeutice cât mai bune. În acest sens, scopul acestei lucrări este de a evidenţia principalele tipuri de psihoterapie ce pot fi utilizate în tratamentul diferitelor adicţii şi încadrarea lor în managementul terapeutic general.

The World Health Organization (WHO) appreciates that the addiction to alcohol, tobacco and other substances is constantly increasing and represents a serious problem of the healthcare system in general because, beyond the physical and mental dependence, it determines important consequences at social, economic or family level. Thus, since 2004, WHOs report indicates that, worldwide, two billion people use alcohol and 76.3 million of them already have complications related to alcohol consumption. People between the ages of 18 and 24 years old have an increasing risk of substance abuse. Young men have higher rates of substance abuse compared to female adolescents of the same age, but this gender ratio varies according to the class of substances used(1).

Until recent years, in Romania drugs were little known among the general population, because it was only a transit country for most high-risk drugs on their way to the Western Europe. This has changed dramatically in the last years, when the consumption of different types of drugs has increased drastically, and now this phenomenon is also a source of income or the goal of an illegal activity, leading to the development of relatively new health pathologies in our country(2).

The therapeutic management of addictions is variable, depending on the substance involved, as well as the specificity of each patient. The way in which we manage to combine different therapeutic principles, types of interventions, possibly associated with specific medication, must focus on the particularity and individuality of each person. The common goal is social reintegration, with adequate functionality in all areas. One of the most important moments of therapy is probably the initiation of it, preferably as early as possible. Thus, when a person with addiction decides to make the first step on this way, he/she must benefit from all possible services, because otherwise the fight may be lost before being started.

But which are the therapeutic interventions with the highest effect on the entire population at risk for addiction disorders?

What motivates people to change? The correct response to these issues depends in part on where they start. How can we trigger motivation to people to begin thinking about change can be different from what motivates them to begin preparing to take action. As they are prepared, different forces can move them to take action. 

The effectiveness of therapy depends on a number of factors, such as(3):

  • the treatment is applicable and adapted to each type of patient, according to age, sex, cultural and ethnic aspects;

  • addressing the multiple needs of the individual, and not only strictly the problem related to the addiction itself;

  • addressing also the aspects related to the associated medical conditions, the possible comorbid mental disorders, the social, vocational and even the legal aspects, specific to each case.

Therefore, the therapeutic team must be multidisciplinary, with the aim of combining different types of therapeutic services, psychotherapy, counseling or drug therapy, tailored to the needs and specifics of each individual. One of the important aspects to be considered in the therapeutic management is the fact that some people with addictions have, as a comorbidity, a mental disorder, which in turn requires appropriate therapy. The patient may also associate addiction with some infectious diseases that also required appropriate treatment. Thus, the involvement in addiction-specific therapy may increase the therapeutic compliance for many other associated medical conditions.

According to many studies, the duration of the therapy, in order to achieve a significant reduction or even stop the use of a drug, is at least three months, but it can also be for a longer period, depending on the particularities of each case. Additionally, the appearance of relapses will determine the resumption of therapy, possibly its modification and adaptation according to the new needs of the individual, and support those interventions that focus on recruiting and maintaining the individual in therapy, as not to give up too early.

According to Saunders, the therapeutic management in case of addictions to different substances highlights ten main aspects, which must be particularized for each case, namely(3):

  • information and understanding;

  • acceptance and involvement;

  • initiation of treatment – diagnosis and detoxification;

  • pharmacological therapy;

  • psychological therapy;

  • identification and treatment of comorbidities;

  • social and family support;

  • support groups;

  • post-cure program;

  • lifestyle and environmental changes.

The 12-step facilitation therapy (12-step program) was designed to help the addicted person to participate in activities that support abstinence and has already proven effective in alcohol addiction, but it is also used for other types of addiction. This therapy involves three basic rules(4):

  • acceptance, which will allow to realize that addiction is a chronic condition, over which there is no control because it completely changes the lifestyle of a person, and the solution is only abstinence;

  • submission, which represents participation in all support and assistance structures by specialists and other people involved in the recovery process;

  • active involvement in all activities.

Cognitive-behavioral therapy (CBT) is considered a short-term therapy which aims to produce an initial abstinence and subsequent stabilization. But for many people, only 12-16 sessions are not enough to stabilize or at least improve the situation, therefore CBT is only seen as a preparatory therapy for other long-term therapies.

CBT cannot be used if the patients present psychotic symptoms or associate another major mental disorder, which is not clinically stabilized with adequate medication, they do not have a stable home, or they are not stable from a clinical point of view.

CBT can be associated with other types of therapies such as pharmacological therapy for addiction or for a mental disorder associated with addiction. Also, it can be associated with alcoholic group therapies, couple or family therapy, vocational counseling etc. In this regard, a therapeutic team is created, which will permanently maintain the connection concerning the patient’s evolution. In case of CBT, an individual type of therapy is preferred, which should be adapted to the client’s needs and will allow a better connection with the long-term therapist. However, some studies indicate that group therapy is more effective for people with addiction, thus putting pressure on other people participating in the therapeutic group, although the methods used will be more didactic, appropriate to a group, and will not be able to be particularized for each person.

Cognitive therapy aims to teach the patient how to prolong the period without drugs and to avoid the response from the craving period by engaging in constructive activities, communicating with other people in support groups or making a diary.

  • In case of behavioral therapy, maintaining abstinence can be achieved by the following aspects:

  • addressing the motivational aspects for change of the client;

  • developing specific skills to withstand substance use, creating incentives to maintain change;

  • facilitating interpersonal relationships;

  • improving problem-solving skills;

  • replacing substance-specific activities with other appropriate reward-type activities;

  • individual, group or other forms of support for people with addiction.

Considering the chronicity and complication of alcohol addiction, we have to assess the motivation to care, the ability to control himself/herself, and the opportunity of a biological treatment, such as an aversion treatment with disulfiram.

We should try to introduce the Golden Rules for exposure treatment and the role of co-therapist (a friend or wife/husband).  In many cases, alcohol is reported to be used as a form of self-medication.

When the patient will be able to control alcohol ingestion, we may go ahead with the program of the exposure diary(4).

The community approach to reinforcement, as defined by Meyers and Smith in 1995, is “a broad-spectrum behavioral treatment for substance abuse problems that uses social, recreational, family and vocational reinforcements to assist clients in the recovery process. These factors will contribute to maintaining a drug-free lifestyle”(5). This therapy includes(6):

  • functional analysis of drug use;

  • social and recreational counseling;

  • councils regarding the professional opportunities and skills;

  • training on drug refusal;

  • relaxation techniques, training on behavioral skills;

  • advice on relational development.

Motivational improvement therapy (developed by Miller and Rollnick, 1992) is based on the principles of motivational psychology and determines an internal and rapid change, and mobilizes the client’s own change resources with the help of motivational strategies(7).

Interpersonal therapy (Rounsaville and Carroll, 1993) for addictions is characterized by(8,9):

  • adherence to a medical model of mental disorders;

  • it focuses on patients’ difficulties regarding interpersonal relationships;

  • it is concise and the therapist has an exploratory role, similar to that of supportive therapy.

The resistance highlighted during addiction therapy can be determined by the existence of cognitive deficits, associated medical conditions, lack of social support or other environmental stressors. Pregnant women or prisoners are also particular groups at risk. Therefore, it is very important to achieve the best possible case conceptualization, based on a functional analysis that will determine a flexible therapy and adapted to each case.

An important issue related to therapy is that of changing the cultural and socioeconomic context that is associated with a life without drugs. This therapeutic challenge is especially encountered in people who have a long history of illicit drug addiction, which has led to illicit behavior over time, for example those who sell or manufacture various drugs. Therefore, in these situations, the ambivalence regarding the desire for change increases, especially if it is done slowly and towards a lifestyle for which they have few skills and few resources, abandoning a lifestyle to which they felt to belong. Thus, obtaining new social resources must take into account the possibilities of each case, offering new opportunities for employment in various social activities, volunteering or groups. Also in this context, it can be used the computer-assisted therapy, which, according to a study conducted by Carrol and collaborators, showed that the computer-assisted therapy of CBT, performed twice a week, determined a period of abstinence longer and sustained at the six month of assessment compared to cases in which standard counseling was used(10).

For all those therapists who treat people with various addictions, the psychotherapist Newman Cory said that “there is good news and bad news”. The bad news is that these people immediately get a positive but also a negative reinforcement, which will be important obstacles to therapy, even for those who are motivated for change. Thus, an effective treatment must be seen as a difficult and continuous ascent(11).

The areas of therapeutic intervention are represented, according to Beck, Wright, Newman and Liese (1993), precisely by those areas of psychological vulnerability, risk factors for any type of addiction, and which include(6,11):

  • external or internal risk situations for addiction (certain moods, entourage etc.);

  • functional thoughts about the drug and its relationship;

  • automatic thoughts that increase the intentionality of consumption;

  • craving, the urgent physiological need to consume the drug;

  • thoughts regarding the permission to consume, which justifies the use of the drug;

  • behavior, sometimes ritually related to drug use;

  • psychological manifestations that occur when you do not use the drug and a vicious circle is made.

“Drug culture” is linked to a subculture of the individual, group or family with certain socioeconomic and psychological standards. Substance abuse is one of the main causes of morbidity and mortality that could be prevented and a major contributing factor to many social problems, such as domestic violence, theft, suicide etc. The abuse of these substances begins in adolescence, which is why it requires sustained attention from those in the healthcare system in general.

An appropriate therapeutic plan must be the basis of any intervention in the management of drug addiction and aims to establish a set of realistic specific goals, as well as appropriate strategies for achieving these goals(12).

The therapeutic plan should be realized only after a complete evaluation of the patients with addiction, because this plan must be adapted to their needs and offer the necessary support in front of the many difficulties and obstacles that can appear during the therapeutic process.

Thus, the characteristics of the therapeutic plan must have the following aspects(13):

  • to be detailed;

  • to be in accordance with the client’s requirements, but also be approved by the therapist;

  • to be made following the complete evaluation of the patient, the establishment of the objectives and the client’s wishes;

  • to contain practical, realistic objectives, to contain strategies for obtaining them;

  • to involve the participation of other family members or friends.

According to Dale and March, this therapeutic plan must contain(13):

  • complete assessment of the patient’s situation;

  • assessing patient needs;

  • objectives and strategies for obtaining them;

  • assessing the need for support and possible limitations to achieve the objectives;

  • modalities to record the progress obtained;

  • modalities to evaluate the completion of therapy and the evolution.

A specific intervention model for alcohol addiction, according to Mejta and Siegal, is the case management, because people with various drug addictions also have other medical conditions, financial, social or family problems, and sometimes can associate mental disorders, which require attention during therapy(14).

The main attributes of case management for drug addiction are(15):

  • identifying customer needs;

  • monitoring the evolution during therapy;

  • evaluating the types of services that can be provided;

  • connecting people with appropriate therapeutic services.

Thus, patients will benefit from an adequate therapeutic assistance, specific to each case, according to their needs, flexible, and with cultural specificity. Case management is efficient when it ensures good communication between all specialists in the field involved in therapy, while maintaining the confidentiality of the patients(13).

One of the important aspects in terms of therapeutic planning and case management is the establishment of specific objectives. They will be able to guide the therapy and allow the evaluation of the progress made(16). Allsop also believes in setting clear goals that allow therapy to be successful, by counteracting the effects of learned helplessness, which is a mechanism specific to people with drug addiction(17).

There are clear objectives, specific to the therapy of each patient, that will give him a direction, a clear target, and will also allow the patient to keep a record of the progress in the therapy(18). The objectives of the therapy must be adapted and negotiated by each patient, presented in a specific, clear, achievable terms, which will focus on the acquisition of skills, and there are described in positive terms. Also, these objectives will not be limited only to the addiction itself, but will also take into account other areas, such as physical and mental health, social functioning and possible legal implications of the patients(13).

There is no magic solution for treating addictions. This is a long process of mobilizing many services. Addiction is a chronic and recurrent disease that requires repeated treatments until abstinence is achieved.

The treatment will focus on building ego power, reducing shame and developing social skills. Healing means a slow work, a long-term therapy, performed with sincerity and involvement. The therapeutic relationship is formed together with the therapist, who recognizes and confronts those defense and adaptation mechanisms that no longer work.

Bibliografie

  1. World Health Organization. Global Status Report on Alcohol 2004. Department of Mental Health and Substance Abuse. https://www.who.int/substance_abuse/publications/global_status_report_2004_overview.pdf
  2. Prepliceanu D, Voicu V. Abuzul şi dependenţa de substanţe psihoactive. Ed. InfoMedica. Bucureşti, 2004.
  3. Saunders JB, Conigrave KM, Latt NC, Nutt DJ, Marshall EJ. Addiction Medicine, Oxford Specialist Handbooks. 2016.
  4. Di Fiorino M, Gondek T, Alexinschi O. Exercises of Behavoral Therapy. Ed. La Vela, Viareggio, 2017.
  5. Meyers RJ, Roozen HG, Smith JE. The community reinforcement approach: an update of the evidence. Alcohol Res Health. 2011;33(4):380-388.
  6. https://archives.drugabuse.gov/sites/default/files/cbt.pdf
  7. Miller W, Rollnick S. Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy. 2009;37(2):129-140.
  8. Rounsaville BJ, Carroll K. Interpersonal psychotherapy for patients who abuse drugs. In: Eds. Klerman GL, Weissman MM. 1993. New applications of interpersonal psychotherapy. American Psychiatric Association.
  9. McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am. 2010;33(3):511-525.
  10. Carroll KM, Ball SA, Martino S, Nich C, Babuscio TA, Nuro KF, et al. Computer-assisted delivery of cognitive-behavioral therapy for addiction: A randomized trial of CBT4CBT. Am J of Psych. 2008 Jul;165(7):881-8.
  11. Newman CF. Substance abuse. In Whisman MA (Ed.). Adapting cognitive therapy for depression. 2008. New York: Guilford Press.
  12. Davidson R, Velleman R, Mistral W, Howse I. Counselling in substance misuse. A review of the literature. Alcohol and substance misuse working group. 2005.
  13. Dale A, Marsh A. A Guide for Counsellors Working with Alcohol and Other Drug Users: Core Counselling Skills. Best Practice in Alcohol and Other Drug Interventions Working Group: School of Psychology. Curtin University of Technology: Perth, Australia. 2000.  
  14. Metja C, Bokos P, Mickenberg J, Maslar M, Senay E. Improving substance abuse treatment access and retention using a case management approach. Journal of Drug Issues.1997;27(2):329-340.
  15. Siegal H. Comprehensive case management for substance abuse treatment. (Treatment Improvement Protocol (TIP) Series 27.) Substance Abuse and Mental Health Services Administration: Rockville, MD. 1998.
  16. Jarvis T, Tebbutt J, Mattick R. Treatment Approaches for Alcohol and Drug Dependence; an introductory guide. Chichester: John Wiley and Sons Ltd. 1995. 
  17. Allsop S. Goal setting. In: Helfgott S (ed). Helping change: The addiction counsellors training program. Western Australian Alcohol and Drug Authority: Perth. 1997.
  18. Velleman R. Counselling for Alcohol Problems, 2nd Edition. Sage: London. 2001.

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