Goals of psychological therapies in treating drug dependence

By: Tara M. Neavins, Caroline J. Easton, Janet Brotchie and Kathleen M. Carroll

Overview

Psychological therapies encompass a variety of roles in the treatment of drug abuse. These roles differ from those of pharmacotherapy in their time to effect, durability of action, and target symptoms. Unlike psychological therapies that tend to require more time to reveal their effects, pharmacotherapies often exert their effects very soon after their initiation. However, psychological therapies often have more long-lasting effects after completion of treatment and broader applicability than do most pharmacotherapies now in existence. Specifically, most cognitive-behavioral and behavioral therapies can be used across various treatment settings (e.g. inpatient, outpatient, residential), modalities (e.g. group, individual, and family) and a myriad of substance users.

Psychological therapies often rely on teaching coping skills or on employing a motivational approach and are applicable to a large extent to patients who are opiate, cocaine, barbiturate, or cannabis users. In contrast, most pharmacotherapies are warranted only for a single class of substance use and target a relatively narrow band of symptoms. Methadone, for instance, creates cross-tolerance for opioids but would not be expected to (and indeed does not) have an effect on concurrent cocaine dependence; similarly, disulfiram produces nausea after alcohol ingestion but not after intake of other substances (Carroll, 2000).

Although theoretical and technical differences are apparent, cognitive-behavioral and behavioral therapies for drug dependence generally have many similarities. The following discussion highlights the issues that are present, to varying degrees, in most psychological therapies. Moreover, currently available pharmacotherapies for drug dependence would be expected to have little or no effect in these areas commonly addressed by cognitive behavioral and behavioral treatments (Rounsaville & Carroll, 1997).

Cessation of drug use

Ambivalence regarding cessation of drug use is common for individuals who present with drug dependence. Even after negative consequences of drug use have become so overwhelming that treatment may be sought, drug users typically can state several benefits of drug use, express a strong desire or perceived need for drugs, and struggle to imagine what life might be like without drug use (Rounsaville & Carroll, 1997). On the other hand, many drug users may be even more uncertain about treatment given that they have presented for counseling due to the external demands of the legal system, family, friends and relationship partners. Treatments rooted in motivational psychology, including Motivational Interviewing (Miller & Rollnick, 1991; Rollnick et al., 1999) and Motivation
Enhancement Therapy (Miller et al., 1992), concentrate almost exclusively on strategies intended to bolster the patient’s own motivational resources. Specifically, clients may first need to see reasons for changing their behavior before they can benefit from treatment. Motivational therapies are client-centered and understand the ambivalence that many individuals face when considering reducing or eliminating their drug use.

However, the majority of psychological therapies elect to explore the pros and cons of continued substance use in an attempt to increase motivation for treatment and abstinence. In addition to exploring the pros and cons of drug use, motivational strategies general provide clients with feedback derived from an initial assessment session. This feedback often serves to increase motivation to change drug patterns (Carroll, 2000; Rounsaville & Carroll, 1997).

Teaching coping skills and relapse prevention

Social learning theory posits that substance use may represent a means of coping with such things as difficult situations, positive and negative emotional states, and invitations by peers to engage in substance use (Bandura, 1977a, 1977b). By the time that substance use has evolved to the point of drug dependence and treatment-seeking, substance use may represent the individual’s single, overgeneralized pattern of coping with a variety of situations, settings, and states. In order to maximize the probability of achieving and maintaining abstinence, patients would be best-served by understanding high-risk situations that might increase their temptation to use substances and learning more effective means of coping with these risky circumstances. Relapse prevention (Marlatt & Gordon, 1985), a means of increasing self-control and learning to cope with cravings to use substances, has been found to be particularly effective with cocaine-dependent individuals (Carroll et al., 1991a; National Institute on Drug Abuse, 2004). Although cognitive-behavioral therapies are focused primarily on skills training in order to prevent relapse to substances (Carroll, 1998; Marlatt & Gordon, 1985; Monte et al., 1989), many other behavioral therapies devote at least some time to addressing high-risk situations. Childress et al.’s (1984, 1993) work, for instance, has addressed relapse-prevention by examining cue exposure and reactivity, which may enhance patients’ capacity to cope effectively with craving for drugs (Carroll, 2000).

Changing reinforcement contingencies

At the point of entry into drug dependence treatment, many individuals may spend the vast majority of their time acquiring, using, and recovering from substance use to the exclusion of other endeavors and rewards (Rounsaville & Carroll, 1997). Frequently, the drug abuser is isolated from friends and family. The drug addict’s world tends to consist of individuals who use drugs. If the individual happens to be employed, work may have lost any value except for serving as a means of earning enough money to buy more drugs. Hobbies, sports, community and religious group involvement, and other leisure pursuits have probably faded to the background to be replaced by the active demands of drug dependence.

Frequently, daily rewards are narrowed progressively to those derived from drug use, and other diversions may no longer be available or may simply fail to be perceived as pleasurable. When abstinence from substance use is achieved, addicts may be at a loss as to how to structure their time that previously was consumed with acquiring, using, and recovering from drugs. Similarly, newly abstinent addicts may struggle to find rewards that can replace those derived from drug use. In light of these factors, behavioral therapies, such as the Community Reinforcement Approach (CRA (Azrin, 1976)) and voucher based contingency management (Budney & Higgins, 1998; Budney et al., 2000), assist patients with identifying and creating fulfilling and reinforcing alternatives to drug use (Carroll, 2000).

Fostering management of painful affects

Negative emotions and affects appear to be strong catalysts for relapse to substance use (Marlatt & Gordon, 1985). Some clinicians have asserted that inability to regulate affect is a salient factor underlying the development of compulsive drug use (Khantzian, 1975). Moreover, it is commonly believed that substances enable addicts to ‘numb’ their feelings of anger, sadness, loss, betrayal, guilt and other difficult emotions. Empirical investigations have demonstrated that substance abusers have compromised ability to identify and explicate their affect states (Keller et al., 1995; Taylor et al., 1990). Consequently, an important component of cognitive-behavioral and behavioral therapies’ abilities to treat drug dependence is to help addicts create ways of coping with strong negative affects and to learn to recognize the source of these disturbing emotions (Rounsaville & Carroll, 1997). While many psychodynamically oriented treatments, such as Supportive-Expressive Therapy (Luborsky, 1984), emphasize the role of affect in the treatment of cocaine abuse, for instance, many types of psychological therapies give attention to a myriad of ways to cope with strong emotions (Carroll, 2000).

Improving interpersonal functioning and enhancing social support

Studies have repeatedly shown that the presence of an adequate network of social support is protective in preventing relapse to drug dependence (Longabaugh et al., 1993; Marlatt & Gordon, 1985). Three issues are particularly relevant to the social networks of many drug addicts. First, even prior to onset of drug use, these individuals often have failed to develop meaningful relationships with peers, intimate partners and family members. Second, if they have been able to achieve satisfactory relationships, these relationships tend to erode under the weight of the drug use. Third, drug misusers tend to have few individuals in their social circles that do not abuse substances (Rounsaville & Carroll, 1997). Given these facts, many cognitive-behavioral and behavioral therapies, including family therapy (McCrady & Epstein, 1995), twelve-step approaches (Nowinski et al., 1992), interpersonal therapy (Rounsaville, 1995), and network therapy (Galanter, 1993), place a premium on teaching addicts how to create and maintain a social network devoid of substance users (Carroll, 2000).

Another advantage of twelve-step and network therapy approaches is that once a drug-dependent individual has acquired various skills and knowledge with a particular therapist in a given service, the client can go on to develop contact with a broader network of supportive non-using peers such as that provided by Alcoholics Anonymous (AA). As a consequence, the client can successfully terminate treatment at a service because he/she has not become dependent on one therapist or agency.

Fostering compliance with pharmacotherapy

Substance users often struggle to be compliant with treatment, particularly with pharmacotherapies. Psychological treatments may help serve as vital adjuncts to pharmacotherapies by increasing client levels of compliance. The vast majority of techniques to improve compliance are psychosocial (Carroll, 1997). Examples of these strategies include regular monitoring of medication compliance with feedback; encouraging patients to engage in self-monitoring (e.g. through medication logs or diaries); clear communication between patient and staff about the medication, its anticipated effects, side effects, and benefits; clearly describing the benefits of adherence and the risks of non-compliance; contracting with the patients for adherence; directly reinforcing adherence through incentives or rewards; providing telephone reminders or other cues for taking medication; frequent contact and the provision of support (Haynes et al., 1979; Meichenbaum & Turk, 1987). Given the success of these strategies, it comes as no surprise that research consistently has demonstrated the benefit of adding cognitive-behavioral and behavioral treatments to pharmacological treatments for substance use (Carroll, 1997; McLellan & McKay, 1998). Several of the landmark investigations illustrating the merit of appealing to psychological treatments to enhance outcome for pharmacotherapeutic treatment of drug dependence are highlighted.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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