VARIABLES IN THE PSYCHOTHERAPY OF DRUG ADDICTS

Originalarbeit S 31-36 Wiener Zeitschrift für Suchtforschung! Jg.20. 1997 Nr. 3/4! VARIABLES IN THE PSYCHOTHERAPY OF DRUG ADDICTS GEORGE E. WOODY, M.D. LESTER LUBORSKY, PH.D. A. THOMAS MCLELLAN, PH.D. CHARLES P. O BRIEN, M.D., PH.D. AARON T. BECK, M.D. DELINDA MERCER, M.S. (Substance Abuse Treatment and Research Center of the University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center) Introduction This topic relates to the role of psychiatric symptoms and disorders in the onset and maintenance of addiction. Psychotherapeutic treatments for substance use disorders are widely used in many countries. In the U.S., individual therapy or drug counseling are available in virtually all of the drug-free, methadone maintenance, multi-modality, and detoxification units (National Drug and Alcoholism Treatment Unit Survey, 1982). The types of psychotherapy for treating addiction include individual, family, and group therapies, each with a variety of orientations. Despite the widespread use of psychotherapeutic approaches to treat chemical dependence, only within the last two decades have these approaches begun to be scientifically evaluated. Most of the research on addiction treatment has focused on pharmacological rather than psychosocial interventions, even though some form of psychosocial intervention is at least a part of almost every addiction treatment program. Often psychosocial interventions comprise the entire program (Onken and Blaine, 1990). The relative absence of research on psychosocial treatments for substance use disorders is due, at least in part, to the numerous difficulties encountered in attempting to conduct scientific research in this area (Onken and Blaine, 1990). These methodological problems include problems around compliance with study procedures, recruitment and engagement of patients, and others, and have been discussed in depth elsewhere (Borkovec, 1990; Carroll and Rounsaville, 1990; Crits-Christoph et al., 1990; Howard et al., 1990; Lambert, 1990). Psychotherapy vs. Drug Counseling Psychotherapy for addiction is a psychological treatment that aims to change problematic thoughts, feelings and behaviors through creating a new understanding of the thoughts and feelings that appear to be causally related to the addiction. Change is believed to occur within the context of a supportive relationship with a skilled psychotherapist who provides the patient with the opportunity to explore the underpinnings of maladaptive behaviors, thoughts and feelings and then change undesirable patterns that contribute to the patient s emotional distress. When psychotherapy is used in the treatment of addiction, it must address the addictive behaviors, and the thoughts and feelings that appear to promote, maintain or occur as a result of or in conjunction with, the addiction. Along with the goals specific to addiction, psychotherapy also addresses issues related to other aspects of patients lives under the assumption that some of these contribute to their drug use. Addiction counseling, rather than psychotherapy, is the most widely used psychosocial intervention in substance abuse treatment in the U.S. Counseling is generally defined as the regular management of addicted patients, primarily through giving support, providing structure, monitoring behavior, encouraging abstinence, and providing concrete services such as referral for job counseling, medical services, or legal aid. This approach constantly addresses the addictive behavior, often using the language and concepts of the 12-step program developed by Alcoholics Anonymous. It attempts to modify the dependence/abuse by identifying daily problems and behaviors that contribute to drug use, and by delivering concrete services aimed to overcome these problems. Counseling, like psychotherapy, tries to help the patient deal with addiction-related consequences that have often become a part of their lives. The approach taken in counseling is typically concrete and specific, and does not have the intrapsychic focus typically used in psychotherapy. A Rationale for Using Psychotherapy with Substance Abuse Patients Psychotherapy, in one form or another, sometimes in conjunction with medication, is often the treatment of choice for patients withnon-psychotic emotional problems or psychological distress. It follows then that psychotherapy would have a place in the treatment of addiction because emotional distress seems to contribute to, and result from, chemical dependence. Some abused drugs may temporarily reduce subjective distress, such as opiates, and that is part of the reason for their abuse in some cases. Conversely, many abused drugs cause distress upon withdrawal, often resulting in depression, anxiety, difficulty with sleep, etc. The self-medication hypothesis is one of the theories addressing the relationship between addiction and subjective emotional distress. This hypothesis suggests that some types of drug abuse may begin, continue, or be otherwise fostered as a form of self-medication to treat anxiety, depression, feelings of anger, or other types of subjective distress (Khantzian 1985; Khantzian et al. 1984). This apparent relationship between psychological symptoms and addiction provides a rationale for the use of psychotherapy in the treatment of addiction - if the accompanying psychological distress can be reduced, the person has a better chance to reduce or stop drug self-administration. Research indicates a high level of comorbidity between substance use disorders and a wide range of psychiatric symptoms, many of which meet symptomatic and duration criteria for DSM or ICD diagnoses (Rounsaville et al. 1982; Khantzian and Treece, 1985; and Woody et al., 1983, Weiss et al. 1986, Woody et al. 1990, Rounsaville et al. 31

1991, Kessler et al, 1996). The most common of these psychiatric diagnoses are major depression, dysthymia, most of the anxiety disorders, and personality disorders, especially antisocial personality disorder. Because chronic use of most drugs of abuse (with the exception of opiates and nicotine) will magnify or even produce psychiatric symptoms, it is often difficult to determine which of these symptoms represent independent vs substance-induced psychiatric disorders. However, whether symptoms are substance-induced or represent independent psychiatric disorders (and provided they persist beyond the immediate period associated with intoxication or withdrawal), studies have shown that they have prognostic significance (McLellan et al, 1983). This finding is especially relevant to psychotherapeutic approaches for treating persons with substance use disorders, as the psychotherapies have been adapted specifically to address psychiatric problems. The presence of psychiatric symptoms that appear to represent an independent disorder in addition to the substance use disorder identifies a subgroup of patients referred to as dual diagnosis, in that they have both the substance use disorder and another psychiatric disorder. Studies will be reviewed showing that these patients appear to benefit from an approach that provides professional psychotherapy rather than just drug counseling, because psychotherapy seems to more effectively address the distress associated with persistent psychiatric symptoms (Woody et al. 1983). Treatment Setting for Psychotherapy with Addicts Psychotherapy probably has the best chance to work when it is integrated into an ongoing program that focuses directly on reducing or eliminating drug use. It is probably best not used as a stand-alone treatment in most cases. Washton (1989) describes the components of such a program. It includes a structured, progressive treatment program that is abstinence oriented, provides education about the effects of drugs, encourages family involvement, does frequent urine testing, provides group and individual therapy, supports Twelve-Step participation, and encourages good physical health. In Washton s program, drug-focused counseling and psychotherapy are provided by the same person. Khantzian (1987) also advocates this type of role where the therapist has the primary responsibility for meeting all the treatment needs of the patient. Another model is to assign the patient an addiction counselor and a psychotherapist. The counselor handles the patient s more concrete needs such as talking about current problems, supporting and encouraging efforts to reduce drug use, monitoring progress, providing liaison or consultation with medical personnel, making job referrals, obtaining legal advice, encouraging limit setting by enforcing program rules, and keeping accurate records. This model allows the psychotherapist to focus on therapy, but it also requires coordination of services. Good personal relations between the psychotherapy and counseling staffs are essential in this model. Helpful is commitment of the 32 psychotherapies to the overall program through activities such as working in the facility and interacting with other treatment staff, being involved in making treatment decisions and plans with other staff, and being familiar with program policies and procedures. Therapist Qualities Therapist qualities appear to have an important impact on success in therapy (Luborsky et al. 1985; Luborsky et al. 1986). Kleinman et al. (1990), in investigating crack and cocaine abusers, found that therapist assignment was the strongest predictor of treatment retention, which is often one of the most important predictors of success. Little evidence is available to indicate the type of therapist who may do best with substance abusers, thus it is difficult to comment with certainty on this issue, perhaps partly because substance abusers are such a heterogeneous group. Some guidelines can be offered, however, from the few available studies that have examined therapist qualities as they relate to psychotherapy outcome in general. Three qualities appear to be predictive of outcome: therapist s adjustment, therapist s skill, and his/her interest in helping patients (Luborsky et al. 1985). All of these qualities usually reflect themselves in the therapist-patient relationship. Several studies have shown that therapists who from the beginning of treatment form a positive relationship that is perceived by the patient as helping appear to have a better chance of success than those who form less positive bonds (Luborsky et al. 1985). Related to these qualities is the therapist s interest in, and comfort with, certain kinds of problems. Some therapists have strong negative reactions to the manipulative, sociopathic, impulsive, or demanding behavior that is often seen in addicts. Others react negatively to the self-induced quality of substance abuse, which sets it apart from many other disorders in which the patient has relatively little to do with the onset or continuation of the illness. Therapists with such predominantly negative reactions will probably not do well with these patients. Therapists may occasionally need to extend themselves a little more with addicts than with other types of patients. The dependency needs of the patients often express themselves in the doctor-patient relationship, and an occasional appropriate, concrete supportive response is probably useful, especially in the early phases of treatment. This may involve greeting the patient warmly on entering the office, actively seeking to reestablish contact when an appointment is missed, acknowledging improvements when they occur, or seeing the patient occasionally at unscheduled times if the need is present and the time is available. Models of Individual Psychotherapy for Substance Abuse Many of the techniques and principles of psychotherapy used with addicts are similar to those used in psychotherapy with other patients. However, to treat addicts effectively it is important to combine general knowledge of psycho-

therapy with knowledge of the factors specific to addiction such as the lifestyle, pharmacological effects of drugs, and how the interpersonal dependency needs of the patients are expressed. It is also important to appreciate the power of the dependence, the loss of control that accompanies the addiction, and of the biopsychosocial consequences that can result. Therapists who are not familiar with these issues will probably have difficulty relating to the patients and forming positive, helping relationships. In modifying the supportive-expressive form of psychotherapy for use with substance abusers, Luborsky and colleagues (1977) identified certain special aspects of therapy that are particularly important and are listed: 1. Much time and energy on the therapist s part is required to introduce the patients to treatment and to engage them in it. 2. The treatment goals must be formulated early and kept in sight. 3. Much attention must be given by the therapist to developing a positive relationship and supporting the patient. 4. The therapist has to keep abreast of the patient s compliance with the overall drug treatment program, which includes adherence to rules and avoiding unrescribed drug taking. This information come from the patient s selfreport and from urine and breath analysis, and may also be provided by family, friends, and other treatment staff. 5. If the patient is receiving methadone, attention should be given as to when the patient feels therapy is best, before or after the daily dose. Methadone usually is such a central part of the patient s life that establishing an agreed-upon time for therapy around the dosing schedule could determine whether the patient engages or drops out of therapy. Psychotherapeutic techniques from several orientations have been adapted to focus specifically on the treatment of addiction. Supportive-expressive psychotherapy (Luborsky 1984), which derives from psychoanalytic therapy, is one that has been modified to address substance use disorders, specifically opiate and cocaine dependence (Luborsky et al, 1995). Interpersonal psychotherapy, another supportive/dynamic model, has also been adapted for use in the treatment of opiate dependence (Rounsaville et al. 1983) and cocaine abuse and dependence (Rounsaville et al. 1985). The most prominent contributions to addiction treatment in the cognitive therapy area are: cognitive therapy (Beck and Emory, 1977; Beck et al. 1990).; relapse prevention (Gorski 1990; Gorski and Miller 1986; Marlatt and Gordon 1985; Carroll et al. 1991); and social learning theory (Annis, 1990). Family therapy (Stanton and Todd, 1982) and group therapy (LaRosa et al. 1974; Willett, 1973) have also been used to treat addiction either alone or in combination with individual therapy. Studies on Psychotherapy Efficacy with Drug Addicts It is only in the last two decades that the psychosocial components of drug abuse treatment have been the subject of scientific investigation. A substantial majority of the research on psychotherapy in the treatment of addiction has concluded that it can be an effective treatment modality (LaRosa et al. 1974; Stanton and Todd, 1982; Woody et al. 1983; Carroll, Rounsaville & Gawin, 1991). These studies and reviews have examined individual, family, and group psychotherapies. The comparison of specific models of therapy for substance use disorders has become the focus of much interest. One study compared the addition of supportive-expressive psychotherapy (SE) and cognitive behavioral therapy (CB) to standard drug counseling, with drug counseling alone (DC) for methadone-maintained opiate addicts (Woody et al., 1983). It found that patients with higher levels of psychopathology ( high severity ) who received the professional psychotherapies significantly reduced their drug use and also benefitted in several other important ways. Comparable patients who received drug counseling alone benefitted only in the area of drug use, and the benefits obtained were less than those achieved by the psychotherapy groups. In contrast, patients with low levels of psychopathology ( low severity ) made significant gains in drug use and in other areas as well. Among these low severity patients, there were no significant differences in outcome between the three treatment conditons (Woody et. al., 1984). Neither type of psychotherapy was significantly more effective than the other, a finding that is consistent with much of the psychotherapy outcome research literature (Luborsky et al. 1975; Smith et al. 1977; Smith et al. 1980). An interesting finding emerged when data were examined to assess outcome of patients receiving psychotherapy who had antisocial personality disorder. It was found that patients with antisocial personality disorder alone only improved in the area of drug use, whereas those with antisocial personality disorder and current or past depression improved considerable and to a degree similar to that of persons without antisocial personality disorder. These findings, though preliminary, suggested that antisocial personality disorder is a heterogeneous category, and that some persons who have this problem are more therapy amenable than others. It also suggested that it is a mistake to conclude that antisocial personality disorder is always associated with poor treatment outcome (Woody et al, 1985). The overall conclusion of these studies was that the addition of professional psychotherapy to drug counseling provided no additional benefit if the patient had few or no psychiatric symptoms. However, psychotherapy helped substantially in both drug use and in other important areas if the patient had high levels of psychiatric symptoms. This finding had immediate practical significance: identifying patients with high levels of psychiatric symptoms and providing additional, psychiatrically-focused treatment to the standard drug-focused approach could improve their prognosis. This finding was further examined in a later study of psychotherapy done in community-based methadone programs. In this study, methadone maintained patients with high levels of psychiatric symptoms were assigned to be trea- 33

ted by two paraprofessional counselors, or by one counselor and a psychotherapist. Only one type of psychotherapy, supportive-expressive, was studied since the earlier study shown that both therapies did equally well. The extra counseling and psychotherapy were available for 6 months. Results showed that most patients improved and that there were no differences in outcome between groups at the 6 month evaluation point. However, by 12 months the gains achieved by the counseling group diminished while those in the psychotherapy group were maintained or became more pronounced. The result was that statistically and clinically differences emerged at 12 months, all favoring the psychotherapy group (Woody et al, 1995). A related study (McLellan et al. 1993) examined three levels of treatment services in methadone maintained opiate addicts. The three levels varied both according to their intensity and quality. They were: minimal services (10 minutes of counseling once/month), standard services (one drug-focused counseling session per week with referral to other sites for treatment of associated psychiatric, family and vocational problems); and enhanced services (standard counseling plus psychotherapy, family therapy and vocational services available on site). Only about 30% of patients receiving minimal services did well; two thirds did very poorly and had to be administratively transferred to the standard condition. Upon transfer, most improved substantially within 6 weeks. Patients receiving enhanced services did somewhat better than those in the standard treatment condition. Thus, there was a stepwise progression of improvement associated with receiving increasing levels of psychosocial services, including psychotherapy. This research on the efficacy of psychosocial treatments in combination with methadone maintenance is consistent with other studies which suggest that only some substance abuse patients can be successfully treated with a purely psychotherapeutic approach (Carroll et al. 1991). Much research has been directed toward possible pharmacological treatments for addiction and it seems likely that in many situations optimal treatment involves a combination of psychotherapy or counseling, or both, plus an appropriate pharmacological intervention. A multi-site study is currently in progress examining psychotherapy and counseling for persons with cocaine dependence. In this outpatient study, all patients receive once/week group therapy following a 12-step approach. Patients are then randomly assigned to group therapy alone, group therapy plus individual drug counseling, group therapy plus supportive-expressive psychotherapy, or group plus cognitive-behavioral psychotherapy. Therapists have been carefully selected, trained and supervised in an effort to reduce variability in therapist effects on outcome. If therapist effects have been minimized by these methods, the data will be able to more clearly focus on the effect of the psychotherapeutic and counseling techniques themselves. This study is the largest yet done on psychotherapy and counseling for cocaine addicts, and results will be available within about one year. Hypotheses have been guided by 34 the work with methadone maintenance and are that: most patients will improve, group counseling alone will show the least improvement, patients with antisocial personality disorder will not progress as well as those without it, and patients with high levels of psychiatric symptoms will improve more if they receive professional psychotherapy than if they have counseling alone. Confirmation of the results of the methadone studies in this project will provide very credible evidence that psychotherapy has a useful role in addiction treatment. Implications For Treatment Even without new data, there is now considerable evidence that psychotherapy can be effective in the treatment of persons with substance use disorders. However, it also appears that certain conditions must be met in order the maximize the chances for patients to become engaged in therapy and for positive outcomes to occur. Usually the chemically dependent patient requires more structure and greater frequency of visits than traditional psychotherapy provides. Pharmacological treatments are often needed in addition to psychotherapy, and psychotherapy must often be integrated with other psychosocial interventions. In fact, psychotherapy appears to be most effective when combined with other treatment services, either within the context of a structured addiction treatment program (McLellan et al. 1993) or when the totality of ancillary services is organized as needed by the individual psychotherapist (Khantzian 1987). Frequent, observed urine and breath testing is an important aspect of the treatment program structure. Each of these tests encourages honesty and helps hold the patient accountable for his/her behavior. Prompt feedback on drugpositive and drug-negative urines helps the patient feel that the therapist is concerned and is monitoring progress in recovery. Appropriate confrontation and analysis of what led to use is important in the case of any lapse to drug use, whether it is discovered through urine or breath testing, or by patient s self-report. Positive feedback for clean urines is often a powerful reinforcer for abstinence. Many clinicians find that involvement of significant family members in the treatment process is also helpful. Family members are usually informed of the nature and consequences of addiction and of the treatment process, and their support may be enlisted through occasional family meetings. Most counselors and therapists pay special attention to any factors in the family that may undermine treatment, such as addiction in a family member or the development of family crises in response to the patient s improvement. If such factors exist, family therapy may be necessary, as well. At least one controlled study of structural family therapy, used in combination with drug counseling for patients on methadone maintenance, showed positive results (Stanton & Todd 1982). Thus far, research has not indicated that one kind of psychotherapy is superior to any other for the treatment of addiction, although the different models of psychodynamic,

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