.

Treating Alcohol and Drug Problems in Psychotherapy Practice

Doing What Works

The Guilford Press

Contents

Introduction

Considering that this book is written specifically for psychotherapists, we begin by discussing why we think all mental health practitioners should be able to address alcohol and drug problems competently and routinely in their patients. We then discuss the unique advantages and limitations of office-based treatment and for which patients it may be best suited. The final section of this chapter addresses logistical considerations in treating patients with substance use disorders (SUDs) in office practice.

Before delving into these issues we feel it is important to address a long-standing problem that has contributed in many ways to our motivations for writing this book. Namely, why practitioners from all of the various mental health disciplines have long overlooked or avoided dealing with the problems of SUDs, and why have so few have developed special expertise or chosen to specialize in this area. Although this situation has been improved somewhat in recent years, lack of adequate clinical attention to such pervasive and potentially destructive disorders, though perplexing at first, can be understood in light of certain barriers that have existed over the course of many decades. These barriers, as discussed later, include gaps in professional education and training on SUDs and their treatment, a stereotyped view of individuals with alcohol and drug problems that discourages therapists from engaging them, and conflicts between certain aspects of traditional psychotherapy and the basic principles of addiction treatment.

The various mental health disciplines that educate and train clinicians need to overcome these barriers because failure to identify, treat, and/or properly refer patients with significant alcohol and drug problems can lead to poor clinical outcomes and may also result in legal liabilities for therapists who misdiagnose or overlook these problems (Zweben & Clark, 1991). Those of us who specialize in treating SUDs frequently see patients who were in therapy for years with well-intentioned psychotherapists who apparently did not assess the nature and extent of a patient's involvement with alcohol and drugs, or knew of the problem but did not recognize the need to intervene until the patient's substance use caused a severe crisis. Regrettably, some therapists find out about a patient's alcohol and drug problems only after the patient ends up in a hospital emergency room for treatment of an overdose or suddenly drops out of therapy to seek specialized help from an addiction treatment program or practitioner.

We recognize, however, that responsibility for poor outcomes with these patients often does not lie with the therapist. Many addicted patients actively withhold information from therapists about their substance use out of fear of rejection or just not being ready to address this issue. Because such patients rarely show detectable signs of intoxication when they appear for therapy sessions, even a seasoned addiction specialist may be unable to accurately identify the problem when the patient is deliberately trying to hide it. We can recall numerous cases in our own clinical experiences when we concluded, based on the available information, that no alcohol or drug problem was present, only to find out at a later time that the patient was arrested, fired from a job, or admitted to an inpatient facility for an untreated addiction. Regrettably, incidents like this sometimes cannot be prevented, despite a clinician's best efforts and intentions.

WHY PSYCHOTHERAPISTS HAVE AVOIDED DEALING WITH SUDS

Education and Training Gaps

The most obvious reason why psychotherapists have avoided dealing with SUDs is that most mental health professionals (we ourselves included) received little if any formal training in the diagnosis and treatment of SUDs during graduate school, internship, or beyond. Despite the extraordinary prevalence of SUDs among people who seek mental health services, astonishingly few training programs in the mental health professions (e.g., psychology, psychiatry, social work, mental health counseling) offer specific course work or clinical supervision in this area and most offer none at all. There is a core knowledge base and skill set for treating SUDs that is glaringly absent from most professional training programs. This deficiency fosters professional disinterest, a sense of clinical impotence, and negative stereotyping of patients with alcohol and drug problems. One consequence is that many therapists assume as a matter of course that patients with SUDs can and should be treated only by specialists or in addiction treatment programs. These therapists are quick to refer patients with alcohol and drug problems, especially those with more severe problems, to other caregivers and/or discharge them from their own practices. This is unfortunate, considering that many substance-abusing patients respond well to intervention by therapists with whom they have established a good therapeutic relationship. The fact is that therapists are often in an excellent position to help patients recognize an alcohol or drug problem and develop the motivation to address it. Even in cases in which the patient's substance abuse problem is more severe than the therapist feels prepared to deal with, cultivating the patient's readiness to accept referral for further assessment and/or specialized treatment, when indicated, is critically important.

The failure of most graduate training programs to address SUDs has led to a continuing dearth of competent practitioners in this area. Although some therapists seek extra training, it may be difficult to assess true proficiency. This situation is beginning to change, however, now that certain professional organizations have developed credentialing mechanisms for practitioners who demonstrate at least basic knowledge and clinical expertise in diagnosing and treating SUDs. For example, the American Psychological Association now offers a certificate of proficiency for psychologists who meet certain criteria including documented hours of clinical experience and clinical supervision in addition to passing a written certification examination. A similar credential is offered by the American Psychiatric Association.

Stereotyped Views of Patients with Alcohol and Drug Problems

Patients who abuse alcohol and drugs have long been stereotyped by mental health professionals as being character disordered and largely unresponsive to psychotherapeutic interventions. Historically, psychotherapists have been influenced by the prevailing view of substance abusers as impulsive, untrustworthy, highly resistant to treatment, and unmotivated to change. Patients with serious alcohol and drug problems are assumed to have borderline, narcissistic, antisocial, and other personality disorders that render them untreatable or as having a poor prognosis at best. Unfortunately, therapists lacking positive experiences with substance-abusing patients have not had an opportunity to see that the distortions in personality and behavior so commonly seen during active addiction often disappear or decrease markedly after the substance use stops. These observations suggest that in many individuals these distortions are often secondary to the alcohol and drug use and not indicative of an underlying personality disorder. Although some substance-abusing patients do indeed exhibit antisocial and other personality disorders that predate their addiction and persist even after they stop using alcohol and drugs, these individuals are the minority, not the majority, of the addicted population. Research has consistently failed to support the notion of a predisposing "addictive personality" common to all people who become addicted to alcohol and drugs. To the contrary, contemporary research shows that chronic use of psychoactive substances induces stereotypic distortions in behavior and personality as a result of complex changes in brain activity caused by these substances and the extraordinary behavioral demands of maintaining an active addiction while concealing it from others. Along with cessation of substance use and sufficient time for brain functions to recover from repeated neurological insult by drugs, these aberrations in behavior and personality often resolve quite rapidly. Such observations have led many experts to conclude that addiction is quite literally a substance-induced "brain disease" (Leshner, 1997).

Clinicians familiar with the dynamics of addiction, as compared with those who lack this familiarity, are likely to view the behavior of substance-abusing patients in ways that allow them to respond more effectively. The patient will likely be seen not as character disordered or resistant, but rather as highly ambivalent about relinquishing alcohol and drugs and acting out this internal struggle by giving in to strong urges and cravings to use. The therapist will acknowledge that cravings and urges are common features of the disorder, especially in the early phases of establishing abstinence, and offer helpful suggestions for dealing with such situations. For example, the therapist will offer suggestions about how the patient can avoid "high-risk" situations that stimulate the desire to use and will also teach the patient ways to manage the cravings to prevent them from leading to actual use. The therapist will be less likely to view any lapses to substance use as evidence of resistance, willful noncompliance, or lack of motivation, but rather as a reflection of the ambivalence and lingering attachment to substances that are part of the addictive disorder. The therapist will also acknowledge the inherent difficulties in counteracting what often are physiological and psychological compulsions to use alcohol and drugs even in the face of serious negative consequences. In this way, the more addiction-savvy clinician can join with the patient in acknowledging the struggle involved in achieving abstinence and offer specific behavioral and motivational techniques to enhance the patient's ability to change. This stance fosters development of a strong working alliance that is more empathic and supportive than standard confrontational approaches and more likely to engage and retain patients through the rocky course of early treatment.

Conflicts between Psychodynamic Therapy and Addiction Treatment

Certain aspects of psychodynamic psychotherapy are at odds with some basic principles that inform and guide the treatment of SUDs. For example, many mental health professionals were taught to uncover the underlying or root causes of psychological or behavioral problems as a necessary step in the process of resolving the problems. This can be a setup for failure when dealing with SUDs. As Margolis and Zweben (1998) state, searching for the root causes of an addiction in the early stages of therapy can be likened to a paramedic rushing to the scene of an accident, where victims are lying on the ground bleeding, and taking time out to find out what caused the accident. Helping an individual to stop using alcohol and drugs requires amazingly little understanding of the factors that may have contributed to development of the problem. Focusing on the presumed underlying causes of alcohol or drug use ignores the fact that substance abuse is a distinct disorder and that there are a multitude of contributing forces that maintain an individual's substance-using behavior having virtually nothing to do with the reasons why he may have started using alcohol and drugs in the first place. It also fosters the dangerous idea that once the underlying causes are adequately resolved, the person's alcohol or drug problem will automatically disappear. In addition, attempting to uncover deep-seated emotionally-laden material too early in treatment often poses a very real danger of stimulating overwhelming affects that are likely to reignite the patient's desire to self-medicate with alcohol and drugs. In the first few weeks and months after stopping substance use, many patients experience labile moods and have great difficulty managing their emotions. They often feel like an emotional "raw nerve," which is quite different from the numbed or anesthetized emotional state in which they existed during their active addiction. Feelings that have been chemically suppressed by alcohol and drugs for many years often surface spontaneously once abstinence is established. A therapist's attempt to elicit these feelings too early in treatment can overwhelm a patient's shaky sense of self and threaten her still fragile commitment to reducing or completely stopping alcohol and drug use. Once the chemical veil of substance use is removed, patients often begin to experience uncomfortable feelings that they have not been accustomed to dealing with for a long time. This is often compounded by intense feelings of shame and guilt that emerge as patients face the reality of negative consequences caused by their prior substance use and the challenging task of dealing with life problems without the buffering effects of alcohol and drugs. A deep sense of loss, grief, and resentment about having to give up alcohol and drugs (feelings often likened to those of losing a "best friend") also contributes to patients' discomfort and instability in the early phases. In light of these considerations, therapists should pay careful attention to the timing of interventions in the early phases and be mindful of the patient's tenuous hold on abstinence.

Discomfort with the Disease Model and 12-Step Program Philosophy

Many therapists, from both psychodynamic and behavioral orientations, have difficulty with the notion that addiction is an incurable disease and with other tenets of 12-step programs. Psychodynamic therapy tends to view addiction as a symptom of unresolved psychological problems rather than as a primary problem requiring targeted intervention. Within this framework, the underlying or "real" problem must be attended to first and sufficiently resolved before the patient will be able to stop using the addictive substances. Similarly, but for entirely different reasons, behaviorally oriented therapists are among the most vociferous opponents of the disease model. They point to the absence of a scientific basis for the disease model and abstinence-only approaches to treatment, viewing addictive substance use not as a permanent incurable disorder, but as a learned behavior perpetuated by a combination of physiological, psychological, and social reinforcers.

These long-standing ideological conflicts have created a rift between the communities of mental health practitioners on the one hand, and mainstream addiction treatment providers and self-help programs on the other. This has led to an unfortunate situation in which therapists sometimes feel threatened by or competitive with AA and traditional treatment. Anti-AA therapists may not only fail to encourage a patient's involvement in AA, but go so far as to devalue the program and actually discourage patients from embracing the 12-step philosophy. Similarly, more than a few people in AA are hostile to the idea of psychotherapy for alcohol-and drug-addicted persons, and especially toward "enabling" therapists who fail to support complete abstinence from all psychoactive substances as essential to recovery. Fueling the antagonism, some AA zealots contend that psychotherapy is harmful to addicted persons and should be categorically avoided by people in recovery.

As discussed in Chapter 4, certain elements of the disease model and 12-step philosophy have enormous therapeutic value and can be utilized for patients' benefit regardless of your theoretical orientation. You need not accept or believe unequivocally in all aspects of the disease model in order to utilize selected aspects of this model to help your patients. To quote an AA slogan, when questioning the value of AA you are advised to "take what you need and leave the rest."

WHY ALL THERAPISTS SHOULD KNOW HOW TO TREAT SUDs

There are many compelling reasons why all practicing therapists should acquire the skills required to address SUDs competently and routinely in their patients, as discussed in the following sections.

Prevalence and Consequences of Untreated SUDs

First and foremost among these reasons is that in addition to being highly prevalent in the general population, SUDs are particularly common among people who seek help for other types of mental health problems. Alcohol and drug abuse is so widespread in clinical populations that patients with SUDs are likely to appear in the caseload of every mental health practitioner. Clinicians cannot assume that substance abuse is absent even if there are no clear warning signs. Instead, they must be proactive and assess all patients routinely and methodically for SUDs, whether or not substance abuse is a presenting complaint. SUDs are frequently overlooked or misdiagnosed in mental health patients, partly because chronic alcohol and drug use can and often does induce behavioral changes and psychiatric symptoms that mimic almost any type of mental health problem, ranging from anxiety and depressive disorders to personality disorders and psychoses. Moreover, failure to address alcohol and drug problems creates an opportunity for these problems to fester and result in increasingly adverse outcomes. Untreated SUDs not only can diminish or completely nullify the effectiveness of both psychotherapy and pharmacotherapy for other mental health problems, but are associated with extraordinarily high rates of morbidity and mortality. Suicide rates among people with serious alcohol and drug problems are many times greater than the general population rates. Alcohol and drug abuse contributes to deaths and serious injuries resulting from overdose, drowning, homicide, and domestic violence. Substance abuse is associated with a wide variety of other serious health problems, including sexual abuse, exposure to sexually transmitted diseases (e.g., HIV, hepatitis C, genital herpes), drug-induced psychiatric disorders, adverse interactions with medications prescribed for other medical conditions, and with a wide range of serious medical problems directly caused or exacerbated by alcohol and drug use (Institute of Medicine, 1990).