Alcohol and drug-dependent patients frequently arrive with an array of problems, deficits, and defenses that challenge and baffle the therapist, so much so that psychoanalytic theorists over the years have been fairly pessimistic about their t rea ta bili ty. ' Research into the process of treatment with alcohol/ drug-dependent patients shows that there aro effective interventions.2 Traditionally, effectiveness is measured by abstinence; however, improvement in job functioning, interpersonal relationships, medical and psychiatric symptoms, and legal problems could also measure success.
The more comprehensive the treatment plan, the greater improvement for those patients who remain engaged. This is true for opiate addicts on methadone3 as well as alcoholics in 12-step programs.- As an effective team member, the psychiatrist must understand what he or she brings to the therapy, what can be expected from the patients, and what therapeutic techniques have had greatest success.
FEATURES OF THE THERAPIST
Therapists bring Io the treatment setting emotional barriers in the form of their responses to the attitudes, behaviors, and personality styles of the aleo hoi /drug-dependent patients.4 Some therapists are repelled by the manipulative, drugseeking behaviors, rejecting these patients outright. Others may be overwhelmed by the neediness and constant crises that alcohol /drugdependent patients experience. Some psychiatrists accept the user's denial at face value, believing the patient's stories, and feel frustrated if their efforts have not succeeded after a period of time. If they discover that their patients continue to use alcohol /drugs, they may feel angry and betrayed. These emotional reactions may be the first indication to the therapists that they suspect alcohol/drug dependence ill their patients. Such counteriransference feelings should not be taken literally or run away from, but they should be used to deepen the therapeutic process.
lmhoff suggests that some of these emotional reactions stimulate codependent behaviors.4 Codependency, the continued investment of one's self-esteem in the ability to control another's behavior, comes in two types: primary and secondary.3 While primary codependency is a stable personality style, secondary codependency is temporary; it occurs when one is interacting with an addicted individual but does not persist in other interactions. It is important for the therapist to remember that neither behavior serves the patient. In the best case, a therapist exhibiting a primary codependency will only stall the patient's progress; in the worst case, such therapists may actually prevent recovery. Secondary codependency is less serious and more easily combated byproper training.
Finally, the therapist must remember the critical importance of taking an alcohol/drug history. Omitting the history because the patient doesn't look like an addict all too often leads to misguided therapy, which is uninformed about the "covert" alcohol/drug dependency. Such therapy inadvertently encourages the patient's denial and misses an opportunity to make an important intervention. A careful screening history is essential for any initial assessment.
FEATURES OF THE PATIENT
Openness and receptivity to individual, group, and family counseling are obviously important features for patients to bring to the treatment situation, but many of them manifest other, less helpful attitudes. Some come from families that discourage public discussion of problems and must overcome that obstacle before counseling can be successful. Many alcohol/drugdependent people feel ashamed of their problems and fear they are the only ones to behave as they do. Feeling isolated, they may be reluctant to reveal their "badness." Court-referred patients may be angry even to find themselves in the treatment setting; they are frequently reluctant to talk openly at first, engaging with hostile opposition to the entire process.
FEATURES OF THE PROCESS OF TREATMENT
Because alcohol and drug addictions are common disorders,5 one might conclude that this diagnosis is readily achieved. Yet studies have shown that 25% to 50% of alcoholics provide unreliable histories, interfering with the diagnostician's recognition of their disorder. Patients tend to minimize or falsify information regarding the recent past (the last few months) more than the distant past; therefore, psychiatrists should be aware that histories about the distant past may include more accurate diagnostic information. It is also important to realize that people who met the criteria for alcohol dependence 20 years ago almost never drink in a safe and controlled fashion in the present.7
Since the diagnosis of addiction is considered a lifetime diagnosis, knowing the patient's history is vital if the therapist is to provide effective treatment. To circumvent denial at the start, the diagnostician should talk to the family and to the referring person or agency to get collaborative information regarding the patient's alcohol/drug use. Drug screening is another important technique in gathering collateral information for a reliable history. Such collaborative data will lead to a more accurate assessment and, therefore, a more effective treatment.
Due to the high early dropout rate of many alcohol/drug-dependence programs, engagement is a critical part of any effective therapy. Continuity of care helps retain alcoholics and addicts; so do individualized treatment plans." Culturally sensitive programs engage ethnic minorities more effectively by recognizing cultural differences in identity, interpersonal style, and decision-making priorities, and by acknowledging these differences as important.9 Therapeutic communities have found that family involvement improves retention and thereby outcome."1 Coercion to attend, if it is integrated clearly into a contingency contract, also has been shown to improve program retention and outcome.'0
Motivation, denial, and cognitive understanding of alcohol/drug dependence are three interlocking psychological features of the patient that are usually addressed in the early phase of treatment. Influencing one often changes the other two. Consequently, a variety of interventions focusing on these three features will improve the commitment to abstinence and improve the patient's capacity to cooperate and be introspective in therapy. Later in treatment more attention can be paid to interpersonal styles and deficits in self-soothing, selfesteem, and self-care. Studies have shown that education groups, process groups, and skills-building groups can all enhance patient outcome.2 Individual counseling and individual psychotherapy have both been shown to be effective with methadone maintenance patients and alcoholics.8 Moreover, with addicted patients who are significantly depressed, psychotherapy makes an additional improvement in their long-term outcome.3
Tiebout described three clinically useful stages of gaining cooperation from alcoholic patients.11 In the first stage of cooperation, alcoholics do not perceive any difficulty with their drinking behaviors. Therapists should approach them as if they were sleeping, encouraging them to wake up and consider the possibility that their drinking is causing problems. The approach here is an invitation to explore the possibilities of alcohol/ drug dependence.
During the second stage of gaining cooperation, alcohol /drugdependent people perceive that there are problems and try to solve them in their own way. Because they are not open to outside help, they try to prove that their drinking or drug use is reasonable and controllable. At this stage, the therapist should sLiggest that these behaviors are out of control. Although patients in stage two reject that suggestion, they end up demonstrating its validity in spite of themselves. Focusing on the loss of control will be met with denial, but such focusing highlights the loss of control for the patients.
As alcohol/drug addicts feel their efforts to correct matters are failing, they become more receptive to an outside source of help. This is the third stage of cooperation. A good therapeutic alliance can now be established through this belief that there is a problem and that the psychiatrist or treatment team can (or must) help with it.
Loss of Control
When the patients are out of control, the psychiatrist must make some difficult interventions, beginning with confronting the patients with their behavioral loss of control. Sometimes the psychiatrist discovers that patients are fully aware of the situation but cannot do anything about it. In those cases, the psychiatrist must assist them in regaining control, either as inpatients or outpatients. The choice of treatment setting will depend upon the past history of alcohol/drug withdrawal symptoms as well as the occurrence of medical or psychiatric comorbidity.12 Outpatient management is viable only if they can stop using alcohol /drugs and the crisis calms down, if the crisis doesn't subside, the psychiatrist must decide when to require residential treatment.
When patients deny loss of control, the psychiatrist faces a more complicated and volatile situation. Because denial and motivation can change rather dramatically when people are detoxified, a trial of abstinence is useful. Cooperation with the family and significant others is useful because they can confront the patients, which may induce them to go into a residential program.
Because such comments lead to denial, unkept promises, and even fights, families frequently give up telling the alcohol/drug-dependent members how painful it is for the family. The alcohol/drugdependent members then assume that the family does not mind their alcohol/drug use. To interrupt this cycle, the treatment team should schedule a conjoint interview in which the family can begin to describe the pain, fear, and frustration that they have been experiencing because of the patient's alcohol/ drug use. Often this technique increases the dependent person's awareness and motivation to seek help. Even when it doesn't, however, it may empower the family to realize they don't have to endure these behaviors helplessly. The family can then seek alternative ways to meet their emotional and social needs.
As the family begins its recovery, family denial of the problem fades. The rules "don't talk, don't trust, and don't feel" are shattered and people begin to grow. At this point the alcohol/drug-dependent member sees that things have changed and that the family is doing better. This may prompt the dependent member to come into treatment in order to feel better also.13
Residential treatment programs are usually designed according to the Minnesota Model, oriented around the 12 steps of Alcoholics Anonymous (AA).14 The length of such programs is often 28 days; however, there are variations that last from three to six weeks, depending upon the needs of the populations served. Staff is usually composed of physicians, nurses, psychologists, social workers, and certified addiction counselors. They work together to maintain an intensive, drug-free milieu program that usually begins about 6:30 in the morning with wake-up and finishes after dinner about CHK). Rules are enforced rigidly to keep the unit drug-free and focused on the treatment of alcohol/drug dependence.
The patients are usually admitted in a state of crisis. They often need detoxification from one or more drugs, and their vital signs are monitored carefully. Most alcoholic patients can be managed without medication, using emotional support, low stimulation, and medical attention as needed. |S Opiate addicts are often detoxified to ease their withdrawal and keep them in treatment. Cocaine-dependent patients may or may not have symptoms that fit the pattern of stimulant withdrawal. While they rarely require medicai detoxification, some cocaine addicts are overwhelmed by drug craving and are engaged more effectively with a tapering dose of bromocriptine.16 Patients who have withdrawal from CNS depressants need to be managed carefully to prevent seizures and delirium. Drug screening and a search for drugs are typical upon admission. A careful medical exam is necessary since alcohol/ drug-addicted patients come with a variety of medical problems.
Once the patients have been stabilized, they can be integrated into the group activities of the rehabilitation program. A variety of group and individual therapies is carefully orchestrated to instill hope, break down denial, and facilitate discussion about the myriad problems associated with alcohol /drug dependence.
During the rehabilitation program, patients recover their sense of health and vigor. Their appetite and sleep become more normal, their thinking becomes clearer, and their craving for alcohol /drugs diminishes. Because mood regulation can remain labile for weeks and cognitive functioning may improve for months, many researchers have conceptualized a post-acute withdrawal syndrome.1' These neuropsychological deficits are well served by plenty of repetition and structure in these programs. Staff encourage 12-step involvement during the program and afterward as a way to continue external support, prevent relapses, and provide self-care skills during this vulnerable period of recovery. Patients are introduced to members who come to 12-step meetings, are taken to various community meetings, and are encouraged to find a sponsor who will act as a personal support.
The group setting is well suited for interventions that tackle the problems of denial, low motivation, and distorted cognitive set. Denial loosens its grip as people in the group are rewarded for their openness. The isolation of addiction begins to melt and defensive barriers shrink. Acceptance and understanding soothe the pains of guilt and shame. In this kind of atmosphere, confrontations can be most effective because the alcohol/ drug addicts know that the coniron tcrs, i.e., group members, are not sitting in judgment, but understand from their own experience.
As the stories unravel within the group, educational material - the chronic effects of alcohol and drugs, the impact on family as well as the individual, the progression of the illness - is presented, discussed, and debated. When the cognitive set changes and denial lessens, the level of motivation increases. Some group members feel a tremendous burden has been lifted by the opportunity to tell their story "in public." Others may see the benefits and tell their stories individually to a therapist, where the same process occurs. The 12 steps are most frequently used to guide the process toward a longterm recovery. l* These steps enumerate a particular sequence in the process and focus the initia] work in therapy toward a commitment to abstinence. This focus is different from that of traditional psychodynamic psychotherapy, which analyzes conflicts, interprets unconscious fantasies, and facilitates the growth of" developmental deficits. These efforts are not inappropriate. Quite the contrary, alcoholics and drug addicts have their share of conflicts, fantasies, and deficits; however, they can be improved only after recuperating physically and neurologica Uy from the chronic effects of alcohol and drugs.
It is not surprising, then, that the first step in AA is: "We admitted we were powerless over alcohol, that our lives had become unmanageable."1* Alcohol/drug addicts cannot commit themselves to abstinence until they are convinced that atcohol/drugs make them sick.
Surrender and Changing Behaviors
Surrender is an AA term that describes eloquently the psychological change that occurs when addicts give up trying to continue using alcohol or drugs.19 In surrender, they accept the idea that life is out of control. Before such a moment of surrender, they have been engaged in struggles to gain control of their alcohol/drug use, as well as their life. They frequently feel as if they arc in a war to defend themselves from the dangerous world- In surrendering, in losing this personal wa r, they gi ve Lip fighting and accept that they are out of control. In such a moment of surrender a paradox is resolved because, in defeat, they gain all the power they need to grow healthy and emerge victorious.
AA emerges as a guiding support, replete with caring, wisdom, and understanding. The psychiatrist can offer empathy, guidance, and wisdom in a similar fashion, either in conjunction with AA/NA (Narcotics Anonymous), or alone, for those alcohol/drug addicts who refuse to attend 12-step programs.
The content of group and individual counseling runs the gamut from day to day, even while the focus is always recovery-oriented. It can be confrontative if the patients are in denial, inspiring if they feel demoralized and hopeless, and supportive if they are laden with guilt and shame. Since the family is in crisis too, family therapy is usually conducted by a social worker who educates the family members about alcohol/drug addiction, as well as its impact on the family. The combination of group, individual, and family counseling encourages the patients to explore issues and expand their awareness.
The last weekend of the rehabilitation program is often used for a therapeutic pass, to begin the reentry process and to gain insight into the impact of environmental cues on the patients. In the shelter of the residential program, there are few cues that trigger a desire for alcohol/drugs; however, once at home or back on the street, there may be powerful conditioned responses that cause craving for the drug of choice.211 The patient's experience while on pass is used to make adjustments in postdischarge treatment plans. Surreptitious alcohol/ drug use on pass is picked up with drug screening and used to confront the patient's lack of honesty and commitment.
Postdischarge patients are encouraged to attend a support group for program alumni, frequently called aftercare.21 For out-of-town patients, there are usually local arrangements made at home. Aftercare is not psychotherapy and is not identical to treatment in outpatient alcohol/drug addiction clinics. Rather, it is more a continuation of the i n patient rehabilitation program and focuses on the problems of reentry into the community, consolidation of recent gains, and the maintenance of abstinence. Aftercare has been shown to be particularly effective for men.2
Recovery and Spirituality
Recovery is a specialized term that involves abstinence, psychological growth, a healthy lifestyle, and a change in one's spiritual view of the world.22 While abstinence from psychoactive drugs and alcohol is a prerequisite, it is not sufficient to bring about recovery. Psychological growth is also necessary to move beyond the developmental arrests that typically occur as a result of chronic and heavy alcohol/drug use.
Many dependent people also have developmental arrests from their childhood, which preceded the alcohol/drug use. The deficits in self-care and self-soothing leave the patient vulnerable to impulsive and quick solutions to life's difficult problems. Learning how to take care of oneself, learning how to settle down when upset, and learning the self-discipline to deal effectively with life's vicissitudes become important aspects of recovery.'1
Spirituality has to do with the view of one's self as it relates to the cosmos and humanity.22 This includes how we relate to other human beings and how we see ourselves within society as a whole. The alcohol/drug-dependent person is frequently very focused on his drug-taking. What becomes important to that person is to keep the supply lines open and the interferences at a minimum. Family and friends are used to legitimize such a lifestyle and to cover the social deficits created by frequent intoxication.
During the process of surrender, the alcohol/drug-dependent individual admits that his efforts have been misguided and ineffectual. Such a realization is frequently overwhelming, leaving the person momentarily frantic and helpless. Turning it over to God and trusting that He will take care of things is an important transition encouraged by AA, which counteracts this overwhelming sense of being out of control.18 AA is careful not to make God a religious entity but to leave it up to the individual to define what this Higher Power shall be. Such a I Iigher Power can usher in a new humility and view of the world that facilitates growth and recovery. A healthy new lifestyle can now develop that maintains a new orientation toward the world. These are the fruits of recovery.
Treating alcohol/drug dependence is a very complicated process. Psychiatry must now conceptualize it as a biopsychosocioculrural disease, necessitating interventions for all aspects of the illness. Psychiatrists must organize their own thinking before they can intervene with these illnesses. They must look into their own attitudes and stereotypes about the patients they will treat. They must understand what strategies and interventions they can use to engage and retain the patients successfully.
Once the alcohol/drug-dependent patients are engaged in treatment, the psychiatrist must understand how to reorganize or rehabilitate the immediate family, as well as the dependent patient. In the alcohol/drug-dependent family, the system and the patient are so integrally connected that one cannot be treated without changing the other. This usually necessitates a combination of individual, family, and group therapy.
When the patients are committed Io abstinence, a variety of gains occur just by virtue of remaining abstinent. As they become confident that they ca n live wi thou t alcohol or drugs, the patients see the limitations of their personal styles. Such a recognition brings about a shift in the focus of therapy. Initially, therapy focuses on the need to remain abstinent and the skills to do it. Later, treatment can focus on living a joyful and productive life while sober. The role of the psychiatrist is to facilitate the unfolding of this new, vigorous self as the recovering individual faces internal and external obstacles along the path of recovery.
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