Psychotherapy for the Treatment of Substance AbuseRichard Balon, MD
Wayne State University, Detroit, MI, USA
Edited by Marc Galanter and Herbert D. Kleber. Arlington, VA: American Psychiatric Publishing, Inc.; 2011; ISBN: 978-1-585-623907; pp 427; $67 (paperback; with a DVD).
Psychotherapy and behavioral approaches are the most common and, in many cases of substance abuse (eg, in persons using sedatives or stimulants), the only effective treatment modalities. Nevertheless, I would guess that when asked what psychotherapies are used for substance abuse, most psychiatrists not specialized in addictions would reply “Alcoholics Anonymous (AA) and motivational enhancement.” Maybe some would add “individual psychotherapy and some cognitive-behavioral therapy,” without knowing much more as to which, when, and how to use these therapies. Yet, there is a large body of literature available on various psychotherapies and behavioral approaches to substance abuse. Many of us (including myself) would probably try to excuse ourselves, pointing out that the body of literature is too large to get through and to make sense out of it.
Well, no more.
Two experts in the field of substance abuse, Drs. Marc Galanter and Herbert D. Kleber, put together a practical volume summarizing the knowledge and practical aspects of using psychotherapies and behavioral approaches for substance abuse. They adapted the contents of this book from another book of theirs, The American Psychiatric Publishing Textbook of Substance Abuse Treatment, now in its fourth edition.
The new book consists of 14 chapters (written by 29 authors) and is accompanied by a DVD on Network Therapy. The first chapter, “Assessment of the patient,” is a standard, detailed fare on assessing the patient with goals to 1) identify the presence of substance abuse; 2) make an accurate diagnosis; 3) formulate and help initiate appropriate interventions and treatment; and 4) enhance the patient’s motivation for change (p 2). A useful part of this chapter reviews numerous medical problems associated with specific substances—alcohol, cocaine, nicotine, opioids, sedatives, but not much on methamphetamine. A part of this chapter focuses on physical and mental status examinations and includes a discussion of various biological markers and common screening instruments and standardized interviews. The chapter also includes a case illustration, a list of key clinical concepts, and suggested reading. The following chapter, “Testing to identify recent drug use,” emphasizes that although the diagnosis of substance abuse is primarily clinical, laboratory testing to “identify recent drug use is increasingly important in clinical settings” (p 53). Drug testing is particularly useful in diagnosing and managing substance abuse because the 2 “hallmarks of addictive disorders are dishonesty about substance abuse and continued use despite problems caused by that use” (p 54). This chapter clearly explains the biology of drug tests—immunoassay screening tests using highly specific monoclonal antibodies; gas chromatography-mass spectrometry—and sample selection (the advantages and disadvantages of testing blood, urine, hair, oral fluid, sweat; eg, how hair testing could help distinguish between light, moderate, and heavy drug use during the preceding 90 days or more, making this testing especially useful as part of the evaluation for admission to addiction treatment [p 58]). The authors also discuss the advantages and disadvantages of on-site vs laboratory drug tests and how to deal with difficult results. They remind us that, “Drug tests detect recent drug use. They do not detect dependence, intoxication, impairment, or addiction” (p 75). A brief chapter on “Cross-cultural aspects of addiction therapy” is an interesting introduction into a cultural aspect of substance abuse that is not frequently considered. It includes discussions of several good clinical cases. The last part of this chapter focused on culture and recovery, reviews 3 potent instruments of recovery: significance of the family as the conduit of cultural norms and values; a major positive role of formal religious affiliation and practice; and the fact that “the spread of 12-step programs to various parts of the world is an example of the common values placed on spiritual growth as an ingredient of recovery” (p 93). Movements in other cultures may have significant differences from traditional 12-step programs— eg, may be aligned with professional treatment community (12-step program is independent), may include family participation, may not see anonymity as necessary, and the role of religion may be relative. Chapter 4, “Patient placement criteria,” advises the clinician how to choose the optimal treatment setting for an addicted patient. The text reviews the American Society of Addiction Medicine Placement Criteria which are the subject of several books.1,2 This concludes what I consider the first part of this book—the steps needed to take prior to any psychotherapeutic or behavioral intervention.
“Patient motivation is a necessary ingredient in substance abuse treatment and recovery” (p 125) and patients frequently refuse to acknowledge problems or seek treatment. Originally, the patient’s motivation for recovery and treatment was viewed mostly, if not completely, as the patient’s responsibility (p 125). More recently, “treatment providers are being asked to motivate and not to merely educate or medicate substance-abusing patients” (p 126). Chapter 5, “Motivational enhancement,” provides guidance and strategies for motivational enhancement in patients with various substance abuses. Chapter 6, “Intervention with the addicted person,” discusses “the goals of intervention with the addicted person, some general techniques in confronting and then intervening, and some specific intervention models such as Vernon Johnson’s seminal intervention [Johnson’s model promotes the idea that chemical dependency is a disease one cannot blame on the individual (p 156)], the Community Reinforcement and Family Training (CRAFT) paradigm, and the Pressure to Change protocol” (p 153).
The reviews of various psychotherapies and behavioral interventions finally start in chapter 7 on “Cognitive-behavioral therapies,” which “are among the well-defined and rigorously studied psychotherapeutic interventions for substance abuse disorders” (p 175). The next chapter, “Contingency management,” discusses treatments based on the principle of operant conditioning which have one central common feature: “the systematic application of reinforcing or punishing consequences to achieve therapeutic goals” (p 193). This chapter reviews the generic types of contingencies—positive reinforcement, negative reinforcement, positive punishment, and negative punishment—and strategies to consider when designing an effective contingency management intervention. It also includes a discussion of voucher-based reinforcement therapy and the Fishbowl Procedure. Chapter 9 describes the use of psychodynamic psychotherapy for substance abuse (are any practitioners still using it?).
Chapter 10, “Network therapy,” reviews a way of integrating many approaches previously discussed. “In network therapy, family members and/or close friends meet together with the therapist and patient at intervals parallel to the patient’s individual therapy” (p xix) (networks usually consist of 3 to 4 members). The authors delineate the principles of network treatment and advice on how to keep the network’s agenda focused. The accompanying DVD presents a discussion and case examples of network therapy with the book’s editor, Dr. Marc Galanter (segments of the DVD include: what is network therapy; starting a network; maintaining abstinence; caring for the network; and securing future behavior). Chapter 11 on group therapy points out that it is the “most commonly used psychosocial treatment for substance abuse and dependence, is the treatment of choice for many patients; is clinically effective and cost-effective” (p 277). The types of group treatments reviewed include self-help groups, interpersonal therapy groups, cognitive-behavioral therapy groups, modified dynamic therapy groups, relapse prevention groups, groups in therapeutic communities, groups for adolescent substance abusers, and the use of homogenous groups. The following chapter, “Twelve-step facilitation for co-occurring addiction and mental health disorders,” is a great review of a topic useful for practitioners dealing with dual diagnosis patients (these days, who doesn’t see them?). An interesting part of this chapter discusses the characteristics of the desired therapist.
Chapter 13 provides a solid overview of family therapy as an important component of treatment for alcoholism and drug abuse. Finally, the last chapter, “The history of Alcoholics Anonymous and the experience of patient,” is an interesting, yet misplaced piece of history of the AA movement. From an experiential point of view, one should watch the movie “My name is Bill W.” with James Woods, JoBeth Williams, and James Garner, also dealing with this piece of history. James Woods’ performance as Bill Wilson is very convincing, excellent!
This is a well-thought of and well-conceptualized volume that would be useful for anybody treating patients with substance abuse or co-occurring mental illness. There is a bit of overlap between the first and second chapter, but repetition is not harmful here. The accompanying DVD on network therapy is useful. As the otherwise solid text does not always provide detailed, concrete advice on how to conduct some therapies, it would be useful to expand the DVD in the next edition and include examples of all discussed therapies. Nevertheless, I would recommend this volume to anyone treating people with alcoholism and other forms of substance abuse and definitely to those teaching residents and fellows in addiction psychiatry/medicine.
- Mee-Lee D. ed. Patient placement criteria for the treatment of substance-related disorders. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc.; 2001.
- Fishman MJ, Shulman GR, Mee-Lee D. et al, eds. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
Annals of Clinical Psychiatry ©2012 Frontline Medical Communications.