All from Review Article JIACAM Vol. 1, No. 1, Article 2 Psychosocial Treatment of Substance Use Disorders in Adolescents by Anil Malhotra, Debasish Basu, Nitin Gupta
General measures of intervention: 3 major strategies are used in current relapse prevention and intervention programmes: 1) Social support approaches. These focus on the patient's need for emotional support from family members and friends. Support from family, friends and other recovering addicts can play a vital role in relapse prevention and intervention. 2) Lifestyle change approaches. These focus on helping patients develop and sustain new social identities as drug-free individuals, including breaking ties with drug users, developing new interests, pleasures and social contacts. 3) Cognitive-behavioral approaches. These emphasize identifying internal and external cues associated with craving, and then learning how to avoid them, or, if they do occur, to prevent them from turning into a full-blown relapse. The common and popular approaches are- cognitive behavior therapy (CBT), behavioural self- control training (BSCT), motivation enhancement therapy (MET), coping skills training, and cue exposure (CST & CE). CBT generally tends to incorporate many interventions in its fold and is effective. BSCT focuses on controlled drinking and has been found to be effective. MET has recently become a very popular mode of treatment that involves a less directive, non-confrontational approach wherein the aim is to make the patient understand the negative effects of alcohol/drugs with feedback about various options for change. It has been found to be as an effective adjunct to the more extensive psychosocial treatment package. CST & CE involve persons being able to identify internal/external factors that can trigger a lapse/relapse and ways of countering them effectively. Jointly they have been found to be efficacious, especially for alcohol abuse.
"High-risk" situations or factors preceding relapse include: 1) Stress. Whether due to discrete negative life events or everyday hassles, stress greatly increases vulnerability to relapse. 2) Negative emotions. A wide range of `negative' emotional states can precipitate relapse. These include anger, anxiety, depression, frustration, or even boredom. 3) Positive emotions. Good feelings that come from socializing can sometimes trigger relapse. In other cases, drug use might be used as a reward or a means of celebration. 4) Interpersonal conflict. Relapse is often associated with conflict with family members and other individuals. This may particularly manifest as lack of trust by family members despite the patient being drug free for a period of time. The resultant anger or frustration may act as a strong precipitant for relapse. 5) Social pressure. Sometimes social pressure is overt, as and when someone offers the addict a drug. Often it is more indirect. Being enmeshed in a social network in which other people abuse drugs is especially risky. 6) Use of other substances. Use of any one intoxicant drug can trigger cravings for the primary drug of abuse or undermine self-control. 7) Presence of drug-related cues. Environmental cues (e.g., drug paraphernalia) elicit strong craving in some people who are trying to maintain abstinence, and may even cause a `conditioned' withdrawal syndrome.
Non-pharmacological interventions for effective and global management of drug abuse.Other than short-term goal of strengthening pharmacological efficacy, psychosocial treatment serves the even more important long-term goal of abstinence maintenance. Long-term abstinence also necessarily implies, ultimately, a change of life style and adoption of a more productive life style.Therapist mediated: These can be of two types: 1) Brief Interventions (BIs) and 2) Extended Interventions (EIs). BIs are characterized by involving 1-4 sessions. They improve staff efficiency and are generally cost effective. The main characteristics of BI are: keeping the goal of reduced or non-problem alcohol/drug use as opposed to abstinence; generally delivered by a nonspecialist; generally directed at non-dependent rather than dependent individuals; addressing the person’s motivation to change habits; being self-directed; and having certain key components/ingredients (feedback of risk involved, encouraging responsibility for change, advice, alternative options, enhancing self-efficacy). BIs have demonstrated a 20-30% reduction in excessive drinking of alcohol. EIs are characterized by involving 5-12 sessions, which are carried out either in a group or alone. The type of intervention delivered depends upon the aims of the treatment, and can be-relapse prevention programs, cognitive behavior therapy, behavioral interventions, social skill training, supportive-expressive psychotherapy etc. Varied types of EIs have been found to have similar benefits- results being similar across both inpatients and outpatients. However, it has been seen that it is necessary to address problems with psychiatric illness and lifestyle concurrent with drug/alcohol abuse.
Non-therapist mediated: These are essentially Self-Help Groups (SHGs); the commonest and popular ones being-Alcoholic Anonymous (AA), Narcotic Anonymous (NA), Cocaine Anonymous etc. The SHG is a group of individuals with similar problems who meet voluntarily to help each other to help themselves. The common theme of all SHGs is of mutual aid- of individuals helping each other by offering friendship and sharing common experiences.
1) Individual psychotherapy and group psychotherapy: In this, the common issues and strategies include- setting the resolve to stop, teaching coping skills, changing reinforcement contingencies, fostering management of painful affects, improving interpersonal functioning and enhancing social support. The treatment goals are- establishing abstinence, establishing stable functioning, preventing relapse, addressing psychological issues, and managing care considerations. 2) Family (marital for some) therapies: In this, one has to define the problem, and it involves negotiating the contact, establishing the context for a drug free life, ceasing substance abuse, managing the crisis and stabilizing the family, and family reorganization and recovery. 3) Relapse Prevention: This involves specific techniques of - exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and identifying high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. The central element involves anticipating the problems patients are likely to meet and helping them develop effective coping strategies. 4) Supportive-Expressive Psychotherapy: This has two main components i.e. supportive techniques to help patients feel comfortable in discussing their personal experiences, and expressive techniques to help patients identify and work through interpersonal relationship issues. 5) Individualized Drug Counselling: This focuses directly on reducing or stopping the addict’s illicit drug use. It also covers other related areas of impaired functioning like employment status, illegal activity, family / social relations, and content and structure of the patient’s recovery program. Through its emphasis on short-term behavioral goals, it also helps the patient to develop coping strategies, tools for abstaining from drug use, and maintaining abstinence. 6) Motivation Enhancement Therapy: This approach employs strategies to evoke rapid and internally motivated change in the client. The first treatment session focuses on providing feedback generated from the initial assessment battery to stimulate discussion regarding personal substance use and to elicit self-motivational statements. In subsequent sessions the therapist monitors change, reviews cessation strategies being used, continues to encourage commitment to change or sustained abstinence, and sometimes encourages the clients to bring a significant other to the sessions. 7) Behavioral Therapy for Adolescents: Therapeutic activities include fulfilling specific assignments, rehearsing desired behaviors, recording and reviewing progress, with praise and privileges given for meeting assigned goals. Urine samples are collected regularly to monitor drug use. The therapy aims to equip the patient to gain three types of control viz. stimulus control, urge control, social control. 8) Multidimensional Family Therapy (MDFT) for Adolescents: This is an outpatient family-based drug abuse treatment for teenagers. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations. During individual sessions, the therapist and adolescent work on important developmental tasks like developing decision-making, negotiation, and problem-solving skills. Parallel sessions are held with family members. Parents examine their own particular parenting style, and learning to distinguish influence from control, and to have a positive and developmentally appropriate influence on their child. 9) MultisystemicTherapy (MST): This addresses factors associated with serious antisocial behavior in children and adolescents who abuse drugs. These factors focus on the characteristics of the adolescent (favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighbourhood (criminal subculture). 10) Combined Behavioral and Nicotine Replacement Therapy: This has two main components. First, the transdermal nicotine patch or nicotine gum, which reduces symptoms of withdrawal, producing better initial abstinence; and second, the behavioral component, which concurrently provides support and reinforcement of coping skills. yielding better long-term outcomes. The patients practice skills in treatment, social, and work settings. They learn other coping techniques like cigarette refusal skills, assertiveness, and time management. 11) Community Reinforcement Approach (CRA) Plus Vouchers: This involves an intensive 24-week outpatient therapy. The treatment goals are two-fold i.e. to achieve abstinence long enough for patients to learn new life skills that will help sustain abstinence, and to reduce alcohol consumption for patients whose drinking is associated with drug use. Patients attend one or two individual counselling sessions per week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counselling, and developing new recreational activities and social networks. 12) Day Treatment With Abstinence Contingencies and Vouchers: For the first 2 months, participants must spend 5.5 hours daily in the program, which provides lunch and transportation to and from shelters. Interventions include individual assessment and goal setting, individual and group counselling, multiple psycho-educational groups, and patient-governed community meetings. Individual counselling occurs once a week, and group therapy sessions are held three times a week. After 2 months of day treatment and at least 2 weeks of abstinence, participants graduate to a 4-month work component that pays wages that can be used to rent inexpensive, drug-free housing. A voucher system also rewards drug-free related social and recreational activities. 13) The Matrix Model: This provides a framework for engaging stimulant abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use by urine testing. The program includes education for family members affected by the addiction. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behaviour change. The interaction between the therapist and the patient is realistic and direct, but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention. 14) Treatment materials draw heavily on other tested treatment approaches. This approach includes elements pertaining to the areas of relapse prevention, family and group therapies, drug education, and self-help participation.