What is the role of psychotherapy in realising and sustaining recovery from addiction?

What is the role of psychotherapy in realising and sustaining recovery from addiction? By Guinever Robinson

Addiction is a chronic and debilitating disorder which is characterised by a compulsive need to partake in, and continue to partake in, some behaviour even when the behaviour becomes detrimental to the self. The category of addiction is broad and incorporates both substance-related addictions, such as alcohol dependence and drug abuse, and activity-related addictions, including pathological gambling as well as problematic obsessions with shopping, eating, and even the internet. Regardless of the type of addiction there are several factors involved in the etiopathogenesis of addiction and these factors can be categorised as biological, psychological and social.

The term psychotherapy is also broad and encompasses a variety of sub-types including psychodynamic therapy, cognitive-behavioural therapy, person-centred therapy, and, more recently, mindfulness-based therapy. In the treatment of addiction, therapy is often used as an adjunct to the main form of treatment which may follow either a total abstinence model of treatment or the harm reduction model of treatment. Regardless of the type of therapy, or the model followed, psychotherapy can help address both the psychological and social aspects which may both be fuelling dependence and inhibiting recovery.

The psychotherapies used in the treatment of addiction disorders include the traditional psychotherapies, originally designed to tackle other psychiatric conditions, such as cognitive behavioural therapy (CBT), supportive-expressive therapy (SET), and interpersonal therapy (IPT), as well as those developed specifically to tackle addictive behaviours and processes, such as motivational interviewing (MI) (Woody, 2003). MI, which emphasises moving individuals towards recovery at their own pace, emerged as a response to the difficulties practitioners faced in treating ambivalent clients who were not ready or willing to give up their use of substances, which excluded them from partaking in many of the services which demand complete abstinence (Parks et al., 2004; Woody, 2003).

In terms of efficacy, evidence suggests that these psychotherapies, either used alone or in conjunction with another therapy or treatment method, can help addicts to overcome their addiction. For example, in a study investigating treatments for alcohol addiction, two behavioural-based therapies were compared against the standard form of out-patient care consisting of regular contact with a staff member at a clinic and self-help groups (Burtscheidt et al., 2002). In terms of total abstinence at 12-month follow-up both behavioural-based therapies proved significantly more effective than standard care amongst all those who remained in treatment, many more also improved their levels of drinking even if they had not reached complete abstinence. This same trend was maintained at 30-month follow-up. Unfortunately, this study suffered high drop-out amongst an already small sample size possibly biasing the results. In a larger sample of regular amphetamine users, Baker et al. (2005) found that CBT combined with a self-help book, as compared to a control group who were given a self-help book alone, brought about a significant reduction in amphetamine use with more CBT sessions relating to greater reductions in use. They also found reductions in the use of other drugs, in drug-related harm, and in levels of psychiatric distress, although the validity of comparing an active therapy treatment against the use of a self-help book, which lacks many of the features shown to make therapy effective, can be questioned. When compared against active treatments CBT still appears to be the most effective method in treating methamphetamine addicts (Lee & Rawson, 2008).

Other studies have demonstrated that even very brief psychotherapeutic interventions can have long term effects. To illustrate, a 1.5-day intervention targeting smoking, which consisted of psychoeducation and cognitive training, produced both higher levels of, and longer term, abstinence rates than a control group who were administered a bupropion-only treatment (Zernig et al., 2008). Further, Babor (2004) found that, in a sample of chronic marijuana users, a brief 2-session treatment of motivational enhancement therapy was effective at reducing use as compared to a delayed treatment control. However, brief sessions appear not to be as useful in more severe forms of substance addiction. For example, adolescents provided with a single session of MI reduced smoking, alcohol and marijuana use but there was little notable change in use of stimulants or other illicit drugs (McCambridge & Strang, 2004).

When it comes to more severe substance addiction, it is common to compare treatment as usual (TAU), which is often drug replacement therapy where the addiction has been to heroin, with TAU plus psychotherapy. This is a practical consideration as drug replacement therapy can alleviate withdrawal symptoms which may complicate psychotherapeutic work (Carroll, 1997; Greenfield & Hennessy, 2011). It is also more appropriate for those not yet ready to commit to abstinence, but for whom a reduction in drug-related harm would be beneficial (Uchtenhagen, 2013). Clinically, it is important to know whether psychotherapy has any added benefit over and above the use of medical-based treatments alone. A study by Pan et al. (2015), which compared the proportion of opiate-free urine tests of 120 opiate-addicts undergoing methadone maintenance treatment (MMT) combined with weekly CBT sessions against 120 participants who simply underwent MMT, found that the former group had more opiate-free tests at 12 and 26 weeks and this difference was statistically significant. Further, CBT brought about improvements in psychological distress which may mediate outcome. This is a common finding amongst similar studies (Hayes et al., 2004; Montoya et al., 2005; Scherbaum et al., 2005) and in a large-scale systematic review (Dugosh et al., 2016).

In some cases, TAU is a self-help group like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). In a study which aimed to test the efficacy of psychotherapy to prevent relapse, a cognitive-behavioural relapse prevention (CBRP) intervention and a mindfulness-based intervention (MBRP) were compared against a standard 12-step after care program in patients who had completed a 28-day residential programme (Bowen et al., 2014). Both the CBRP and MBRP intervention had more maintained abstinence from drug use and more reduced days of heavy drinking. In those who had relapsed, both interventions were able to produce longer duration before relapse and fewer days of use upon relapse. In contrast, the 12-step aftercare program suffered a high percentage of drop-out.

It is likely that the specific role psychotherapy plays, the mechanisms underlying its effectiveness, are complex and multifaceted. In many cases, no one sub-type of psychotherapy appears to be largely more effective than another (Dennis et al., 2004; Imel et al., 2008). This means that teasing apart any therapy-specific mechanisms can be difficult. However, as has been seen, psychotherapy is useful. In fact, one meta-analysis found that, compared to controls, those who receive some form of psychotherapeutic intervention are more than twice as likely to achieve abstinence (Dutra et al., 2008). Thus, despite differences in theory and, somewhat, in practice, each therapy modality will have commonalities in the issues they address. Issues which are unlikely to be tackled via pharmacotherapy or detox methods alone.

Psychotherapy confronts the psychosocial problems which make susceptibility to problem behaviour more likely and cause difficulty when trying to overcome the addiction.

The psychosocial difficulties linked to the development and maintenance of addiction include shyness and social deficits (Santesso et al., 2004), low self-esteem (Alavi, 2011; Riquelme et al., 2018), lack of emotion regulation and self-management skills (Lowe et al., 2013; Zareban et al., 2017), interpersonal conflict (Schiff et al., 2014; Unger et al., 2003), and a tendency towards behavioural misconduct, a transient, unstructured lifestyle, and lack of accomplishment (Arteaga et al., 2010; Gau et al., 2007; Hawkins et al., 1992). Of course, none of these factors work in isolation. For example, low self-esteem and low social competence or academic achievement may work together to create a greater susceptibility to substance-use. Such a finding was elucidated in a study conducted by Wu and colleagues (2014), where, in a sample of male Chinese adolescents, a relationship between self-esteem and academic competence, and prevalence of drug use was discovered. In females, drug use was associated with relationships between body-image, self-esteem and social competence. In other studies, a greater risk of substance abuse is associated with the presence of a greater number of adverse social and psychological factors (Turner & Lloyd, 2003). Similarly, when more negative social and psychological factors are present the number of substances used, and the severity of addiction is increased (Day et al., 2015; Poudel et al., 2016).

Although most psychotherapies deal with psychosocial issues, different psychotherapies vary in the type of problem and the methods used. For example, CBT, founded as it is in cognitive and behavioural principles, is more appropriate at tackling thought processes, conditioned behavioural responses, and the coping abilities of clients. Increases in coping skills following CBT have been related to significant reductions in gambling behaviour in a sample of pathological gamblers both at post-treatment and follow-up (Petry et al., 2007). Similarly, in a randomised controlled trial (RCT) conducted by Kiluk et al. (2010), a significant increase in coping skills gained through computerised CBT were found amongst a sample of substance abusing individuals. Furthermore, the quality of the coping skills gained were found to be a significant mediator of abstinence at follow-up.One functional imaging study found increased neural activity in brain regions associated with ‘cognitive control’ following CBT for substance abusers (DeVito et al., 2012). Unfortunately, this finding was not related to abstinence or decreases in substance use though it is likely to have implications for coping with cravings and self-monitoring and thus, long-term recovery (DeVito et al., 2017). In other studies, increases in self-esteem following psychotherapy have been related to greater positive outcomes (Hartzler et al., 2011; Hyde et al., 2008; LaChance et al., 2009; Litt et al., 2005).

In a longitudinal study conducted by Vaillant (1988) primary psychosocial predictors of long-term recovery were largely interpersonal (See also Laudet et al., 2002; Margolis et al., 2000). Consistent with this, in those suffering high marital and family conflict and lacking constructive social bonds far worse outcomes are reported (Leach & Kranzler, 2013; Mathew et al., 2018). Interpersonal and family therapies are two therapies specifically designed to tackle problems like the above. Proponents of interpersonal therapy (IPT) posit that there is a two-way relationship between a client’s interpersonal functioning and their psychological wellbeing (Weissman et al., 2000). Through different techniques ITP teaches clients how to identify potential conflicts, how to resolve conflicts when they arise, and to improve communication skills and their ability to trust others (Robertson et al., 2008). Through such an intervention addicts can improve their social connections with supportive others. In a study by Gamble et al. (2013) ITP was well received as an adjunct to primary treatment in alcohol-abusing women who stated the treatment helped them identify connections between their relationships and their symptoms. In addition, completion of IPT saw significant reductions in drinking behaviour. However, ITP does not involve the participation of significant others in the therapy process. Family therapy on the other hand specifically targets dysfunctional processes occurring between the client and their family (Liddle, 2013). Family therapy works by fostering communication, improving family practices and increasing understanding of the problems and needs of each family member (Liddle, 2016; Liu et al., 2015) Family therapy has even been shown to foster changes at the neural level. Using a sample of online-gaming addicted individuals from dysfunctional families, Han et al. (2012) observed an increase in brain activity in response to parental affection and this increase was related to decreased addiction severity.

Improving interpersonal functioning is likely to improve an individual’s ability to partake in interpersonal activities such as self-help groups and employment which both provide the individual with opportunities to increase social support, but also provide the addict with new sources of reinforcement, responsibility and structure (Moos, 2006). This may make IPT and family-based therapies particularly useful at post-treatment. CBT on the other hand may be more effective during treatment to help tackle cravings, negative emotions, and conditioned responses, though through skills training CBT is likely to impact on relationships, and through building interpersonal functioning individuals are likely to develop cognitive and emotional coping skills. Some evidence suggests combining the methods for the best results (Barrowclough et al., 2001).

Psychotherapy improves rates of retention in, and adherence to, TAU, allowing TAU to work more effectively.

Research suggests that a minimum of three months in treatment is required for any positive changes to occur (Proctor & Herschman, 2014). Further, the longer treatment continues the better the outcome (Conners et al., 2006; Zhang et al., 2003). Unfortunately, treatment drop-out and lack of treatment compliance is a commonly cited issue associated with worse outcomes throughout the addiction literature (Brorson et al., 2013). One study noted that 33.4% of those referred to an outpatient treatment facility for substance abuse did not follow up, of those who did follow up over 20% did not attend their first session and amongst those who attended their first session over 47% abandoned the treatment over the next 12 months (Roncero et al., 2012). Other studies have found that, in the initial stages of treatment, up to 60 percent of individuals fail to return for subsequent sessions (Basu et al., 2017; King & Canada, 2004). These rates can vary depending on treatment method and addiction type. For example, higher drop-out is seen in detoxification programs versus maintenance medication programs (Hoseinie et al., 2017), and amongst those taking heroin or cocaine (Evans et al., 2009). Problems with compliance are just as severe with barely half of patients remaining drug free both at the beginning and end of treatment, 30 percent failing to adhere to medication at the end of treatment and between 10 and 20 percent failing to comply at any stage (Blum et al., 2014).

Predictors of early treatment termination are complex and often inconsistent (Brocato & Wagner, 2008; Claus & Kindleberger, 2011). Using a person-orientated approach studies have found that patients’ reasons for ending treatment mainly involve lack of social support, lack of connection with treatment staff, and lack of motivation (Ball et al., 2006; Palmer et al., 2009). In one qualitative study, 15 in-patient drop-outs were asked what would motivate them to stay in treatment. They stressed the need for staff to be more supportive, for treatment with an emphasis on coping with negative emotions, and for more opportunities to partake in constructive activities (Nordheim et al., 2018).

Given these findings the benefits of structured contact with a psychotherapist are clear. First, regular sessions in psychotherapy gives patients the opportunity to build a relationship with a caring other. This relationship, called the therapeutic alliance, is a ‘non-specific’ component of therapy with considerable power over outcomes both generally (Ardito & Rabellino, 2011) and in cases of addiction (Barber et al., 2006; urbanoski et al., 2012). In terms of retention, studies have demonstrated that a strong alliance created early in therapy can significantly improve drop-out rates (De Weert-Van Oene et al., 2001; Meier et al., 2006). Despite this, results are mixed, especially when using client-rated measures of alliance (Meier et al., 2005). However, inconsistent results could be due to the influence of other variables. For example, in patients with severe psychiatric co-morbidity the therapeutic alliance was found to have a much stronger effect on retention rates than amongst patients with low symptom severity (Petry & Bickel, 1999). Similarly, in a study investigating the effects of both client motivation and therapeutic alliance it was found that for those entering therapy with high motivation a good therapeutic alliance had only a small effect on outcomes, but for those with low motivation a strong therapeutic alliance was related to significantly better outcomes (Ilgen et al., 2006). Nevertheless, more research is needed, especially as many studies exclude those with the most severe symptoms from participation (Sellman, 2009).

Concerning motivation to change, thanks to an upsurge in research indicating that client-related variables, as opposed to demographic or addiction-related variables, were more consistent predictors of outcomes there is now a plethora of research investigating client motivation and its effects (Groshkova, 2010). A lot of this research makes use of the stages of change model which argues that there are several stages of change and that, depending on what stage a client is at, different approaches are needed to move the client towards recovery (Prochaska and Diclemente, 1983). In general, the model provides a means of measuring motivation in terms of ‘readiness for change’, a concept which has been useful for predicting outcomes (Collins et al., 2012; Myers et al., 2016). Motivational interviewing is a specific therapy designed to tackle client motivation, which has been found to be effective in moving clients towards recovery (Burke et al., 2003; Lundahl et al., 2010). Compared to controls, MI also significantly improved retention (Carroll et al., 2006; Secades-Villa et al., 2009). However, non-specific factors found amongst all therapies have been related to changes in motivation. For example, the therapeutic alliance was significantly related to changes in motivation brought about by treatment (Brocato & Wagner, 2008).

Psychotherapy treats psychiatric disorders co-occurring with the addiction disorder.

Many clinical and epidemiological studies conducted in the past 20 years have demonstrated that the co-occurrence of many other psychiatric conditions is a common phenomenon amongst addicted individuals (European Monitoring Centre for Drugs and Drug Addiction, 2013). in some studies, between 70 to 90 percent of those presenting for treatment were identified as having another current psychiatric disorder (Adamson et al., 2006; Kumar et al., 2010; Weaver et al., 2003). The most common co-morbid psychiatric disorders include mood disorders, anxiety disorders and post-traumatic stress disorder (PTSD). Due to the high prevalence of co-morbidity many have argued that addiction is the result of individuals self-medicating psychological pain (Blume et al., 2000; Khantzian, 1997). Regardless of whether psychiatric illness preceded the addiction severe psychiatric symptoms are a significant contributor to poor prognosis (Morisano et al., 2017; Tomlinson et al., 2004).

As has been mentioned previously, many of the psychotherapies used to treat addiction are those adapted from therapies originally intended to treat psychiatric symptoms. In this domain their efficacy is well documented (Cuijipers et al., 2013; Driessen & Hollon, 2010). For example, CBT is one of the best methods for treating depression (Mohr et al., 2001; Weersing & Weiz, 2002). When combined with pharmacotherapy its efficacy is unparalleled (March et al., 2007; Vitiello, 2009). Studies looking at integrated treatments for tackling substance-abuse comorbid with depression, and other mental illnesses, have found psychotherapies effectively reduce both psychiatric symptoms and substance-use (Kelly & Daley, 2013). Unfortunately, there are few studies looking directly at the relationship between psychiatric symptom reduction and addiction-related outcomes.

Psychotherapy for addiction is likely useful in more ways than just described here. For example, many have argued that addiction treatment should not be so simply concerned with abstinence but also with harm reduction (Tatarsky, 2003). With a harm reduction model any change, including but not limited to abstinence, is positive. Thus, the drug addict who learns to moderate his drug use, turns to safer forms of drugs or methods of administering his drugs, or simply learns to acknowledge that his drug use may be harmful has gained from participating in treatment. Based on the same principles already mentioned, such as building coping skills or developing motivation, psychotherapy is likely the best method for harm-reduction. Especially with many established substance-use treatment facilities, such as Alcoholics Anonymous or in-patient detoxing programs, demanding abstinence.

In sum, psychotherapy for addiction is an effective method for treating addiction and it is effective for many reasons. The role it plays involves helping move addicts towards readiness for change, tackling psychosocial barriers to change, and in reducing psychiatric symptoms which may precede addiction and causes significantly worse prognosis. Although building social support, gaining employment, or simply gaining insight into one’s addiction is not the primary aim of many standard treatment methods for addiction, which focus primarily on producing abstinence, they are all important factors in maintaining recovery which are tackled in psychotherapy. Therefore, the role psychotherapy plays in realising and sustaining recovery is an important one. Although more research is needed in some areas in order to truly elucidate its efficacy.

 

An essay by:

Guinever Robinson

Undergraduate

The University of Chester

 

 Congratulations, Guinever Robinson -WINNER OF THE 2018/19 Castle Craig ESSAY COMPETITION

 

 

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