COMPONENTS
OF SUCCESSFUL
TREATMENT
PROGRAMS
R. Jeffrey Goldsmith, M.D.
Engagement
and Retention
Extinguishing
Craving
Comprehensive
Approach
Skilled
Staff
Research findings suggest that physicians who understand the many interventions that have been shown to be effective in treating addictive disorders will have multiple opportunities to help patients with alcohol and other drug problems. Indeed, physicians play a crucial role in the identification and engagement of patients in addiction treatment, as well as in the management of denial and enhancement of motivation for treatment. Many addiction medicine specialists participate in the development of a comprehensive treatment plan, while others are in a position to supervise and coordinate the treatment team. Understanding the various components of treatment and their effectiveness, as well as how they should be grouped and sequenced, is essential.
Engagement and retention are among the more important factors in the
treatment process. Recent studies show that more treatment generally results in
better outcome (DeLeon, 1991). While this has surface validity, it is not clear
whether the finding reflects the actual influence of treatment or simply the
ability of good‑prognosis patients to stay in treatment, or both.
Further, studies with time limited residential programs have found that program
completion‑‑rather than just total number of sessions‑‑is
significantly related to outcome (Welte et al, 1981). This may reflect the
patient's capacity to commit to the treatment regimen.
Engaging a patient who is markedly ambivalent about giving up alcohol
or drugs requires working with issues of poor motivation and denial. Miller and
Rollnick (1991) have developed a technique of motivational interviewing that
strives to enhance motivation, while Goldsmith (1990) has developed a denial‑focused
psychotherapy that improves motivation by expanding self‑awareness. Both
strategies have been successful in working with ambivalent patients. The use of
coercion (such as court ordered treatment) also seems to enhance engagement
(Brandsma, 1980).
Because alcohol and drug addiction are chronic illnesses, treatment and
recovery are long‑term processes. Outpatient treatment beyond three
months (with or without inpatient treatment) is associated with greater
abstinence in a dose‑related fashion (Hoffmann & Miller, 1992). Valliant (1983) reports that psychological adjustments of abstinent
patients were similar to those of drinkers when the patients had less than
three years' abstinence. At 10 years' abstinence, however, the patients'
level of psychosocial adjustment was the same as for nondrinkers.
Continuity of care is another important element in the retention of
patients. Maintaining continuity between intake and counseling sessions has
been correlated with higher retention rates Nirenberg, Sobell & Sobell,
1980). Counselors who call patients and send them letters immediately on a
missed appointment increase their rates of patient retention (Koumans, Muller &
Miller, 1967).
Individualized treatment plans negotiated with patients also have been
associated with higher retention and improved outcomes (Adelman & Weiss,
1989). This is understandable in light of the multiple life problems that
addicted persons bring to treatment. Such crises may motivate the patient to
avoid the negative consequences of addiction, such as legal problems or family
break‑up, and offer an opportunity for therapeutic bonding. Management of
such a crisis can enhance a commitment to abstinence and strengthen the
alliance between the therapist and patient. Conversely, crisis also can
distract from an abstinence orientation and become a behavioral form of denial.
Other factors associated with improved engagement and retention include the treatment
of psychiatric comorbidity (Woody et al, 1991), the inclusion of family members
in the treatment process (McCrady, 1984), and the adoption of a culturally
sensitive approach (
Research at the Philadelphia Veterans Administration Hospital has
demonstrated that certain sub‑groups of addicts experience a marked
conditioned withdrawal response when viewing videotapes of people using or
buying drugs, or when shown drug paraphernalia (Childress et al, 1992). Such
conditioned responses can be extinguished through controlled exposure to triggering
events, or "cues," resulting in fewer relapses. Also, avoidance of
the environmental cues that stimulate craving ("stimulus avoidance")
can be effective. Indeed, this concept underlies Alcoholics Anonymous'
recommendation to avoid "people, places, and
things" connected to the drinking days. These principles, combined with
relapse prevention techniques, are critical elements of long‑term
recovery.
Continued refinement of the array of treatment components to meet the needs of specific patients appears to be critical. Elements whose utility are supported by recent research include individual, family and group therapy (including self‑help groups).
INDIVIDUAL THERAPY. Individual counseling with
alcoholics and addicts is helpful (Moos, Finney & Cronkite, 1990), as is
psychotherapy. Treatment of psychiatric co‑morbidity also is associated
with improved treatment outcomes (Woody et al, 1990), particularly where the co‑morbid
illness is depression. There is a consensus that psychotherapy with alcoholics
and addicts must begin with abstinence or a focus on abstinence (Kaufman &
Reoux, 1988; Khantzian, Halliday & McAuliffe, 1990; Zweben, 1986). Once
abstinence is secured, the focus can shift to include other pertinent issues.
FAMILY INTERVENTION. Research into family
dynamics with alcoholics and addicts have shown two patterns of family
functioning, both of which appear to be maladaptive or dysfunctional
(Steinglass et al, 1987). One pattern occurs while the alcoholic or addict is
engaged in alcohol or other drug use, while the other occurs during a period of
abstinence. Family therapy is important to correct these maladaptive patterns,
to catalyze growth, and to reduce the likelihood that family tension will
trigger a relapse. Studies in the 1950s (Gliedman et al, 1956) found that the
outcome was better for the alcoholic if the spouse was treated concurrently in
a separate group, followed by conjoint sessions. More recent studies have shown
that spousal participation not only improves the alcoholic's commitment to
abstinence, but also can diminish the rate of marital separation by focusing
conjoint sessions on the spousal relationship (McCrady, 1984, 1985). For all of
these reasons, family interventions are critical elements of comprehensive
treatment.
GROUP INTERVENTION. Many studies have found
that group therapy focusing on social skills, coping styles, education about
the addictions, interpersonal dynamics, and the treatment of self‑deficits
is useful in achieving and retaining recovery (Brandsma & Patterson, 1985;
Moos, Finney & Cronkite, 1990; Brown, 1985; Khantzian, Halliday &
McAuliffe, 1990). Such groups usually are part of a comprehensive program that
includes individual and family counseling. Their focus can vary to meet
individual needs: social skills, assertiveness training, and interpersonal
groups all address the interpersonal styles that are critical in maintaining
effective family, social, and economic functioning. Educational groups focus on
correcting popular myths about alcohol and drug addiction and suggesting useful
pathways to recovery. Psychotherapy and "feelings" groups encourage
the expression of affect, tension, frustration, fear, etc. They allow for the
projection of issues onto the group members and provide insight into and
resolution of conflicts through identification with the members' and the
group's capacity to solve problems. Expressive arts therapy groups (music, art,
psychodrama, etc.) offer alternative modes for the expression of issues
troubling, distracting, or holding back patients.
The dynamics of groups allow and even encourage interpersonal feedback,
which evokes issues of confrontation, understanding, compassion, trust, and
support. Group leaders can facilitate the healthy development of these issues
or interfere with their emergence, depending on their leadership skills. Group
composition also can be important to the group process: group therapy research
suggests that women do better in all‑female groups, while men do better
in coeducational groups (Aries, 1976). Reasons postulated for this difference
are that women seem to be inhibited in the presence of men, while men are more
open to talk about feelings with women present. Structuring groups to reflect
these differences can be a problem in the typical addiction treatment setting,
where men usually outnumber women by as much as10 to 1.
Participation in Twelve Step groups also improves recovery for most
patients. Recent CATOR studies have shown that people who were regular
participants in Alcoholics Anonymous (AA) had longer periods of sobriety than
those who did not attend (Hoffmann & Miller, 1992). What makes AA and other
Twelve Step groups so special is the spectrum of interventions that occur as
part of the Twelve Step recovery process (Chappel, 1992). These groups have the
capacity for intensive, structured involvement and an individualized program.
In populous parts of the country, Alcoholics Anonymous meetings occur at all
times of the day, seven days a week. This allows for continuity as well as intensity
("90 meetings in 90 days"). For the ambivalent patient, the meetings
offer understanding, acceptance, and education about the illness and the road
to recovery. In addition, hearing other people's stories becomes a subtle
confrontation, encouraging the listener to think about those issues and
situations that make him or her uneasy. The newly abstinent AA member often
needs support from and affiliation with non‑drinkers, including some help
with feelings of being "lost" without drugs or alcohol. Working the
Twelve Steps deepens introspection, accelerates recovery, and enhances the
individual's sense of competence, which has been eroded by the addictive
process (Goldsmith, 1993). It also sets into motion a process that puts the
addict in touch with his or her inner life, psychological pain and maladaptive
behaviors, which he or she can work on, and avoids blaming external forces that
cannot be controlled. It sets into motion "change" in a process of
acceptance, forgiveness, and making amends, which frees the person from the
mistakes and misconduct of the past, while it encourages a healthy
responsibility for those acts.
The spiritual side of the Twelve Steps offers a broader view of life
that opens up the psyche to the common experience of the human condition and
with it, the cleansing feelings of connectedness, appreciation, gratitude, and
serenity. When the change to a new spiritual orientation is sudden, it is
similar to a conversion experience, bringing with it a change in personality,
new energy, endurance, and inner harmony (James, 1958). When the change is
gradual, it resembles the "simple growth into new habits."
Research into the effects of the quality and type of therapist who
treats the addict provides another key to successful treatment outcome.
Research into psychotherapy has found considerable variation from one therapist
to the next, even when the treatment protocol is strictly followed. , Crits‑Christoph,
Beebe and Connolly (1990) developed a strategy to analyze studies for the
impact of the therapist on treatment outcomes. Some of their studies found
virtually no therapist effect, while others found that as much as 29 % of the
total variance could be attributed to differences in therapist styles.
What accounts for this variation? Graduate training is not the issue;
some of the studies that show considerable variance used professionally
trained, licensed therapists, such as psychologists and psychiatrists. Staff
codependency has been suggested as an explanation for sub optimal therapist
interventions (Imhof, 1990). This includes behaviors triggered from past
experiences in an alcoholic or drug addicted family, as well as behaviors
triggered by actions on the part of current patients. Health caregivers are
known to have negative attitudes about alcoholics and addicts when they begin
training (Bergen, Price & Kinney, 1980); for many, these attitudes become
more negative over the course of their education (Chappel & Schnoll, 1977).
One survey discovered that 13 % of therapist positions available had been
vacant, almost half of them for more than six months (Crits‑Christoph,
Beebe & Connolly, 1990).
Perhaps the most significant staff skill is the therapist's ability to
engage the patient to continue in treatment. To study this factor, McCaul and
Svikis (1991) focused on interventions that could be made with the counselors
in order to enhance retention of addicts in treatment. Simply, they established
a minimum participation level for routine clients and set out to study the past
and future participation rate for individual and group counseling. A
supervisory monitoring system was established to give monthly feedback on the
caseload performance for each counselor; this feedback produced a significantly
greater retention of clients. Thus, the capacity to engage and retain patients
appears to be a variable that is amenable to positive changes in staff and
supervisory behaviors.
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