| Abstract|| |
Addictive disorders have a strong psychosocial component in their etiogenesis, and hence psychosocial approaches form a significant part of management planning with a role in prevention, treatment, relapse prevention and long term rehabilitation. Due to a number of myths and misconceptions associated with addictive disorders, there is often strong resistance from the patients as well as the families towards treatment. The disorder is often perceived as a bad habit and hence not requiring treatment. It is very important to break this barrier to bring the patient and the family in treatment engagement. This article summarizes the need for psychosocial management of the addictive disorders, dealing with treatment resistance building therapeutic alliance, and improving the long term outcome.
Keywords: Psychosocial interventions, therapeutic factors, resistance
|How to cite this article:|
Chadda RK, Chatterjee B. Need for psychosocial interventions: From resistance to therapeutic alliance. Indian J Psychiatry 2018;60, Suppl S2:440-3
| Introduction|| |
Addictive disorders are often seen as an evil/immoral act, and the user as an immoral person. Sometimes it is considered as merely a social problem and the user as an anti-social element. In line with these myths and pre-conceived notions, often people consider “solutions” which are not only unscientific and irrelevant, but sometimes potentially harmful and injurious to the person. Social and familial pressure and even ostracization are considered as means to “force” the person to stop an addictive substance, which on the contrary further complicates the problem, as the user becomes resistant to any kind of treatment-seeking, and/or left with no psychosocial support. Most of these are due to lack of understanding of the medical model of the illness and non-availability or lack of awareness about the treatment facilities available in the community.
Addictive disorders like any other medical disorder have a biological, social and psychological component, and thus require a multi-pronged and comprehensive approach to their management. Treatment of these disorders includes both pharmacological and psychosocial interventions, and both play an important role in improvement and recovery. Pharmacological interventions take care predominantly of the physiological dependence aspect of the illness like withdrawal, tolerance and to an extent, of the craving in some substances. On the other hand, psychosocial interventions have a role to play in almost every domain and every step of the treatment. At the outset, these help in changing the outlook towards the disorders, creating awareness, improving the outlook towards the illness among the substance user and the caregiver, and improving motivation of the substance user. This may be considered as the first step in management of addictive disorders. These interventions work on the principle that appropriate and timely help without “pressurizing” the user to stop substance use has a potential to bring about a positive change in an individual by improving the motivation for treatment and thus, creating a strong and lasting therapeutic alliance. Most of these interventions (described below) are well-proven, short, easy-to-administer and require minimal training, and can be applied in any setting.
Even after initiation of the treatment, multiple complications which have accumulated and increased during the drug use career, affect the life situation like the family, finances, social life, education or job, and legal complications. These complications need to be resolved since these are not adequately addressed by the pharmacological interventions. Psychosocial interventions, along with appropriate pharmacological intervention, not only help in controlling the substance use problem, but also help in improving functioning by lifestyle modification and learning of alternative ways of coping and pleasure seeking, and thus facilitating reintegration into the society.
Even after maintaining adequately on treatment for considerable period of time, many of them relapse. This is because like most of the mental illness, addictive disorders are also chronic, relapsing illnesses. Psychosocial interventions also play an important role in preventing relapse by helping the subjects identify various triggers of relapse, cognitive distortions behind them, and teaching various skills to deal with them. Psychosocial interventions are also useful when focus is needed on the family, social surroundings like peers etc., which may be responsible to trigger relapse.
Despite the proven efficacy of the psychosocial interventions in general, it is often believed that psychosocial interventions are time consuming and require specialized training. However, many of the interventions are brief, can be easily learnt, delivered effectively in a short time, and improve outcome. Thus, psychosocial interventions play an integral role in managing various aspects and stages of the course of addictive disorder and complement pharmacological interventions, and have a potential to improve the overall treatment outcome.
Psychosocial interventions for Addictive Disorders – clinical application
Psychosocial interventions include a range of psychological or social interventions (with an overlap or different levels of combinations), used to address substance-related or addictive behaviour problems. The interventions need to be systematic, directive, definite in terms of content, duration and goal i.e. aimed at bringing about a specific targeted change in the client's behaviour. This is in contrast to general counselling, where non-directive methods like reflective listening is used, and the basic aim is to help the client gain an insight into any given problem and to make the client come up with a solution, which can further lead to a desired behavioural change. However, counselling skills are important for an effective psychosocial intervention which in turn determines adherence to treatment and follow-up, as well as the outcome.
Before starting an individualized psychosocial intervention, a thorough clinical assessment including preferably by objective instruments is necessary. This would also help in selecting the specific interventions, formulating treatment programme, and setting an appropriate, realistic treatment goal (e.g. reduction of psychosocial or physical complications associated with the target problem, reduction of risky behaviours, attaining controlled or non-dependent use of the substance or reducing the addictive behaviours or complete abstinence from the problem drug or attaining abstinence from all drugs or control of all target behaviour problems).
Psychosocial intervention – from initiation to rehabilitation
Psychosocial interventions can be categorized on the basis of – philosophy (cognitive -behavioral, motivational or social, family, peer support), type of drugs or behaviours on which efficacy is proven, length of sessions (brief intervention vs extended intervention), modality of therapy application (by therapist, self-help or by peers), type of population (community reinforcement approach and multi-systemic therapy is effective in adolescents, family therapy in adolescents and women), applied individually or in group setting, etc.
As noted in the previous section, psychosocial interventions, as a group are generally recognized as having value throughout the treatment process – from bringing the patient into treatment to reintegration in the society. Therefore, from the clinical perspective, the interventions can be categorized depending on the stage of treatment, it is being applied: interventions to recognize the problem, treat the problem and to maintain and retain in treatment. Some basic principles of the psychosocial interventions are discussed as below:
- Psychosocial interventions that help 'recognize' addiction problems –
- Brief interventions – Time-limited intervention for hazardous or harmful pattern of substance users or addictive behaviour:
Aim is to achieve a specific short term goal like facilitating referral to a specialized treatment setting, reducing frequency and quantity (extent) of substance use (behaviour), and reducing risk associated with addictive behaviour, Advantage is that these can be applied by non-specialists like lay physician, nurses or health workers, need sessions of short duration (each session can last for 5-20 mins), with limited number (1-4 sessions), and can be applied in various non-specialized setting (emergency department, community, etc.).
- Motivational Enhancement Therapy (MET) –
MET is aimed at increasing motivation by resolving ambivalence about engaging in treatment and commitment to stop drug use by going through various stages of change. The therapy involves recognizing a problem, searching for a way to change, and then acting and maintaining the change. MET is a therapist-mediated, patient-centred collaborative style of intervention. There is definite evidence of efficacy in alcohol and cannabis dependence.
- Psychosocial interventions that help during treatment–
- Relapse prevention (RP) – RP is designed as abstinence-maintenance programme following cessation of drug use. It involves specific techniques of exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings and identifying high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and handling desire to use. Strategies include coping skills training, handling difficult life situations, analyzing the cause of relapse, learning skills to overcome such situations and lifestyle modifications to minimize exposure to high-risk situations, and fill the void created due to cessation of drug use.
- Cognitive behaviour therapy (CBT) – CBT helps the clients to address the thoughts, believed to underlie the drug problems or addictive behaviour, and learn to recognize and handle what triggers them. CBT is administered by a person trained in it
- Family-based interventions – In family based interventions, the underlying premise is that treating an individual in isolation would not solve the problems in the family system. The therapy involves negotiating with the clients, establishing the context for a drug free life, ceasing substance abuse, managing the crisis and stabilizing the family, and family reorganization and recovery. Family based interventions are important in all cases of addictive disorders in our settings, where family can play an important role in acute as well as long term treatment
- Psychosocial interventions that help to maintain and retain in treatment –
- Contingency management- Contingency management is a behavioural management technique based on the principle of reward reinforcement. Aim is to reinforce positive behaviours. The therapy is usually applied in abstinent individuals to maintain pro-social behaviours which remove the person from, the settings of substance use or addictive behaviours. It can be applied in multiple settings like community, in-patient and residential.
- Self-help group – Self-help groups are peer-led, voluntary, not-for-profit organizations where people meet to discuss and address shared addiction problems and provide support for each other. The groups are usually led by former drug users wherein the senior members often mentor the new ones. The basic principle is the social networks approach. The groups aim to create a drug-free supportive network around the individual during the recovery process and provide opportunities to share experiences and feelings. Some of the popular self-help groups include Alcoholic Anonymous (AA), Narcotic Anonymous (NA). AA is based on 12-step model and has been shown to be reasonable efficacy in reducing alcohol use.
Principles for effective psychosocial intervention
Although the effectiveness of treatment in addictive disorders depends on multiple factors, certain principles which can be universally applied to increase the efficacy are:-
- Addictive disorders are potentially chronic disorders with high relapse rate. It is useful to remember that the risk of relapse will always be there even after prolonged period of abstinence. This does not necessary mean the failure of treatment.
- No single treatment is appropriate for every individual. The treatment needs to be individualized based on the nature of addiction, personality characteristics, risk factors, support available and others.
- Treatment must be readily available. Engaging clients in treatment process as early as possible and as soon as they are ready, is critical. In most cases, this is more critical than the highly specialized but delayed treatment.
- Psychological interventions including counselling are the most commonly used psychosocial method of treatment employed for addictive disorders. These are also one of the most important treatment modalities for addictive disorders as these address multiple issues related to treatment like patient's motivation, incentivizing and maintaining abstinence, imparting skills to resist drug use or addictive behaviour, providing alternate pleasurable activities, improving problem-solving skills and facilitating better interpersonal relationships.
- Psychosocial intervention in order to be effective should address to the multiple needs of the patient and not only the addiction problem. The other issues may include medical, psychological, social, vocational, and legal problems.
- Pharmacological interventions when combined with psychosocial intervention have proved to be more efficacious than either of the intervention alone.
- Adequate duration of treatment engagement. The psychosocial intervention planned must be of adequate duration so as to achieve its desired goals. Keeping a client in treatment for the necessary duration is a challenge which must be considered while formulating a psychosocial intervention. Relapse and drop-out does not mean failure of the intervention but indicate that the intervention and the client requirement are not adequately matched and thus, requires further modification.
- Continuous assessment of changing needs. Besides the intervention for addictive disorder, the client may have other needs and requirement which may be indirectly related to the outcome of substance use, e.g. vocational rehabilitation or medical services. These must be assessed regularly and must be addressed.
- Assessment and treatment of co-morbid conditions like mental illness. Comorbid psychiatric illness results in poor outcome, both for the addictive disorder and the psychiatric illness. These must be diagnosed early and must be treatment effectively.
Challenges in delivery of psychosocial interventions
Poor treatment retention, i.e. dropout and high non-compliance rates are common in addictive disorders. In some large-scale studies, dropout has been reported to be as high as 50% within first 3 months, minimum time considered to be required to assess effectiveness of treatment. Thus, in many cases, the extent and duration of treatment actually received by clients is well below the desired intervention. The factors which must be considered are -
- Client characteristics: Client specific features are an important determinant for treatment retention: Many studies have found differences between the intake characteristics of patients who do well or poorly following treatment of various kinds. Most common reasons related to treatment retention are those related to client rather than programme characteristics, like severity of addiction, financial problems, motivation for abstinence and connectedness with the treatment staff. Better outcomes have been associated with higher education and social class, higher social stability and social support, lesser severity of addiction, higher motivation, and less psychopathology. The findings suggest that the development of early therapeutic alliance and active problem solving of potential barriers to treatment attendance may influence treatment retention.
- Personal characteristics of therapist. Therapist characteristics also affect the outcome. Clients show better adherence to treatment and outcome with therapists who can express empathy, are able to forge a good therapeutic alliance, and with whom the client perceives a greater treatment satisfaction.
- Matching treatment expectations. Both the therapist and the client enter the treatment alliance with some expectation from each other and also from the alliance. Thus, the extent of the differences between what the patient expects and what they receive is likely to interfere with progress or reduce treatment adherence. Matching the patient with a specific addiction disorder with the right type of treatment programme is still an elusive goal for addiction treatment providers.
Summary and future directions
Psychosocial interventions play a significant role in the treatment and rehabilitation of addictive disorders. These play a complimentary role to the pharmacological interventions. In the addictive disorders, where there is no effective pharmacological treatment, psychosocial interventions are the mainstay treatment. The interventions are more directive and structured than general counselling but flexible enough to be applied in variety of setting, with varying client characteristics, and by therapists with varying level of expertise. Clinically, each intervention serves different purpose, right from engaging in treatment to maintaining of abstinent status and reintegration with the society. However, psychosocial interventions should only be offered after a thorough assessment and must be individualized according the client needs. They require clearly defined treatment plans, measurable goals and a review process. Both client and counsellor characteristics and adequate duration of engagement are important criteria for success. In general, no particular intervention has higher efficacy than the other in general and treatment needs to be planned as per individual needs and options available.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Rakesh K Chadda
Professor and Head, Department of Psychiatry and Chief, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None