Treatment of Drug Addiction Using Psychotherapy and Skills-Training

1. Description, Rationale, and Overview

1.1 General Description of Approach

Drug counseling using psychotherapy and coping strategies is integrated with abstinence-based psychotherapy and skills-training techniques. The most important aspects of treatment are improving motivation for change, learning non-chemical coping skills, and helping patients overcome impulses to self-medicate mental illnesses through drug counseling. Based on each client’s unique needs, clients receive a mix of cognitive-behavioral, motivational, and insight-oriented therapy.

Empathic, client-centered, and flexible, this psychotherapeutic and skills-training approach is client-centered and focused on skill development. The foremost objective of drug counseling is to prevent premature dropout and accelerate therapeutic change. Instead of working against clients’ resistance to change, the counsellor works with them and through them. Drug counseling often involves confronting denial aggressively, contrary to this approach and counterproductive. In an outpatient treatment program that is structured yet flexible, group and individual counselling are offered, as well as psychoeducation for the primary client and family drug counseling. Pharmacotherapy for co-occurring psychiatric disorders is also administered whenever needed.

It is encouraged for patients to participate in self-help, but they are not obligated to do so, and acceptance of being an addict or alcoholic does not require drug counseling. Treatment for drug and alcohol addictions has developed different psychological and social methods that help people overcome addiction differently and differently. In drug counseling, treatment is usually customized according to resources (money and health insurance) and lifestyle. Psychotherapy teaches patients to interact with others more emotionally and socially maturely through social skills/interpersonal/growth training. Many addicts cannot cope with their feelings healthily and may do this by self-destructing.

Social skills/interpersonal/growth therapy aims to model healthy relationships with others during group sessions of drug counseling. In exploratory psychotherapy, a client will understand how the experiences of his/her past (trauma, violence, abuse, etc.) affects their current behavior. For patients with severe symptoms of psychosis or other serious psychological problems, exploratory forms of psychotherapy are not recommended as they often involve recalling painful memories. Recovery drug counseling can be traumatizing regardless of how well organized this treatment is. The best types of psychotherapy for improving functioning are those focused on coping (the most effective psychotherapy methods also involve coping). There has been a lot of evidence to suggest that mental health recovery is possible without bringing up past traumas and drug counseling

1.2 Objectives and Goals for the Approach

Motivate the client to change.

• Establish total abstinence from mood-altering drugs for the client to break the addiction cycle.
• Help clients learn how to cope and solve problems to maintain abstinence over time.
• Guidance and support during trouble spots and setbacks might otherwise cause a relapse.

1.3 Theoretical Basis/Mechanism of Action

Psychoactive drug addiction has been identified as a multifaceted, multi-structured problem involving several factors, including physical and mental aspects and social drug counseling. Accordingly, treatment must provide structure and support because compulsive psychoactive drug use is a behavioral cycle in which structure, support, and feedback are necessary to break it and provide opportunities to develop adaptive problem-solving skills to prevent relapse to drug use in turn drug counseling is required.

Patients who receive psychotherapy benefit from a safe and trusting environment to discuss their drug counseling problems. He encourages the patient to express himself or herself emotionally, making an effort to listen to him or her. As a guide/authority figure, the therapist should help protect the patient by explaining what they should and should not do during drug counseling. These types of treatments aren’t exploratory, and they don’t dig deep into the history a patient has. The therapy drug counseling is beneficial to those with emotional and social vulnerabilities and those who become unorganized during stressful situations.

1.4 Agent for Change

The purpose of psychotherapy and skill training is to facilitate a therapeutic alliance between clients and counsellors and build strong relationships within drug counseling groups. The same counsellor provides group therapy and drug counseling to the client to ensure continuity of care.

1.5 Factors that cause drug abuse and addiction

An addictive behavior is the result of biological, psychological, and socioeconomic factors that trigger maladaptive behavior (self-medication) and drug counseling. The initial exposure to psychoactive drugs may have been influenced by social and cultural factors (such as peer pressure). Still, the driving force behind continued, repeated use of these substances (before physical and pharmacological addiction developed) is the desire to affect one’s internal mood and experience. Psychoactive drugs can intensify, modulate, destroy, or transform certain feelings in ways that cannot be achieved through other means (nonchemical) of drug counseling.

2. Contrast with Other Counseling Methods 

2.1 Counseling Approaches Likely to Be Similar

Washington (1989) argues that this approach does contain a great deal of originality. There is also a psychological component that incorporates motivational drug counseling techniques described by Miller and Rollnick (1991), relapse prevention techniques told by Marlatt and Gordon (1985), and psychodynamic approaches told by Brehm and Khantzian (1992).

2.2. Various Counseling Methods

Clinical flexibility is valued by clinicians who work with clients collaboratively and consider the specific needs of each individual when offering drug counseling. In contrast, traditional treatment programs tend to be aggressive and confrontational. Drug counseling strongly encourages participation in an alcoholic’s assistance program or a similar organization. It is not mandatory.

3. Format

It is usual to combine group therapy and individual counseling twice to four times a week in drug counseling. Each client is subjected to supervised urine testing twice a week, and breathalyzer tests are randomly administered during the program. drug counseling will be provided for those who refuse to enter group therapy. For most clients receiving drug counseling, group therapy is the treatment of choice. After working through their concerns about participating in a group, many clients agree to enter group therapy. Psychological and interpersonal impairments may make some clients unable to tolerate group therapy. The treatments include individual therapy twice a week, breathalyzer testing, drug counseling, and drug testing.

3.1 Treatment Modalities

The treatment program includes group and drug counseling, in addition to professional education, monitoring of urine and urine testing to encourage abstinence, and pharmacotherapy, where necessary, for co-occurring psychotic disorders.

3.2 A treatment setting that is ideal

As an outpatient treatment approach, this approach acknowledges clients’ constant exposure to stresses and pressures of everyday life and accesses a wide range of psychoactive drugs and drug counseling. Likewise, outpatient dropout rates are most high during the first few months of treatment, when therapeutic engagement and retention strategies are most important. Furthermore, retention strategies are also highly important, particularly since drug counseling dropout rates are at their highest at the start of treatment.

3.3 Treatment Duration

Their variable lengths distinguish programs that use this format. A drug counseling program may last between 12 and 24 weeks from the time of admission until it is completed. In drug counseling, objective measures of clinical progress are used (clean urine, regular attendance at meetings, and building a sober support network with self-help and adaptive problem-solving skills). Individual treatment durations are adjusted based on predefined behavioural contingencies. There are estimated to be around 40 therapeutic sessions from admission to completion of the treatment drug counseling.

3.4 The Compatibility Of This Treatment With Other Treatments

Since this approach is based on the belief that whatever works best is preferred, it can easily be combined with other treatments. It is critical that the medication offered is clinically appropriate and does not represent “euphoric drug counseling.” There is no anti-medication bias in the program. The use of naltrexone and disulfiram has been shown to help foster RP. Clinically necessary psychotropic medications are prescribed. Examples include antidepressants and antipsychotics. In the drug counseling program, methadone is not administered.

3,5 Why self-help programs are essential

However, clients are not required to attend drug counseling under this program, even if it recommends the opportunity for self-help groups but does not mandate them. Self-help is explained to clients as a basic method that offers advantages over professional treatment. They receive information regarding drug counseling in their community and are assigned a buddy if they don’t want to attend the meetings alone. Self-help meetings are not used as a threat or an indicator that clients will be terminated from treatment if they refuse to attend. They are neither seen as intractable resistance nor as a denial. Drug counseling program clients attend self-help meetings in the vast majority.

4. Counselor Training and Characteristics

4.1 Education Requirements

Our clinical staff members are all required to have a master’s degree in social work, drug counselling, or psychology.

4.2 Required Qualifications, Experience, and Training

A state-certified clinical social worker, clinical psychologist, or drug counseling expert, plus three years of full-time experience working in a drug and alcohol rehabilitation program (preferably an outpatient program), is required for all counsellors.

4.3 Recovery Status of the Counselor

Status matters little to the counsellor. It is not the recovery status of counsellors that determines their selection, but only their demonstrated clinical competence.

4.4 Characteristics of an Ideal Counselor

Counselors should offer clients a warm, empathic, unbiased, and flexible approach in their drug counseling. Counselors who develop an observing ego are also more likely to accept and respond constructively to feedback, specifically regarding countertransference and control issues, which are likely to occur with highly ambivalent and resistant clients during drug counseling. Besides strong communication skills, the counselor should also establish rules of conduct that are consistently enforced in the therapeutic (nonpunitive) setting with clients undergoing drug counseling.

 4.5 Prescribed Behaviors of Counselors

During each phase of the program, the counsellor is responsible for motivating, engaging, guiding, educating, and retaining clients. The counsellor should use various methods to motivate clients, provide problem-solving skills, and empower them.

• Emphasize the strengths of the client instead of their weaknesses.
• Resistance should be joined rather than assaulted.
• Power struggles and aggressive confrontations should be avoided.
• Instead of pontificating treatment goals, negotiate them.
• Clients should be responsible for the change.

4.6 Activities Prohibited by Counselors

Drug counseling should be avoided when dealing with resistant or apathetic clients. Counsellors sometimes lose sight of the objective of treatment: for the client to become more motivated and open to change, they must engage them in a friendly, cooperative, positive interaction. It is one of our goals to teach our counsellors how to avoid missteps in a drug counseling process while avoiding countertransferential reactions.

These Include:

• They predict disaster if they fail to heed the counsellor’s advice.
• She tells the client that positive consequences for drug use will help motivate him or her to change.
• It is ignored when the client’s goals differ from its goals.
• When clients fail to conform to the program, I feel frustrated.
• In negotiating a change in a treatment plan based on clarifying the client’s ambivalence about change, I wish to impose negative consequences on non-compliant clients (“throwing them out of treatment”).

4.7 Recommended Supervision

The counsellor’s job is a demanding one. Clinical supervision is required to sharpen clinical skills, ensure consistency in the treatment approach, and provide the counsellor with emotional support and encouragement. During drug counseling, all counsellors receive one hour of group supervision and one hour of individual supervision each week. Supervisors use statistical reports (computer printouts) to monitor each counsellor’s client caseload and work performance. Among the information included in these reports is client retention and completion, attendance at sessions, urine test results, and goal achievement ratings for drug counseling.

Measures of all counsellors’ work performance include data on the number of clinical services provided to clients (i.e., numbers of sessions), responses to positive urine test results and missed sessions, timeliness of follow-up on clients who drop out or fail to show up for sessions, and counsellors’ compliance with chart-noting requirements. Client retention rates are very important to the success of drug counseling, and supervisors study dropout rates carefully. Supervisors occasionally sit in on counsellors’ group sessions to directly observe their therapeutic skills in action. Videotaping and audiotaping sessions (with the client’s written consent) are also used in supervision. As well as supervisory meetings, the drug counsellors participate in daily case conferences to assign new cases and discuss special problems. Once each month, there is an in-service training session on a specific clinical topic.

5. Relationship Between Clients and Counselors 

5.1 What Is the Counselor’s Role?

The counselor serves a multidimensional role as collaborator, teacher, adviser, and change-facilitator.

5.2 Who Talks More?

In general, the client talks more. However, the counselor does not hesitate to offer education, advice, and guidance where appropriate.

5.3 How Directive Is the Counselor?

The counselor takes an active role, offering specific advice and direction, particularly during the early phases of treatment where immediate behavioral changes are required to establish and maintain abstinence.

5.4 Therapeutic Alliance

In addition to creating a therapeutic alliance between the client and the counsellor, drug counseling is also one of the most important TA approaches. Building a positive TA requires the counsellor to start where the client is (i.e., accepting and working within the client’s frame of reference). It stands in stark contrast to traditional approaches that insist on the client following the counsellor’s (program’s) frame of reference as the starting point for drug counseling.

Suppose, for example, that the client first minimizes the severity of the drug usage problem or does not agree that drug counseling is necessary. In that case, the counsellor refrains from accusing the client of being in denial (a tactic likely to heighten rather than reduce the client’s defensiveness) and instead asks the client to cooperate in a time-limited experiment (usually involving a trial period of abstinence) to assess the nature and extent of his or her involvement with psychoactive drugs. Coerced or mandated clients pose the greatest challenge to getting a TA started. Clients usually come to drug counseling angry, suspicious, and mistrusting.

Building a Relationship Under These Trying Circumstances Requires a Great Deal of Clinical Finesse on The Part of The Counselor, Who Makes Every Effort To:

• Empathize with the client’s plight and the fact that no one likes to be told what to do.
• Accept without challenge the client’s primary motivation for coming to treatment?to get the coercing agent (e.g., court, employer) “off my [the client’s] back.”
• Compliment the client for facing the realities of the situation by showing up at the session.
• Detach himself or herself as much as possible from the coercing agent and offer to help the client solve the problem or problems that led to the current situation.

6. Populations Targeted

 6.1 Clients Best Suited for this Counseling Approach

It is best suited to clients with psychoactive drug addiction and can show up for scheduled outpatient sessions for drug counseling. The program admits clients who actively use alcohol and other drugs and those who have already achieved abstinence as inpatients or outpatients. The program treats all types of chemical addiction and cross-addictions irrespective of the client’s drug of choice (e.g., alcohol, cocaine, heroin) and has been used successfully with adult and adolescent populations (treated separately).

People with chronic unemployment and dysfunctional lifestyles are treated separately from those with a higher level of psychosocial functioning who receive drug counseling. The program is coeducational, but a special women’s group is available for those who prefer to be treated in an all-female environment. Psychiatric illness drug counseling is combined with a dual-focus program (separate from the mainstream program) to address the special needs of clients.

6.2 Clients Poorly Suited for This Counseling Approach

Patients who are not suitable for this approach include those whose psychosocial functioning is so impaired that they cannot attend all treatment sessions and those with suicidal thoughts or psychotic illnesses in need of more structured, intensive care, such as those receiving inpatient or partial hospitalization programs that provide drug counseling.

7. Assessment

The pretreatment evaluation process begins by asking the client to fill out an extensive self-administered assessment questionnaire (the Washton Institute Intake Evaluation Form) (Washton 1995) immediately prior to a 1-hour, face-to-face clinical interview with the intake counselor.

The Assessment Questionnaire Covers the Domains Of:

• Drug use.
• Motivation and readiness for change.
• Psychiatric history and status.
• Family history.
• Vocational history.
• Criminal history.
• Treatment history.

During the subsequent clinical interview, the counsellor seeks to clarify and expand the information already provided by the client on the assessment form. However, perhaps more importantly, the counsellor actively motivates and engages the client through therapeutic drug counseling. Where indicated, the pretreatment evaluation process may require one or more additional sessions and may also include a formal psychiatric assessment. One of the most important components of a pretreatment evaluation is assessing motivation and readiness for change in drug counseling.

This involves identifying with the client both internal and external factors currently driving him or her to at least explore the possibility of change. In addition, it involves helping the client identify its ambivalence about stopping a psychoactive drug use by objectively considering both the positive and negative effects and determining the level of consistency between the client’s goals and the program’s goals for drug counseling.

Some clients want to reduce treatment goals rather than completely stop using their drug of choice. Drug counseling. On the other hand, others prefer to give up only the substance that is causing them problems (e.g., cocaine) and not the substance they see as relatively benign (e.g., alcohol and marijuana). Clients who want to enter an early abstinence group must agree to stop using all psychoactive drugs (total abstinence) for at least a trial period. Clients who do not agree to meet this requirement are offered time-limited drug counseling (up to 6 weeks) to help them move toward trial abstinence as a short-term treatment goal drug counseling.

During treatment, clinical progress is measured throughout each client’s participation in the program. During their participation in the program drug counseling, all client data is stored, processed, and reported using an automated office management system.

These Data Include:

• Urine test results.
• Attendance at scheduled sessions.
• Counselor ratings of the client’s progress toward achieving specified treatment goals.
• Client’s self-ratings of progress toward achieving treatment goals.

The data are reviewed monthly (or weekly, if needed) to continuously adjust the treatment to individual client needs, provide supervisory feedback to counselors, and improve overall treatment effectiveness. Followup treatment studies have been conducted on sample populations at 1- to 2-year intervals after treatment.

Follow-up Measures Include Assessments Of:

• Drug use.
• Psychosocial functioning.
• Involvement in self-help.
• Utilization of other treatment resources.

8. Content and Format of The Session

8.1 Format for a Typical Session

Early in the abstinence phase of the program, each client is asked what his or her clean and sober time has been and what issue they would like to discuss in the group drug counseling session. Every client is expected to identify at least one issue for discussion at each session. The therapist (group leader) may pull together the issues of two or more group members into a theme for that session or may begin the session with a specific topic as part of a revolving PE sequence. Generally, two group sessions per week are devoted to discussing concerns and struggles raised by clients (using the guidance and framing provided by the group leader); one session is devoted to presenting a short lecture and guiding a full discussion on drug counseling.

8.2 Several Typical Session Topics or Themes

Following is a partial list of topics and themes in the PE sequence (Washton 1989, 1991): tips for quitting; finding your motivation to quit; how serious is your problem? Taking a closer look; identifying your high-risk situations; coping with your high-risk situations; dealing with cravings and urges; why total abstinence? Is it really necessary to give up everything?; warning signs of relapse, rating your relapse potential? Drug counseling realistically assessed. Tips for managing slips; managing anger and frustration; finding balance in your life; having fun without getting high; defining your personal goals; managing problems in your relationships; building self-esteem; nutrition and drug counseling. AIDS and other sexually transmitted diseases? How to avoid them; overview of treatment and recovery; how your family can help without hurting? A look at addiction.

8.3 Session Structure

The purpose of each session is to enhance the client’s motivation for change and improve his or her ability to cope adaptively with the problems of everyday life without reverting to psychoactive drug use. Drug counseling sessions are neither highly structured nor unstructured in order to achieve this goal. The PE sessions serve more to stimulate discussion than present material in a didactic manner. The group leader takes an active role in helping each group member relate the lecture topic to his or her situation. Rather than simply providing factual information, drug counseling aims to encourage emotional and behavioral changes.

8.4 Strategies for Dealing With Common Clinical Problems

Lateness and absenteeism are addressed therapeutically as behavioural manifestations of a client’s ambivalence about change. In the intake interview and in drug counseling, the importance of clients arriving on time at sessions is emphasized. Clients are instructed not to come to the clinic within 12 hours of any alcohol or other drug use. If a client arrives showing clear-cut behavioural signs of intoxication (e.g., slurred speech, uncoordinated movements, breath smelling of alcohol), he or she is asked to leave the premises and return the next day. An intoxicated client can be taken home by a family member for drug counseling if a counsellor suspects that he or she is severely impaired. According to the program’s variable-length treatment protocol, each unexcused absence extends by 2 to 4 weeks the time required for program completion. In the event of a client’s third unexcused absence or fifth unexcused lateness, he or she is moved from the early abstinence group to a stabilization group where more attention is paid to overcoming early obstacles to changing drug counseling.

8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation

Enhancing a client’s motivation for change is an essential part of the counsellor’s role in this approach. Denote a client’s denial, resistance, or poor motivation as unhelpful is distinctly unhelpful when it comes to drug counseling. Problems in complying with the treatment program are framed regarding the client’s ambivalence, reluctance, and fears about change. The counsellor works collaboratively and cooperatively with the client to overcome these obstacles. When non-compliance occurs, the counsellor actively engages with the client’s resistance and finds creative approaches to drug counseling.

This approach recognizes that aggressive confrontation is more likely to precipitate dropouts from treatment in outpatient drug counseling. Although this approach avoids the use of aggressive tactics, it is important to mention that it does not promote a laissez-faire, anything-goes attitude toward client noncompliance. As part of this approach, clients may be given limitations and constructive feedback to improve their motivation for change rather than being required to admit they’re addicted without drug counseling.

8.6 Strategies for Dealing With Crises

In the event of emergencies or crisis situations during nonclinic hours, counselors and supervisors can be paged via a 24-hour telephone answering service. Crises are met with supportive interventions to stabilize the crisis situation and prevent relapse and dropout. The client is provided with frequent individual counseling sessions until the immediate crisis situation is stabilized.

8.7 Counselor’s Response to Slips and Relapses

Slips are treated as avoidable mistakes and manifestations of ambivalence. During drug counseling, a careful analysis of the thoughts, feelings, circumstances, and set-up behaviours leading up to the slip is conducted. The first goal of this debriefing is to help the client recognize and accept the role of personal choice and responsibility in determining drug-using behaviour. An abstinence plan is developed that employs specific decision-making strategies, problem-solving techniques, and behavioral avoidance techniques for drug counseling. The variable-length treatment protocol stipulates that each slip increases a client’s length of stay in the program by 2 to 4 weeks.

On the occasion of a third slip (or sooner if the counsellor deems it necessary), the client is transferred to a stabilization group. During this course the group develops a daily behaviour action plan for abstinence drug counseling. Upon achieving two consecutive weeks of total abstinence and perfect attendance in the stabilization group, the client is eligible to return to his or her early abstinence group. A second slip of the tongue during the stabilization group results in suspension from group treatment for a minimum of two weeks and referral to inpatient drug counseling. During the suspension, the client may also be given the option of attending the clinic for twice-a-week urine testing and once-a-week drug counseling for a maximum of 4 weeks. If the client achieves 2? Once the drug counseling program has ended, he or she can return to early abstinence group drug advice.

9. A Significant Other’s Role in Treatment

Active efforts involve significant others (SOs) in the treatment. The program also provides clients and their significant others with a drug counseling program. The program consists of a conjoint multiple family group that meets once per week for 12 consecutive weeks. The group provides support, education, and counselling geared toward enhancing family members’ ability to cope adaptively with their loved one’s addiction and teaching them how to break the vicious cycle of enabling and provoking behaviors that perpetuate the problem of drug counseling. Participants learn and practice specific problem solving and communication skills using guided role-play exercises. For problems requiring more individualized attention, couples and families are also used alongside drug counseling.

For more information don’t hesitate to call on our toll free number 615-490-9376 and our staff will be happy to serve you on matters relating to drug counselling and much more.

References

Brehm, N.M., and Khantzian, E.J. A psychodynamic perspective. In: Lowinson, J.H.; Ruiz, P.; Millman, R.B.; and Langrod, J., eds. Substance Abuse: A Comprehensive Textbook. 2d ed. Baltimore: Williams & Wilkins, 1992. pp. 106-117.Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press, 1991.Washton, A.M. Cocaine Addiction: Treatment, Recovery, and Relapse Prevention. New York: Norton, 1989.Washton, A.M. Cocaine Recovery Workbooks. Center City, MN: Hazelden Educational Materials, 1991.Washton, A.M., ed. Psychotherapy and Substance Abuse: A Practitioner’s Handbook. New York: Guilford Press, 1995.