TREATMENT TYPES

This section provides the reader with brief descriptions of some of the diverse ways that people with substance-related problems can be helped. Treatment Types presents descriptions of distinct interventions that are applicable to dependence on each of a variety of drugs. In practice, though, treatment programs are hybrids, incorporating features from several distinct treatment modalities and adapting them to specific needs having to do with age, gender, ethnic, racial, and socioeconomic factors, provider preference, and the economic realities that govern delivery of treatment.

Neither this section nor the one above on Treatment is exhaustive. A number of substance dependence interventions employed in other countries and by certain U.S. ethnic groups (such as sweat lodges among some Native American tribes) are not covered. Nevertheless, the entries included here should allow the reader to become reasonably familiar with what is considered mainstream treatment in the United States today.

This section contains the following articles: An Overview; Acupuncture; Approaches based on Behavioral Principles; Aversion Therapy; Behavior Modification; Cognitive Therapy; Contingency Management; Family Therapy; Group Therapy; Hypnosis; Long-Term versus Brief; Minnesota Model; Nonmedical Detoxification; Outpatient versus Inpatient; Pharmacotherapy, An Overview; Psychological Approaches; Self-Help and Anonymous Groups; Therapeutic Communities; Traditional Dynamic Psychotherapy ; and Twelve Steps, The.

An Overview

According to the 1998 National Household Survey on Drug Abuse, of the 23.1 million Americans who used an illicit drug in the past year, 1.9 million reported some health problem due to their illicit drug use, 3.5 million reported an emotional or psychological problem due to their drug use, and 4.1 million were dependent on an illicit drug. An estimated 963,000 had received treatment or counseling for their drug use. In addition to those dependent on illicit drugs, another 9.7 million Americans are estimated to be dependent on alcohol, including 915,000 youths age 12-17. Current treatment capacity, including public and private facilities for illicit drug and alcohol treatment, is about 1.7 million treatment episodes a year—clearly short of the need.

Prior to referring an addicted patient to treatment, it is important to address certain questions: (1) What are the possible treatment alternatives? (2) What treatment modalities are best suited for a particular patient? (3) What is the efficacy of the preferred treatment? and (4) Is the chosen treatment available to the patient? As will be noted, the information base needed to answer these is often not available.

TREATMENT ALTERNATIVES

Treatment Setting.

Excellent treatment can be delivered within both outpatient and inpatient settings. A more expensive inpatient program does not offer the best treatment for all individuals. The appropriate placement of a drug-dependent individual in a treatment program requires the consideration of several factors, including drugs that are being used, level of psychiatric distress, potential medical complications, family or other support, and availability of child care. Intensity of treatment is not necessarily a function of setting since some outpatient treatment programs provide more intense treatment than do inpatient ones.

Inpatient Programs.

Usually, inpatient settings are of three types: (1) detoxification units within medical hospitals, (2) dual-diagnosis programs within psychiatric hospitals, and (3) rehabilitation programs. The first two settings are best utilized when there is a risk of serious medical problems (e.g., seizures) or psychiatric difficulties (e.g., suicidal ideation). Medical units generally employ pharmacologic detoxification protocols that are based on the type of drugs abused and the patient's concomitant medical condition. The length of stay is usually less than two weeks. Although many patients mistakenly believe that after detoxification no further intervention is necessary, detoxification is only the beginning of treatment. The next treatment placement should be based on the needs of the patient, but, unfortunately, it often depends on other factors (e.g., community resources or the patient's insurance coverage or ability to pay).

Dual-diagnosis programs are usually based in psychiatric hospitals and are designed to treat patients with both serious psychiatric illnesses and substance-use disorders. Treatment may include individual, group, and family therapy, pharmacotherapy, relaxation techniques, and education. Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) groups may also be offered. Individuals may reside in these hospital units from several weeks to several months.

Rehabilitation units are usually free-standing facilities that are often based on the AA Twelve-Step model of treatment. Some carry out uncomplicated pharmacologic detoxifications, but many patients are already detoxified at entry. Some rehabilitation programs are staffed to offer psychiatric evaluation or treatment (or both). Therapy usually consists of education, group therapy, individual meetings, and at times, specialized groups (e.g., a women's group), usually provided by drug or alcohol counselors. Social workers may provide family therapy. Traditionally, the standard length of stay was twenty-eight days, but lack of data to support the advantages of this length and reimbursement issues have often compelled programs to reduce treatment to less than fourteen days.

Outpatient Programs.

Outpatient treatment generally consists of drug-free treatment or, in cases of opiate addiction, methadone treatment. The time for outpatient drug-free treatment can range from once a week to daily daylong activities. In comprehensive treatment programs, individuals may be initially enrolled in an intensive outpatient program consisting of many structured daily activities (e.g., group therapy, individual therapy, self-help groups, educational groups, stress-management groups) and "graduate" over a certain period (ranging from one to six months) to weekly or biweekly clinic visits. Random urine testing is usually an integral part of these programs. Completion of the intensive portion of the program is usually determined by documented behaviors such as length of abstinence, attendance in groups, and keeping scheduled appointments. Initiation of change—for example, the avoidance of drug-using friends or the desire to return to work or school—may suggest readiness for a less-intensive program.

Some outpatient programs have the necessary staff and expertise to provide medically supervised detoxification. Appropriate patient selection is crucial, however. There has been a growing recognition that many patients seeking drug treatment have additional psychiatric disorders (Rounsaville, Weissman, & Kleber, 1983; Weiss et al., 1986; Rounsaville et al., 1991), and, consequently, psychiatrists have been increasingly employed in drug-free outpatient settings to both assess patients and, when necessary, provide additional psychiatric treatment.

Methadone maintenance programs are designed for patients who have been addicted to opiates for at least one year. These patients often have lengthy drug-use histories and have been unable to maintain abstinence after repeated detoxifications. Verification of opiate addiction may be determined by using a naloxone challenge test or by observing withdrawal symptoms. Because of the risk of transmitting the human immunodeficiency virus (HIV), pregnant and HIV-positive opiate-dependent individuals may be given admission priority in some programs. As is the case with drug-free treatment programs, methadone programs vary in the comprehensiveness of their services. Some additional psychosocial services provided by a methadone program may include the teaching of job-hunting skills, family therapy, and parenting groups.

Residential Programs.

Residential programs can be used as a bridge between inpatient and outpatient programs or as an alternative to them. Intermediate-care facilities, similar to those developed at Hazel-Den, allow individuals to live within a residential setting, be employed during the day, and receive comprehensive treatment, including group therapy, individual counseling and monitoring, and education. Both behavioral models and the principles of Alcoholics Anonymous are applied. The average stay is approximately four months.

Therapeutic Communities provide treatment within highly structured, hierarchical residential settings that stress the importance of community and recovering staff in treatment. More recently, professionals with or without prior drug histories are providing managerial expertise and treatment. Within therapeutic communities, behavior is shaped by using rewards and penalties (Kleber, 1989). Drug abusers are constantly confronted by their peers in a variety of situations regarding their functioning within the program. Jobs range from low to high status and are allocated to individuals on the basis of the length of their stay in the community, their competence, and their ability to behave responsibly. Traditional therapeutic communities recommend stays of twelve to twenty-four months whereas newer programs are experimenting with stays of three to six months.

Treatment Modalities.

Treatment interventions can be categorized in terms of behavioral, self-help, psychological, or pharmacological approaches. Although a specific treatment setting may emphasize one type of intervention, additional modalities are often employed. Generally, programs proficient in using diverse treatment methods are more likely to change their therapeutic interventions if the initial approaches appear ineffective.

Behavioral Approaches.

Various behavioral treatments, using the psychological theories of operant and respondent conditioning, have been designed to treat substance abuse. Experimental psychologists found that behavior could be shaped if positive consequences occurred as a result of the changed behavior. Used with drug abusers, operant conditioning is complicated since many positive and negative reinforcers may promote continued drug use. These reinforcers include: (1) the positive sensations related to the drug itself, (2) the avoidance of actual or conditioned withdrawal symptoms, (3) the perceived reduction of distressing psychologic symptoms, (4) the fear of losing a social network centered on drug use, and (5) the anxiety associated with having to confront painful issues once drug use ceases.

Several clinicians have attempted to counter drug-promoting reinforcers with other reinforcers that were contingent on non—drug taking behavior. Higgins et al. (1993) developed a voucher system in which negative urine screens were rewarded with vouchers that could be used to purchase a variety of community-based items viewed as prosocial and consistent with a drug-free lifestyle. When compared to a control group that had received standard drug counseling, it was found that the behavioral group remained in treatment longer and had more discrete periods of abstinence.

Operant techniques can be applied in various treatment settings by using fairly simple yet effective reinforcers. For example, methadone programs may offer drug abusers take-home doses for negative urine results. Because compliance is more likely to occur if the positive reinforcement is temporally linked with the desired behavior, take-home doses immediately offered after two weeks of negative urine tests work better than if the take-home doses are delayed until a prolonged period of abstinence has been accomplished. Contingency management and respondent conditioning are two alternative behavioral interventions that are occasionally used for treating substance abuse. Contingency contracting applies negative contingencies to undesirable behavior. For example, patients who are concealing their drug use from their bosses, family members, or anyone else may be asked to sign a "contract" that allows their therapist to inform one or more specific individuals if their drug use resumes.

Respondent conditioning may involve the use of noxious stimuli. For example, individuals may be given a chemical that induces nausea (e.g., apo-morphine) while receiving an injection of their drug of choice or while handling drug-related paraphernalia. The drug may come to induce unpleasant feelings as a result of its association with the noxious stimuli. Poor patient acceptance, ethical issues, and insufficient data regarding efficacy limit the use of these Aversive Treatment approaches.

Self-Help Approaches.

These interventions have evolved from the personal experiences and ideas generated by Bob Smith and Bill Wilson, two alcoholics who cofounded Alcoholics Anonymous. The organization has grown until, in 2000, it estimated that it numbers more than 99,000 groups worldwide. Although AA's approach to gaining Sobriety (the Twelve Steps) and its principles (the Twelve Traditions) are commonly integrated into many treatment programs, it remains unclear which patients benefit most from self-help programs, particularly when they are used without other interventions. The concepts of AA have also been applied to other psychoactive-substance use disorders (e.g., in the programs of Cocaine Anonymous and Narcotics Anonymous).

Psychological Approaches.

Psychological approaches are used to try to understand the psychological or cognitive issues that promote drug use and, with this knowledge, to provide appropriate treatment interventions. As Zweben (1986) emphasized, the goals of recovery-oriented psychotherapy change as addicted individuals progress in their recovery. The manner in which recovery "progresses" has been clearly conceptualized by Gorski and Miller (1986) in their six-stage developmental model. Each of the stages has a primary goal, and different types of psychological interventions become appropriate, depending on the goal.

During the first two phases, pretreatment and stabilization, the focus is placed on challenging the denial of patients regarding the consequences of their disease and, subsequently, on addressing the symptoms of acute and post-acute withdrawal. For therapists to engage patients into treatment, they need to be skillful at both confrontational and supportive approaches. During the third and fourth stages of early and middle recovery, the patients' major goals are to learn to function without drugs or alcohol and to develop a healthy lifestyle. For these stages, a cognitive approach focused on Relapse Prevention is useful. Marlatt and Gordon (1985) stressed that drug relapse was often due to ineffective coping with high-risk situations. Although individuals have their own unique list of high-risk situations, the situations are usually related to interpersonal conflicts, social pressure, conditioned cues, or negative emotional states. The therapeutic work of this approach is to develop effective coping responses as well as learn to handle a "lapse" (i.e., a single drink or drug administration) such that it does not degenerate into a "relapse" (i.e., problem use).

The final stages, late recovery and maintenance, emphasize personal growth in areas such as self-esteem, spirituality, intimacy, and work while individuals are maintaining a drug-free lifestyle. When there are deficits in these areas, insight-oriented therapy may be helpful. The reasons for continued inadequate functioning can be extremely complex and may involve unresolved issues from childhood. Kaufman and Redoux (1988) emphasized that uncovering core conflicts and confronting maladaptive defenses might elicit intense anxiety. Unless patients were in the late recovery stage, they might revert to their former maladaptive mode of coping—namely, using drugs.

The developmental model should be used as a guideline in understanding the recovery process rather than as a paradigm that is directly applicable to all patients. Additionally, there may be exceptions to when certain psychological interventions should be utilized. For example, an individual with major depression might not benefit from relapse-prevention techniques until the depression has been treated. Pharmacologic Approaches. Medications can serve as useful adjuncts in a comprehensive treatment plan. The appropriate use of these agents depends on the patient's medical and psychiatric status, prior treatment experience, and the clinical setting. Generally, the novel as well as established pharmacotherapies can be put into four classifications: (1) Agonists, (2) Antagonists, (3) antiwithdrawal agents, and (4) anticraving agents.

Agonists bind and activate receptors on cell membranes, and these operations then lead to a cascade of biologic activities. Drugs themselves are usually agonists and may generate strong physiologic responses (i.e., full agonists) or weak responses (i.e., partial agonists). The use of a specific agonist is limited to treatment of abuse of a drug from the same pharmacological class. Agonists are generally used for detoxification or for medication maintenance, and, when chosen for these purposes, they are likely to be well absorbed orally and slowly eliminated from the body. Slowly metabolized medications are less likely to produce a severe withdrawal syndrome but are more likely to produce a protracted, albeit less intense, one. Because agonists induce positive drug effects, they are well accepted. This, however, also means that they have the potential for abuse.

The most commonly used agonist for both maintenance and for opiate withdrawal is methadone, which itself is an opiate. Buprenorphine, a partial opioid agonist, is being evaluated in the mid-1990s and may have less potential for abuse and be associated with fewer withdrawal symptoms than methadone when used for opiate detoxification. L-Alpha-Acetylmethadol (LAAM), also an opiate drug, has recently (1993) received FDA approval for use in treating opiate abuse. Unlike methadone, which must be taken daily, LAAM can be given three times a week, thereby decreasing the number of clinic visits for the patient as well as the risk of medication diversion. Few agonist drugs have been developed for other types of drug abuse, although Nicotine, delivered transdermally, is being used with some success to treat tobacco dependence.

Antagonists prevent agonists (i.e., the abused drug) from producing their full physiologic response, either by blocking the receptor site or by disrupting the functioning of the receptor. Short-acting antagonists are most commonly used for treatment of acute intoxication or overdose and long-acting ones for rapid detoxification and relapse prevention. The benefits of antagonists are that they produce no euphorigenic effect, have no potential for abuse, and produce no withdrawal syndrome. Although generally only antagonists that block the specific receptor activated by the specific drug can be used for drug-abuse treatment, research is suggesting that the opiate antagonist Naltrexone may play a role in diminishing alcohol drinking after a single drink.

Commonly used opioid antagonists include naloxone and naltrexone. Naloxone reverses the respiratory depression associated with opiate overdoses. Naltrexone is used after detoxification to maintain abstinence. Unfortunately, relatively few patients take an antagonist as prescribed because of its lack of pleasant effect, its lack of effect on withdrawal if the patient ceases taking the medication, and at times the persistence of craving (Kleber, 1989). Development of a monthly, long-acting injectable formulation may soon increase compliance when it reaches the market.

Antiwithdrawal medications are given to minimize the discomfort associated with detoxification from drugs that induce physiologic dependence. Agents used for opiate detoxification include methadone, Clonidine, and lofexidine; although effective for opiate detoxification, the latter two have not received FDA approval for this indication. The use of the dopamine agonists bromocriptine and Amantadine have been suggested for the manifestations of cocaine withdrawal, but their efficacy remains unclear. The most appropriate antiwithdrawal regimen for a particular clinical situation is not always the one chosen. This situation may be due to federal and state regulations, physician or patient bias, reimbursement issues, and the lack of available expertise within a community in the use of particular methods (Kleber, 1994).

The development of anticraving agents to treat drug dependence is a new treatment strategy. Earlier conceptualizations of craving focused on the physical aspects (i.e., the individual "craved" the drug because he or she was experiencing physical withdrawal symptoms). Thus the emphasis was placed on developing antiwithdrawal rather than anticraving drugs. During the last decade, as cocaine use soared, clinicians noted that craving could be psychologically based and be a significant relapse trigger (Gawin & Kleber, 1986). Much research was consequently done to find useful anticraving medications. Although desipramine remains promising, no medication has been unequivocally shown to be an effective anticraving agent for cocaine addiction.

ASSESSMENT OF TREATMENT OUTCOME

Although treatment for substance abuse can work, which treatment setting or modality will work best for each patient cannot invariably be predicted. Using a number of outcome studies, researchers at the Institute of Medicine (Gerstein & Harwood, 1990) reached several conclusions regarding the efficacy of various treatment modalities:

1. Methadone Programs Opiate-dependent individuals maintained on methadone exhibit less illicit drug use and other criminal behavior than do individuals discharged after being in the program for a period of time or not treated at all. For opiate-dependent individuals, there are higher retention rates in methadone programs as compared to other programs, and patients tend to do better if they are stabilized at higher doses. Problems include continued use of nonopiate drugs, especially cocaine, and difficulty withdrawing.
2. Therapeutic Communities The length of stay within these communities, even for those who do not complete the program, is the best predictor of treatment outcome measured by drug use, criminal behavior, and social functioning. Graduates from therapeutic communities have superior outcomes when compared to dropouts. Dropout rates are unfortunately as high as 75 percent, although data suggest that even those who do not graduate derive some benefit if they have stayed for a period of time.
3. Outpatient Nonmethadone Programs As with individuals in therapeutic communities, individuals who graduate from these programs have better outcomes than those who drop out, and individuals who enter the programs have better outcomes than those who were contacted but did not begin the programs. These programs tended to treat less severely dependent patients.
4. Chemical Dependency Programs There were inadequate data to evaluate the efficacy of residential or inpatient programs (so-called 28-day Minnesota Model programs) designed to treat drug problems, and there were no data regarding whether hospital or free-standing programs were more effective.

Hubbard (1992) found that individuals referred from the criminal justice system performed as well in treatment as did other patients entering without such pressure, and that drug-abuse treatment provides a favorable cost-benefit ratio to society within one year of completion of treatment.

Recognizing that treatment success is multifactorial, investigators have sought comprehensive yet practical ways to characterize both patients and treatment programs. One instrument increasingly used to assess patient functioning is the Addiction Severity Index (ASI) (McLellan et al., 1980). Using the ASI, the interviewer rates the severity of the patient's problem across six domains: alcohol and drug use, medical status, employment and support status, family and social relationships, legal status, psychiatric status. By giving the ASI at admission and repeating it over time, treatment success can be assessed in a standardized manner. Using this instrument, McLellan et al. (1984) found that opiate-addicted patients with severe psychological problems did worse over time when placed in a therapeutic community compared to those placed in methadone programs. As this study illustrates, it is critically important to assess "nondrug" variables when evaluating treatment response, and to carry out a comprehensive assessment prior to, during, and after treatment.

In the past few years, there has been greater emphasis on understanding how the specific aspects of treatment programs (e.g., therapeutic skills of the counselors, treatment modalities used, psychosocial services offered) influence treatment outcome. In regard to treatment services, McLellan et al. (1992) developed a rapid interview, the Treatment Services Review (TSR), which provides an evaluation of the amount and type of psychosocial services provided to patients during treatment. The investigators have suggested that this type of review might be useful when comparing different programs or for determining if the needs of individual patients were met during treatment. A recent study by McLellan et al. (1993) found that methadone-maintained patients who received enhanced psychosocial services did significantly better than those who received standard or minimal services.

No single study, no matter how comprehensive, can address all of the factors that influence treatment outcome. Instead, studies will need to focus on specific subpopulations of patients when comparing various treatment interventions as well as the impact on treatment of factors often overlooked (e.g., the patient's stage of recovery and the extent of program hours).

RECOMMENDED TREATMENT POLICIES

Since many Americans are still in need of treatment for drug abuse problems, rational treatment policies need to be established on the basis of our current knowledge regarding the extent of the problem and what interventions work. Such policies should address the following issues (Kleber, 1993):

1. Available treatment needs to be expanded. Although there are approximately 6 million individuals in need of drug treatment, the current system can treat less than 2 million a year.
2. Patients need to have access to a wide variety of treatment modalities. Since no one treatment is suitable for all patients, a community with a diversity of treatment services can more likely offer appropriate interventions to its population.
3. For treatment improvement to occur, there must be more funds dedicated to research along with efficient dissemination of new technologies. Without new research, progress will not be achieved. Without training and education of staff regarding new research findings, treatment will not improve.
4. Pressure must be exerted to encourage drug-addicted individuals to enter treatment. As noted earlier, those who enter under pressure from the criminal justice system do as well as those entering voluntarily. The family, employer, or criminal justice system can all be instrumental in getting individuals to enter and remain in treatment. This pressure must be sustained since when it remits, the individual often drops out of treatment.
5. The treatment needs of special populations (e.g., prisoners, pregnant women, HIV-infected individuals) require greater attention. There are few programs designed to treat drug-addicted prisoners while they are incarcerated or newly released. For pregnant drug abusers to engage in treatment, programs need to be accessible, be affordable, include child care (for optimal results), and reflect a nonjudgmental view. For HIV-infected individuals, comprehensive medical care should be linked with the substance-abuse treatment, especially considering the rising incidence of tuberculosis in this group.
6. Rehabilitation and habilitation need to be integrated into substance-abuse treatment programs. Some drug-dependent individuals have the educational background or skills that allow them to gain employment once their drug problem has been treated. Others may require job-seeking skills, job training, or additional schooling prior to seeking employment. A goal of treatment needs to be integration into society, not simply cessation of drug use.

When examining the different modalities of treatment the question is not, "Does treatment work?" but rather, "What works best for a particular individual?" and "What can be done to engage drug abusers in appropriate, well-organized treatment systems?" If these issues are successfully addressed, treatment strategies can be designed for each patient and yet remain affordable. Millions spent on effective treatment will save billions spent elsewhere.

(See also: Abuse Liability of Drugs ; Coerced Treatment for Substance Offenders ; Comorbidity and Vulnerability ; Research ; Substance Abuse and AIDS ; Treatment ; Treatment in the Federal Prison System )

BIBLIOGRAPHY

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Gerstein, D. R., & Harwood, H. J. (1990). Summary-Treating Drug Problems: A study of the evolution, effectiveness, and financing of public and private drug treatment systems, Vol. 1. Institute of Medicine, Committee for the Substance Abuse Coverage Study Division of Health Care Services. Washington, DC: National Academy Press.

Gorski, T., & Miller, M. (1986). Staying sober: A guide for relapse prevention. Independence, MO: Independence Press.

Higgins, S. T., et al. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763-769.

Hubbard, R. L. (1997). Evaluation and treatment outcome. In J. H. Lowinson et al. (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Baltimore: Lippincott Williams & Wilkins.

Kaufman, E., & Redoux, J. (1988). Guidelines for the successful psychotherapy of substance abusers. American Journal of Drug Alcohol Abuse, 14, 199-209.

Kleber, H. D. (1994). Detoxification from opioid drugs. In M. Galanter & H. D. Kleber (Eds.), The American Psychiatric Press Textbook of Substance Abuse Treatment. Washington, DC: American Psychiatric Press.

Kleber, H. D. (1993). America's drug strategy: Lessons of the past… steps toward the future. Paper presented at a Senate Judiciary Committee Hearing, April, Washington, DC.

Kleber, H. D. (1989). Treatment of drug dependence: What works. International Review of Psychiatry, 1, 81-100.

Kosten, T. R., & Stine, S.M. (Eds.). (1997). New treatments for opioid dependence. New York: Guilford Press.

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Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.

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McCance-Katz, E. F., & Kosten, T.R. (Eds.). (1998). New treatments for chemical addictions. Washington, DC: American Psychiatric Press Press.

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McLellan, A. T., et al. (1992). A new measure of substance abuse treatment: Initial studies of the treatment services review. Journal of Nervous and Mental Disease, 180, 101-110.

McLellan, A. T., et al. (1984). The psychiatrically severe drug abuse patient: Methadone maintenance or therapeutic community? American Journal of Drug & Alcohol Abuse, 10, 77-95.

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Nace, E. P. (1997). Alcoholics anonymous. In J. H. Lowinson et al. (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Baltimore: Lippincott Williams & Wilkins.

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Rounsaville, B. J., Weissman, M. M., & Kleber, H.D. (1983). An evaluation of depression in opiate addicts. Research in Community and Mental Health, 3, 257-289.

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Frances R. Levin

Herbert D. Kleber

Revised by Anne Davidson

Acupuncture

The art of acupuncture is an ancient and integral part of the armamentarium used in China for the treatment of medical problems. Acupuncture consists of the insertion of very fine needles into the skin at specific points intended, according to traditional Chinese medicine, to influence specific body functions or body parts. In the traditional Chinese view of the body, life energy, (chi ), circulates through pathways; blockage of the pathways leads to deficiency of chi, or disease. The goal of the traditional acupuncturist is to open up the pathways and stimulate the movement of chi. The specific points for needle insertion are based on traditional anatomy maps that depict which pathways affect which body functions.

Following President Richard M. Nixon's historic trip to China in 1972, considerable public interest in acupuncture was generated when the media observed that acupuncture was not only effective in relieving pain, but could also be a substitute for general anesthesia. The following year, Dr. H. L. Wen, a neurosurgeon in Hong Kong, reported a serendipitous observation that acupuncture with electrical stimulation (AES) eliminated withdrawal symptoms in a narcotics addict on whom he had intended to perform brain surgery to treat drug addiction. The discovery occurred the day before the scheduled surgery while Dr. Wen was demonstrating to the patient that AES could relieve pain. Fifteen minutes after the AES had begun, the patient reported a significant reduction of his drug withdrawal symptoms, which disappeared altogether thirty minutes after AES was started. Dr. Wen followed this patient, noting that AES had to be administered every eight hours for the first three days, and gradually the intervals could be increased. Within a week there were no further signs or symptoms of withdrawal. This led Dr. Wen to conduct a study of AES in 40 narcotics addicts experiencing withdrawal. All but one (who required medication for severe pain and was dropped from the study) were successfully detoxified. It is noteworthy that Dr. Wen's initial observations occurred prior to the discovery, in 1975, of endogenous opioid substances in the brain (also called endorphins).

In a later study, in 1977, Dr. Wen noted that AES increased endorphin levels and relieved abstinence syndromes while simultaneously inhibiting the autonomic nervous system, primarily the para-sympathetic nervous system. The findings by Dr. Wen and several other scientific groups that peripheral stimulation could release endogenous opioid substances in the central nervous system (CNS) gave scientific credibility to the possibility that this traditional Chinese therapy could help to deal with a contemporary problem. Chronic or repeated exposure to opioids leads to adaptive changes in the CNS; withdrawal symptoms occur when these drugs are abruptly discontinued. Since the administration of opioid drugs alleviates withdrawal, it was reasonable to believe that one's own endogenous opioids might do the same.

During the mid-1970s, the use of acupuncture became popular in the United States, despite the absence of the kind of rigorous clinical investigation typically required for new pharmacological treatments. There were probably a number of factors that contributed to its popularity. Because it involved no pharmacological agents, it was seen as being more compatible with the approach espoused by Self-Help groups, ranging from Alcoholics Anonymous (AA) to Therapeutic Communities. Also, acupuncture did not initially require medical personnel, so it was relatively inexpensive compared to either psychotherapy or pharmacotherapy. In addition, its popularity increased at a time when some people objected to using Methadone for drug detoxification or for maintenance, on the grounds that such use made drug-dependent minority-group members dependent upon the medical establishment. A technique from a non-Western tradition seemed, therefore, to have special appeal for treatment programs that dealt predominantly with minorities.

One such program was the Division of Substance Abuse at Lincoln Hospital in the south Bronx, New York, under the leadership of Dr. Michael O. Smith. Smith was interested in alternatives to methadone for detoxification. Based on Wen's work, Smith first used electrical stimulation along with acupuncture, but he later discarded the use of electrical stimulation. Eventually, a standard protocol was developed which used four or five acupuncture points on each ear. By 1975, the use of acupuncture as a treatment for drug abuse was extended to alcohol patients, then later to cocaine and crack-cocaine patients.

In 1985 Smith founded the National Acupuncture Detoxification Association (NADA) at 3115 Broadway, #51, New York, New York 10027. By 1993, when the second international conference of NADA was held in Budapest, Hungary, there were participants from all over the world.

In the early 1990s, the use of acupuncture in addiction treatment had become popular with many people working in the criminal-justice system. Most of the funding for treatment programs using acupuncture at that time came initially from the criminal-justice system, rather than from the federal and state agencies that usually fund drug treatment programs. Although the scientific community had been unable to show the efficacy of acupuncture in properly controlled clinical studies, this relatively inexpensive and easily expanded procedure became the mainstay of a number of "drug courts," where judges involved themselves directly in managing the treatment of drug offenders.

At many clinics in the United States, acupuncture treatment is now offered as part of a broad psychosocial program that has elements of self-help and Twelve-Step programs, plus traditional medicine and alternative medicine (some clinics, for example, use a "sleep mix" tea brewed from a variety of herbs).

As practiced in the United States, several technical procedures broadly described as acupuncture have been used. Standard bilateral acupuncture is the application of five needles to the concha and cartilage ridge of each ear at defined points (shen men, lung, sympathetic, kidney, and liver) determined from traditional Chinese anatomy maps. With unilateral acupuncture, the needles are applied to one ear. Acupressure involves applying pressure by hand or by an object to the same areas. Electroacupuncture applies low level electric current to needles placed at the traditional points. With moxibustion, herbs are burned near the needles to add heat; and with neuroelectric stimulation, low dose electrical current is passed through surface electrodes. Some practitioners advocate the use of surface electrodes and special currents, designating this approach neuroelectrical therapy (NET). There is no more evidence for the efficacy of added electrical current in the acupuncture treatment of drug and alcohol problems than there is for acupuncture itself.

Many acupuncture practitioners in the United States belong to and are accredited by the American Association of Acupuncture and Oriental Medicine (AAAOM), founded in 1981. Others may be accredited by the National Acupuncture and Oriental Medicine Alliance (NAOMA), founded in 1992, which accepts a broader range of training for purposes of certification than AAAOM.

In 1991, the National Institute on Drug Abuse (NIDA) sponsored a technical review of the current state of knowledge about the use of acupuncture in the treatment of alcoholism and other drug-dependence problems. One of the participants, Dr. George Ulett, noted that although there is some evidence that electrical stimulation through needles or electrodes placed at certain points on the body can release endogenous opioids and other neuropeptides in the central nervous system, there is little evidence that such release is caused by needles alone. He also asserted that the critical factor is the frequency characteristic of the current, not the specific placement site of needles or electrodes. This group of researchers concluded that part of the difficulty in deciding whether acupuncture is effective was the lack of standard terminology and standard methods. A number of procedures, all called acupuncture, were being applied to a variety of drug and alcohol problems, but in different ways, over varying periods of time, with results measured in differing ways. For example, different numbers of acupuncture needles could be used, at different sites, with or without electrical current. One study of acupuncture for alcohol detoxification, by Bullock and coworkers, which came closest to being scientifically valid, used appropriate controls (placement of needles in non-sites) and staff who were "blinded" as to which group was control and which was receiving acupuncture at specific body sites. This study found a far better outcome for patients in the specific body-site group than for controls—and that the difference persisted even when measured six months later. However, another research group using similar methodology could not replicate the findings and reported no difference between point-specific acupuncture, sham transdermal stimulation, or standard care (no acupuncture control).

Many practitioners who have used acupuncture, even those who are convinced of its efficacy, report that only a small proportion of people who start treatment actually complete the typical series of ten to twenty treatments. Those who have used the technique believe that the minimal amount of treatment required for benefit is at least one twenty-minute session per day of bilateral acupuncture for at least ten days. In general, among both opioid-dependent and cocaine-dependent patients, those with lighter habits seemed to fare best.

The NIDA technical review panel concluded that, at the time of the review (1991), there was no compelling evidence that acupuncture is an effective treatment for opiate or cocaine dependence. Nevertheless, they found no evidence that acupuncture is harmful.

BIBLIOGRAPHY

Brumbaugh, A. G. (1993). Acupuncture: New perspectives in chemical dependency treatment. Journal of Substance Abuse Treatment, 10, 35-43.

McLellan, A. T., et al. (1993). Acupuncture treatment for drug abuse: A technical review. Journal of Substance Abuse Treatment, 10, 569-576.

Joyce H. Lowinson

Jerome H. Jaffe

Approaches Based on Behavior Principles

Behavioral treatments are based on a model of drug dependence wherein drug use is considered a learned behavior that is directly influenced by antecedent and consequent events associated with drug use. Within this framework, drug use is deemed the primary target of assessment and treatment. The treatments are generally directed toward a goal of complete abstinence from drug use when dealing with dependent individuals, but moderation is an acceptable goal when dealing with non-dependent individuals who engage in problematic use (e.g., drinking and driving). Many of the treatments also focus on the promotion of prosocial behaviors that are incompatible with continuing the lifestyle of a drug abuser.

Three well-known behavioral treatments are covered in this section (for more comprehensive reviews regarding behavioral treatments for alcohol dependence, illicit drug dependence, and nicotine dependence, see Hester & Miller, 1995; Stitzer & Higgins, 1995; U.S. Department of Health and Human Services, 1996, respectively). Each of these treatments has been demonstrated to be efficacious in controlled studies. Contingency management is another prominent behavioral treatment for drug dependence, but is covered in a separate section of this volume. Other important learning-based treatments, such as brief interventions, motivational interviewing, and relapse prevention therapy are covered in the Cognitive Behavioral Treatments section of this volume.

Behavioral Counseling/Skills Training.

Behavioral counseling/skills training emphasizes environmental restructuring and the acquisition of specific skills deemed important to eliminating harmful drug use and avoiding relapse. Whether the treatment goal is abstinence or moderation of harmful use, patients learn how to identify environmental, social and interpersonal antecedents and consequences of their drug use. For example, if drug use or problematic use is more likely when patients are in a particular setting (e.g., bars) or the company of certain individuals (e.g., former high-school buddies), they are counseled to restructure their environment to avoid or minimize contact with those settings or people. Sometimes the goal might be to alter the setting in which the patient socializes with a particular individual (e.g., get together with a particular friend at a sporting event rather than a bar). Regarding consequences, the individual is counseled to make explicit the negative consequences of drug use and to identify healthy alternatives to the positive consequences derived from drug use and intoxication.

Patients often receive coping skills training in areas deemed important to discontinuing drug use and avoiding relapse. To combat the common problem of social pressure to use drugs, for example, patients are systematically instructed in drug-refusal skills through role-playing and other exercises. Other aspects of social skills training and problem solving are also commonly included in behavioral treatments for drug dependence (Monti et al., 1995). When moderation is the goal with problem drinkers, individuals are taught to monitor their drinking, set ingestion limits, and to use specific strategies to limit the amount consumed (e.g., do not drink alcoholic beverages to quench thirst, take small sips, alternate between alcoholic and nonalcoholic drinks) (Hester, 1995).

A relatively extensive scientific literature supports the efficacy of behavioral treatments for various forms of drug dependence and problematic use. For example, a series of clinical trials have demonstrated that social skills training is an efficacious adjunct treatment for alcohol dependence (Miller at al., 1995; Monti et al., 1995). Most of these studies have examined the effectiveness of social skills training as an adjunct to other treatments, and focused on assertiveness and related social skills. In a seminal study on this topic, for example, forty adults hospitalized for alcohol dependence were randomly assigned to either (1) an eight-session skills-training group focused on drinking-related problem-solving or (2) a control group in which similar topics were discussed but no specific training was provided. During a one-year follow-up period, the skills group compared to the control group reported an average of fourfold fewer drinks consumed, sixfold fewer days drunk (eleven versus sixty-four days during the twelve-month follow-up), and a ninefold reduction in duration of drinking episodes (average of five days versus forty-four days).

Although the bulk of the evidence supporting the efficacy of social skills training and other coping skills training has been obtained with alcoholics and problem drinkers, evidence is also available supporting the efficacy of this approach with individuals who abuse or are dependent on illicit drugs like cocaine (Monti et al., 1997).

With regard to teaching non-dependent, problem drinkers to moderate their intake, a series of experimental studies reported over a ten-year period indicated that 20 to 70 percent of clinical samples can learn to drink moderately and that those effects can be sustained for up to two years (Hester, 1995).

Numerous reviews and meta-analyses support the efficacy of behavioral treatments for cessation of cigarette smoking (U.S. Department of Health and Human Services, 1996). The proportion of patients who successfully quit smoking at six- or twelve-month follow-ups generally increases as the intensity of the intervention increases, with 20 percent abstinence rates being common and 40 percent being reported in some early studies with intensive behavioral treatments. Combining behavioral therapy with pharmacological treatments (e.g., nicotine gum or patch) generally increases quit rates above either intervention alone (Hughes, 1995).

Behavioral Marital Therapy.

Evidence from studies with alcohol-dependent individuals (O'Farrell, 1995) and with individuals dependent on illicit drugs (Fals-Stewart et al., 1996) indicates that involving spouses who are not themselves drug abusers in treatment and providing them with behavioral marital therapy can improve the quality of the relationship and drug-use outcomes. The evidence is more robust regarding improvements in marital satisfaction than reductions in drug use, but both have been documented in controlled studies. The rationales for involving spouses in treatment is that they may engage in behavior that initiates or reinforces drug use; they can acquire skills that promote abstinence or moderation; and spouses are an important potential source of alternative reinforcement when drug use ceases. Two aspects of behavioral marital therapy particularly merit mention. First, couples receive training in positive communication skills (how to constructively negotiate for changes in each other's behavior that will improve the quality of the relationship. Second, when treatment involves disulfiram therapy for alcohol dependence, spouses are taught how to effectively monitor compliance with the medication regimen (Azrin et al., 1982).

Multimodal Treatments.

Treatment packages are sometimes implemented that utilize most of the adjunct behavioral treatments noted above as components in a more comprehensive treatment effort, usually for severely dependent individuals. The Community Reinforcement Approach (CRA) is perhaps the best example of a multimodal-behavioral treatment. CRA includes various forms of social skills and problem-solving training, vocational counseling, marital therapy, social/recreational counseling, and socially monitored disulfiram therapy (see Meyers & Smith, 1995).

In the seminal study examining the efficacy of the CRA treatment for alcohol dependence, sixteen males who had been admitted to a state hospital for alcoholism were divided into matched pairs and randomly assigned to receive CRA plus standard hospital care or standard care alone (Hunt & Azrin, 1973). Following discharge from the hospital, CRA patients received a tapered schedule of counseling sessions across several months. During a six-month follow-up period, patients who received CRA reported approximately six- to fourteen-fold less time drinking, unemployed, away from their families, or institutionalized compared to control patients. Several of the CRA elements noted above were added in subsequent studies conducted by this same group of investigators as the treatment moved from being an adjunct to inpatient treatment to a stand-alone, comprehensive treatment that could be delivered in outpatient settings. Findings from these later studies were at least as impressive as in the seminal study (see Meyers & Smith, 1995). Other groups have effectively extended CRA to the treatment of opiate (Abbott et al., 1998; Bickel et al., 1997) and cocaine dependence (Higgins et al., 1993, 2000). A contingency management element was added in the extension of CRA to the treatment of cocaine dependence (see Budney & Higgins, 1998) as well as one of the studies on opiate dependence (Bickel et al, 1997), and is discussed in the section of this volume on contingency management.

BIBLIOGRAPHY

Abbott, P. J., Weller, S. B., Delaney, et al. (1998). Community reinforcement approach in the treatment of opiate addicts. American Journal of Drug and Alcohol Abuse, 24, 17-30.

Azrin, N. H., Sisson, R. W., Meyers, R., et al. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy & Experimental Psychiatry, 13, 105-112.

Bickel, W. K., Amass, L., Higgins, S. T., et al. (1997). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810.

Budney, A.J., &Higgins, S. T. (1998). The community reinforcement plus vouchers approach: Manual 2: National Institute on Drug Abuse therapy manuals for drug addiction. NIH publication #98-4308. Rockville, MD: National Institute on Drug Abuse.

Fals-Stewart, W., Birchler, G. R., & O'Farrell (1996). Behavioral couples therapy for male sub stance abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology, 64, 959-972.

Hester, R.K., &Miller, W. R. (1995). Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition. Boston: Allyn and Bacon.

Hester, R. K. (1995). Behavioral self-control training. In R. K. Hester & W. R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp 148-159. Boston: Allyn and Bacon.

Higgins, S. T., Budney, A. J., Bickel, et al. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763-769.

Higgins, S. T., Wong, C. J., Badger, et al. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and one year of follow-up. Journal of Consulting and Clinical Psychology, 68, 64-72.

Hughes, J. R. (1995). Combining behavioral therapy and pharmacotherapy for smoking cessation: An up date. In L.S. Onken, J.D. Blaine, & J.J. Boren (Eds.), Integrating behavioral therapies with medications in the treatment of drug dependence: NIDA Research Monograph 150, pp. 92-109. Rockville, MD: National institute on Drug Abuse. NIH Publication No. 95-3899.

Hunt, G. M., & Azrin, N. H. (1973). A community-reinforcement approach to alcoholism. Behavior Research and Therapy, 11, 91-104.

Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: the community reinforcement approach. New York: Guilford Press.

Miller, W. R., Brown, J. M., Simpson, et al. (1995). Coping and social skills training. In R.K. Hester & W.R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp 12-44. Boston: Allyn and Bacon.

Monti, P. M., Rohsenow, D. J., Colby, S. M., et al. (1995). Coping and social skills training. In R.K. Hester & W.R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp. 221-241. Boston: Allyn and Bacon.

Monti, P. M., Rohsenow, D. J., Michalec, E., et al. (1997). Brief coping skills treatment for cocaine abuse: substance use outcomes at three months. Addiction, 92, 1717-1728.

O'Farrell, T. J. (1995). Marital and family therapy. In R. K. Hester & W. R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp 195-220. Boston: Allyn and Bacon.

Stitzer, M.L. &Higgins, S. T. (1995). Behavioral treatment of drug and alcohol abuse. In F.E. Bloom & D.J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress (pp. 1807-1819). New York: Raven Press.

U. S. Department of Health and Human Services. Smoking cessation: Clinical practice guidelines. Washington, DC: US Department of Health and Human Services, 1996; Agency for Health Care Policy and Research, Research Publication No. 96-0692.

Stephen T. Higgins

Alan J. Budney

Sarah Heil

Aversion Therapy

For many years, attempts have been made to condition alcoholics to dislike alcohol. For example, alcoholics are asked to taste or smell alcohol just before a preadministered drug makes them nauseated. Repeated pairing of alcohol and nausea results in a conditioned response—after a while, alcohol alone makes them nauseated. Thereafter, it is hoped, the smell or taste of alcohol will cause nausea and discourage drinking.

Instead of pairing alcohol with nausea, other therapists have associated it with pain, shocking patients just after they drink, or they have associated it with panic from not being able to breathe by giving them a drug that causes very brief respiratory paralysis. Others have trained patients to imagine unpleasant effects from drinking, hoping to set up a conditioned response without causing so much physical distress.

Does it work? Some degree of conditioning is usually established, but it is uncertain how long the conditioning lasts. The largest study that involved conditioning alcoholics was conducted many years ago in Seattle, Washington (Lemere & Voegtlin, 1940). More than 34,000 patients conditioned to feel nauseated when exposed to alcohol were studied ten to fifteen years after treatment. Sixty-six percent were abstinent, an impressive recovery rate compared to other treatments. The patients who did best had had booster sessions—that is, they had come back to the clinic after the initial treatment to repeat the conditioning procedure. Of those who attended booster sessions, 90 percent were abstinent. Based on this study, the nausea treatment for alcoholism would seem an outstanding success. Why hasn't it been universally accepted?

One reason is that the results can be attributed to factors other than the conditioning. The patients in the study were a special group. Generally, they were well educated, had jobs, and were well off financially. They may not have received the treatment otherwise, since the clinic where they were treated was private and expensive. Studies of alcoholics have often shown that certain subject characteristics are more predictive of successful treatment outcome than the type of treatment administered. These factors include job stability, living with a relative, absence of a criminal record, and living in a rural community. In the Seattle study there was no control group that did not receive conditioning therapy. It is possible that this select group of patients, many having characteristics that favor a good outcome, would have done as well without conditioning.

Furthermore, in conditioning treatments, motivation is important. Treatment is voluntary and involves acute physical discomfort; presumably few would consent to undergo the therapy if they were not strongly motivated to stop drinking. The Seattle study makes this point graphically clear. Those who came back for booster sessions did better than those who didn't, but another group did better still: those who wanted to come back but couldn't because they lived too far from the hospital. All of these people remained abstinent.

For many years, chemically induced aversive conditioning of alcoholics was virtually ignored in the literature. Then, in 1990, Smith and Frawley published an outcome study of patients who received aversion therapy as part of their inpatient treatment. From a randomly selected sample of 200 patients, 80 percent were located and interviewed by telephone. Between thirteen and twenty-five months had passed since their discharges from the hospital. The overall abstinence rate for the first twelve months was 71 percent; it was 65 percent for the total period.

Follow-up studies of alcoholism treatment rarely report abstinence rates this high. How should these be interpreted?

As in the original Seattle study, in the Smith and Frawley study, the patients, by and large, had good prognostic features. At the time of admission, more than 50 percent were married and had some college education. Nearly 80 percent were employed. They could afford a private hospital. In short, with characteristics that favor a good outcome, they might have done as well without conditioning. Moreover, the inpatient program involved more than aversive conditioning. It included many ingredients found in other treatment programs, including counseling, a family program and aftercare plan, and Alcoholics Anonymous.

One finding in this report was similar to that of the original study—booster sessions are important. One month and three months after discharge, the patients were asked to return for reinforcement treatments. Just as in the original studies, those who returned for the booster sessions had a particularly good outcome. In fact, the most powerful predictor of abstinence was the number of reinforcement treatments utilized by each patient. Those taking two reinforcement treatments had a twelve-month abstinence rate of 70 percent; those who took only one had a 44 percent rate; and those who had no reinforcement had only a 27 percent rate. Seven percent took more than two reinforcement treatments and had a phenomenal twelve-month abstinence rate of 92 percent.

The importance of reinforcement sessions may reflect motivation on the part of the patient, actual Pavlovian conditioning, or both. The paper does not tell whether the patients developed a true conditioned response to alcohol at any time. Information about this would help separate nonspecific motivational factors from actual conditioning.

The study lacked a control group. This was remedied in a report (Smith, Frawley, & Polissar, 1991) that compared 249 alcoholic inpatients who received aversion therapy with patients from a national treatment registry who did not receive aversion therapy. The patients treated with aversion therapy had significantly higher abstinence rates at six and twelve months, suggesting that motivation and good prognostic features may not completely explain the success of this still rather unpopular treatment.

Frawley and Smith (1992) have also reported remarkably high abstinence rates from cocaine (current abstinence of at least six months, 68 percent) among a similar group of patients, with good prognostic features, treated with aversion therapy and follow-up at an average of fifteen months after treatment. Again there was no control group.

Aversion treatment for cigarette smoking has been studied by using appropriate controls. The technique involves encouraging the smoker to keep inhaling at rapid intervals over a period of five to ten minutes until he or she becomes sick, presumably because the nicotine levels exceed the smoker's tolerance levels. This approach has consistently produced higher levels of abstinence from smoking than have control groups.

(See also: Calcium Carbimide ; Disulfiram )

BIBLIOGRAPHY

Frawley, P. J., & Smith, J. W. (1992). One-year follow-up after multimodal inpatient treatment for cocaine and methamphetamine dependencies. Journal of Substance Abuse Treatment, 9, 271-286.

Lemere, F., & Voegtlin, W. L. (1940). Conditioned reflex therapy of alcoholic addiction: Specificity of conditioning against chronic alcoholism. California and Western Medicine, 53 (6), 1-4.

Smith, J. W., & Frawley, P. J. (1990). Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. Journal of Substance Abuse Treatment, 7, 77-82.

Smith, J. W., Frawley, P. J., & Polisser (1991). Six- and twelve-month abstinence rates in inpatient alcoholics treated with aversion therapy compared with matched inpatients from a treatment registry. Alcohol: Clinical and Experimental Research 5, 862-870.

Donald W. Goodwin

Cognitive Therapy

Cognitive treatment is based on the assumption that the way one thinks is a primary determinant of feelings and behavior. Developed from Beck's research (Beck et al., 1979, 1993), cognitive treatment is approached as a collaborative effort between the client and therapist to examine the client's errors and distortions in thinking that contribute to problematic behavior. This examination is fostered through a combination of verbal techniques and behavioral experiments to test the underlying assumptions the client holds about the problematic behavior.

Cognitive treatment in the substance-abuse field was a direct extension of Beck's work. Beck's catalog of distorted thoughts examined in depression were found to be applicable to cognitive distortions and errors that accompany addictive disorders. Various cognitive treatments for substance abuse focus on these distortions and vary primarily in the techniques used to change these thought processes.

In Relapse Prevention (Marlatt & Gordon, 1985), cognitive distortions are viewed as instrumental in the process that leads to relapse. By helping the client thoroughly examine the thoughts that accompany substance use, therapy can reduce the likelihood of a lapse (single use), as well as help prevent a lapse from becoming a relapse (return to uncontrolled use). This is accomplished by examining the following cognitive errors:

1. Overgeneralizing—this is one of the most frequently occurring cognitive errors that helps a single lapse become a full-blown relapse. By viewing the single use as a sign of total relapse, the client overgeneralizes the single use of a substance as a symptom of total failure, thereby allowing for increasing use over time and in a variety of situations. This is sometimes referred to as the Abstinence Violation Effect (AVE).
2. Selective abstraction—by excessively focusing on the immediate lapse, with an accompanying neglect of all past accomplishments and learning, the client interprets a single slip as equivalent to total failure. The individual measures progress almost exclusively in terms of errors and weaknesses.
3. Excessive responsibility—by attributing the cause of a lapse to personal, internal weaknesses or lack of willpower, the client assumes total responsibility for the slip, which in turn makes reassuming control more difficult than when environmental factors are considered partially responsible for the slip.
4. Assuming temporal causality—here, the client views a slip as the first of many to come, thereby dooming all future attempts at self-control.
5. Self-reference—when the client thinks that a lapse becomes the focus of everyone else's attention, believing that others will attribute blame for the event to the client, this adds to feelings of guilt and shame that may already be present within the person.
6. Catastrophizing—the client believes the worst possible outcome will occur from a single use of the substance instead of thinking about how to cope successfully with the initial lapse.
7. Dichotomous thinking—by viewing events in "black and white," clients view their addictive behavior exclusively in terms of abstinence or relapse and leave no logical room for "gray" areas, where they can get back on track once a slip has occurred.
8. Absolute willpower breakdown—here, the client assumes that once willpower has failed, loss of control is inevitable, never to be regained.
9. Body over mind—the cognitive error here is assuming that once a single lapse has occurred, the physiological process of addiction has exclusive control over subsequent behavior, making continued use inevitable.

These errors in thinking are targeted for change in relapse prevention by helping the client learn how to reattribute the cause of a lapse from internal, stable, personal causes to mistakes or errors in the learning process. To facilitate the client's sense of personal control, lapses are viewed as opportunities for corrective learning, instead of indications of total failure. Congruent with the research in the area (Shiffman, 1991), the therapist presents a lapse as a frequently occurring event in the journey toward recovery. The therapist therefore encourages the client to examine the thoughts and expectancies that surround the lapse closely, with the aim of learning alternative coping skills for similar situations that may arise in the future. By re-framing a lapse as a learning opportunity, the client is encouraged to view the event as a chance to hone the skills required for abstinence, thereby countering the cognitive errors of selective abstraction.

To intervene with the errors of overgeneralization and temporal causality, the client is taught to view a lapse as a specific, unique event in time and space, instead of as a symptom with greater significance attached to it (e.g., the beginning of the inevitable end). The errors of self-reference and willpower breakdown can be countered by teaching the client to reattribute a lapse to external, specific, and controllable factors. By examining the difficulty of the high-risk situation, the appropriateness of the coping response employed, and any motivational deficits (fatigue or excessive stress), the client can maintain a sense of control over the event and the process of recovery.

Each of these techniques is aimed at conveying the idea that abstinence is the result of a learning process, requiring an acquisition of skills similar to many other skills one learns. This general metaphor can help the client reverse catastrophizing, by reframing a relapse as a "prolapse," as a fall forward rather than backward. This view, combined with viewing a lapse as a unique event in time, helps the client maintain a sense of personal control, since abstinence or control is framed as just a moment away if use is discontinued.

Several skills are taught to the client in relapse prevention to facilitate these cognitive changes and prevent future lapses. Identifying specific sources of stress that contribute to urges, cravings, or lapses helps isolate the event in time as well as identify other distortions that may be present. For example, clients may identify discussing money with one's spouse as the high-risk situation that preceded a lapse. While discussing the lapse with a therapist, clients can learn to anticipate that discussing money in the marriage may trigger an urge or craving to drink. Teaching clients to use visual imagery, such as viewing the urge as a wave that they can surf, can help manage the feeling that urges will continue to build until they must inevitably be given in to. Self-talk is encouraged if a client believes this will help gain a sense of personal control (such as reciting a phrase to oneself about the goal of abstinence or remembering who can be telephoned when an urge is experienced). In addition, clients are taught to be alert for "apparently irrelevant decisions," which can inadvertently lead to relapse. For example, an abstinent gambler may decide to take a scenic drive through Reno, only to find a situation that would be extremely difficult for many to ignore, thus in this case causing a relapse.

Other theorists have developed treatments based exclusively on changing irrational thinking. Ellis and colleagues (1988) founded a self-help group network called Rational Recovery (RR), based on the principles of rational emotive therapy. Developed as an alternative to the Alcoholics Anonymous network, RR focuses on "addictive thinking" and views abstinence as possible—purely as a result of changing these thought processes. This differs from the relapse prevention model described above, which in its entirety combines cognitive and behavioral techniques. Ellis's RR movement teaches addicts how to identify, their own faulty thinking through a self-help manual (Trimpey, 1989) and the attendance at support groups.

(See also: Alcoholism ; Causes of Substance Abuse ; Disease Concept of Alcoholism and Drug Abuse )

BIBLIOGRAPHY

Beck, Aaron T. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.

Carroll, Kathleen M. (1998). A cognitive behavioral approach: Treating cocaine addiction. Therapy Manuals for Drug Addiction. U.S. Department of Health and Human Services: National Institute on Drug Abuse.

Liese, Bruce S. & Beck, Aaron T. (1997). Back to basics: Fundamental cognitive therapy skills for keeping drug-dependent individuals in treatment. In Lisa S. Onken, Jack D. Blaine, & John J. Boren (Eds), Beyond the therapeutic alliance: Keeping the drug-dependent individual in treatment. NIDA Research Monograph 165, 207-232. U.S. Department of Health and Human Services: National Institute on Drug Abuse.

Molly Carney

Revised by Rebecca Horn

Contingency Management

Contingency management (CM) is an intervention that promotes behavior change by providing positive reinforcement when treatment goals are achieved and withholding reinforcement or providing punitive consequences when undesirable behavior occurs. CM has been used effectively in the treatment of a wide variety of forms of drug dependence, including amphetamine (Boudin, 1972), alcohol (Miller, 1975; Petry et al., 2000), cocaine (Higgins et al., 1993, 2000), marijuana (Budney at al., in press), nicotine (Donatelle et al., 2000), and opiates (Hall, et al., 1979; Bickel et al., 1997).

Contingency management involves an agreement or contract that carefully stipulates the desired behavior change, the schedule and methods for monitoring progress, the consequences that will follow success or failure in making the behavior change, and the duration of the contract. Practical details on the development and implementation of CM interventions can be found in several sources (Budney & Higgins, 1998; Higgins & Silverman, 1999; Petry, 2000)

The most common use of CM with drug-dependent individuals is to reinforce abstinence from drug use. Numerous studies have demonstrated that providing incentives contingent on objective evidence of abstinence from recent drug use (e.g., negative urinalysis results) increases future abstinence (see Higgins & Silverman, 1999; Stitzer & Higgins, 1995). Although compelling evidence regarding the efficacy of CM has been available since the 1970s, interest in this treatment approach was bolstered substantially by successes achieved with CM in the treatment of cocaine dependence. In a seminal study on that topic, thirty-eight cocaine-dependent adults were randomly assigned to twenty-four weeks of behavior therapy including CM or to drug abuse counseling (Higgins et al., 1993). In the CM condition, vouchers redeemable for retail items were earned by submitting specimens that tested negative for cocaine use in urine toxicology testing. More than 50 percent of patients in the CM condition remained in treatment for the recommended twenty-four weeks and achieved several months of continuous cocaine abstinence while only 11 percent of patients in the comparison condition did so. Subsequent studies of CM in the treatment of cocaine dependence replicated those findings and also demonstrated benefits during the year after treatment ended (Higgins et al., 2000; Silverman et al., 1996). These positive results with CM were particularly encouraging because so few other treatment approaches have been shown to be efficacious with cocaine dependence.

Most typically, but not always, CM is used as part of a more comprehensive treatment plan. Indeed, CM can be used to improve compliance with other treatment regimens. Early studies with alcoholics, for example, demonstrated that CM could be used to improve medication compliance among individuals receiving disulfiram (Antabuse) therapy (Liebson et al., 1978). More recent studies have demonstrated CM's efficacy in improving medication compliance among tuberculosis-exposed and HIV-infected drug abusers (Elk, 1999; Rosen et al., 2000). CM can also improve compliance with participation in therapy-related activities among opiate-dependent patients (Bickel et al., 1997; Iguchi et al., 1997). In these applications, patients earned vouchers by completing some minimum number of therapy-related activities weekly. The activities might include attending a job interview if the goal was gaining employment, or attending a self-help meeting if the goal was to increase contact with a social network to support sobriety. Vouchers were provided when patients submitted documentation verifying that they had completed a designated therapeutic activity. Completion of therapeutic activities was associated with greater drug abstinence.

CM is also proving to be capable of improving outcomes with important special populations of drug abusers. Improving adherence to medication regimens among those with infectious diseases was noted above. Another special population is the seriously mentally ill who are also drug-dependent. Results from several preliminary studies indicate that CM may be effective in reducing cigarette smoking (Roll et al., 1998), cocaine use (Shaner et al., 1997), and marijuana use (Sigmon et al., in press) among individuals with schizophrenia. CM is an integral component of a multielement treatment that is efficacious in the treatment of homeless crack and other drug abusers (Milby et al., 2000). Another special group for whom effective treatments are sorely needed is drug-dependent pregnant women. A voucher-based CM intervention has been demonstrated to significantly increase abstinence from cocaine and heroin use while simultaneously increasing vocational skills among pregnant women who were both drug dependent and chronically unemployed (Silverman et al., in press). In another effective CM intervention with pregnant women, vouchers delivered contingent on abstinence from cigarette smoking increased cessation rates during pregnancy and postpartum (Donatelle et al., 2000).

As illustrated in the preceding material, CM is effective in increasing drug abstinence and in improving compliance with treatment regimens for various types of drug dependence and populations. Positive outcomes have been achieved even with some of the most challenging and recalcitrant subgroups of drug abusers. A notable shortcoming associated with CM is a loss of treatment gains when the intervention is terminated. As noted above, beneficial carryover effects have been demonstrated through a year or more posttreatment, and the rates of relapse appear to be comparable to those observed among individuals treated with other interventions. Nevertheless, relapse is an important problem needing improvement. Systematic use of multimodel interventions designed to address the many changes likely to be necessary for longer-term success is one reasonable approach, as is the development of longer-term CM interventions that can be kept in place until the patient gains the requisite skills to sustain abstinence without CM support.

BIBLIOGRAPHY

Bickel, W. K., et al. (1997). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810.

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Stephen T. Higgins

Alan J. Budrey

Sarah Heil

Group and Family Therapy

The illnesses of drug addiction and alcoholism are so severe that they pervade every aspect of an individual's existence. It is rare that so extensive an illness can be reversed by individual therapy alone. Thus therapists are espousing an integration of individual, Twelvestep, group, and family treatment, with specific combinations of treatments tailored to each individual's needs.

Dealing with the family is one more involvement with the patient's ecosystem, which includes working with the treatment team, twelve-step groups, sponsors, employers, EAPs (Employee Assistance Program counselors), managed-care workers, parole officers, and other members of the legal system. However, family work is most critical to the success of treatment.

Group therapy has frequently been designated as the treatment of choice for addicted patients. This article views group therapy as an essential component of the integrated, individualized approach to addicts and alcoholics.

FAMILY THERAPY

The family treatment of substance abuse begins with developing a system to achieve and maintain abstinence. This system, together with specific family therapeutic techniques and knowledge of patterns commonly seen in families with a substance-abusing member, provides a workable, therapeutic approach to substance abuse.

Family treatment of substance abuse must begin with an assessment of the extent of substance dependence as well as the difficulties it presents for the individual and the family. The quantification of substance-abuse history can take place with the entire family present; substance abusers often will be honest in this setting, and "confession" is a helpful way to begin communication. Moreover, other family members can often provide more accurate information than the substance abusers (also known as the identified patient, IP). However, some IPs will give an accurate history only when interviewed alone.

In taking a drug-abuse history, it is important to know current and past use of every type of abusable drug as well as of Alcohol: quantity, quality, duration, expense, how intake was supported and prevented, physical effects, tolerance, withdrawal, and medical complications. At times, other past and present substance abusers within the family are identified; their own use and its consequences should be quantified without putting the family on the defensive. It is also essential to document the family's patterns of reactivity to drug use and abuse. Previous attempts at abstinence and treatment are reviewed to determine components of success and failure. The specific method necessary to achieve abstinence can be decided only after the extent and nature of substance abuse are quantified.

Establishing a System to Achieve a Substance-Free State.

It is critical first to establish a system for enabling the substance abuser to become drug-free, so that family therapy can be effective. The specific methods employed to achieve abstinence vary according to the extent of use, abuse, and dependence. Mild-to-moderate abuse in adolescents can often be controlled if both parents agree on clear limits and expectations, and how to enforce them. Older abusers may stop if they are aware of the medical or psychological consequences to themselves or the effects on their family.

If substance abuse is moderately severe or intermittent and without physical dependence, such as intermittent use of Hallucinogens or weekend Cocaine abuse, the family is offered a variety of measures, such as regular attendance at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or Cocaine Anonymous (CA) for the IP and Al-Anon or Naranon for family members.

If these methods fail, short-term hospitalization or treatment in an intensive outpatient program (20 hours or more per week) may be necessary to establish a substance-free state and to begin effective treatment even with nondependent patients. In more severe cases of drug abuse and dependence, more aggressive methods are necessary to establish a substance-free state.

Family Education.

A substantial amount of family education is generally very helpful in the early stages of the family's involvement in therapy. In many inpatient addiction treatment programs, the family spends several days or more receiving appropriate education. If this is not available, the therapist should include this education process in early sessions.

Some of the issues covered by this educational emphasis are: (1) the physiological and psychological effects of drugs and alcohol; (2) the disease concept; (3) cross addiction (which helps families learn that a recovering cocaine addict should not drink or vice versa); (4) common family systems—emphasizing the family's roles in addiction and recovery, including enabling, scapegoating, and Codependency; (5) the phases of treatment, with an emphasis on the deceptiveness of the "honeymoon" period in early recovery; and (6) the importance of twelve-step family support groups (Alan-ON, Alateen).

Working with Families with Continued Drug Abuse.

The family therapist is in a unique position with regard to continued substance abuse and other manifestations of the IP's resistance to treatment, including total nonparticipation. The family therapist still has a workable and highly motivated patient (s): the family. One technique that can be used with an absent or highly resistant patient is the intervention, which was developed for use with alcoholics but can be readily adapted to work with drug abusers, particularly those who are middle class, involved with their nuclear families, and employed.

In this technique, the family (excluding the abuser) and significant network members (e.g., employer, fellow employees, friends, and neighbors) are coached to confront the subtance abuser with concern, but without hostility, about the destructiveness of his or her drug abuse and behavior. They agree in advance about what treatment is necessary and then insist on it. As many family members as possible should be included, because the breakthrough for acceptance of treatment may come from an apparently uninvolved family member, such as a grandchild or cousin. The involvement of the employer is crucial, and in some cases may be sufficient in and of itself to motivate the drug abuser to seek treatment. The employer who clearly makes treatment a condition of continued employment, who supports time off for treatment, and who guarantees a job on completion of the initial treatment course is a very valuable ally. The employer's model is also a very helpful one for the family, who need to be able to say "We love you, and because we love you, we will not continue to live with you if you continue to abuse drugs and alcohol. If you accept the treatment being offered to you and continue to stay off drugs, we will renew our lifetime commitment to you."

If substance abusers do not meet the above criteria for an intervention or if the intervention has failed, we are left with the problems of dealing with a substance-abusing family. Berenson (1976) offers a workable, three-step therapeutic strategy for dealing with the spouses or other family members of individuals who continue to abuse substances or who are substance dependent. Step one is to calm down the family by explaining problems, solutions, and coping mechanisms. Step two is to create an external support network for family members so that the emotional intensity is not all in the relationship with the substance abuser or redirected to the therapist. There are two types of support systems available to these spouses. One is a self-help group on the Al-Anon, Naranon, or Coanon model; the other is a significant others (SO) group led by a trained therapist. In the former, the group and sponsor provide emotional support, reinforce detachment, and help calm the family. An SO group may provide more insight and less support for remaining with a substance-abusing spouse.

Step three involves giving the client three choices: (1) keep doing exactly what you are doing; (2) detach or emotionally distance yourself from the drug abuser; or (3) separate or physically distance yourself. When the client does not change, it is labeled an overt choice 1. When a client does not choose 2 or 3, the therapist can point out that he or she is in effect choosing not to change. If not changing becomes a choice, then the SO can be helped to choose to make a change. In choice 2, SOs are helped to avoid overreacting emotionally to drug abuse and related behavior, and they are taught strategies for emotional detachment. Leaving, choice 3, is often difficult when the family is emotionally or financially dependent on the substance abuser.

Each of these choices seems impossible to carry out at first. The problem of choosing may be resolved by experiencing the helplessness and powerlessness in pursuing each choice.

As part of the initial contract with a family, it is suggested that the abuser's partner continue individual treatment, Al-Anon, Coanon, or an SO group even if the abuser drops out. Other family members are also encouraged to continue in family therapy and support groups. It should be reemphasized that whenever therapy is maintained with a family in which serious drug abuse continues, the therapist has the responsibility of not maintaining the illusion that the family is resolving problems, when in fact they are really reinforcing them. Even when the substance abuser does not participate in treatment, however, therapy may be quite helpful to the rest of the family.

The concept of the family as a multigenerational system necessitates that the entire family be involved in treatment. The family members for optimum treatment consist of the entire household and any relatives who maintain regular (approximately weekly) contact with the family. In addition, relatively emancipated family members who have less than weekly contact may be very helpful to these families.

The utilization of a multigenerational approach involving grandparents, parents, spouse, and children at the beginning, as well as certain key points throughout, family therapy is advised. However, the key unit with substance abusers younger than about age 24 is the IP with siblings and parents. The critical unit with married substance abusers older than 24 is the IP and spouse. However, the more dependent the IP is on the parents, the more critical is family work with these parents. The majority of sessions should be held with these family units; the participation of other family members is essential to more thorough understanding and permanent change in the family.

Family therapy limited to any dyad is most difficult. The mother-addicted-son dyad is almost impossible to treat as a sole entity; some other significant person, such as a lover, grandparent, aunt, or uncle should be brought in if treatment is to succeed. If there is absolutely no one else available from the natural family network, then surrogate family members in multiple-family therapy groups can provide support and leverage to facilitate restructuring maneuvers.

AN INTEGRATED APPROACH TO A WORKABLE SYSTEM OF FAMILY TREATMENT

Family Diagnosis.

Accurate diagnosis is as important a cornerstone of family therapy as it is in individual therapy. Family diagnosis looks at family interaction and communication patterns and relationships. In assessing a family, it is helpful to construct a map of the basic alliances and roles, as well as to examine the family rules, boundaries, and adaptability.

Family Treatment Techniques.

Each system of family therapy presently in use is briefly summarized below, with an emphasis on the application of these techniques to substance abusers. They are classified into four schools: structural-strategic, psychodynamic, Bowen's systems theory, and behavioral. Any of these types can be applied to substance abusers if their common family patterns are kept in mind and if a method to control substance abuse is implemented.

Structural-Strategic Therapy.

These two types are combined because they were developed by many of the same practitioners, and shifts between the two are frequently made by the therapist, depending on the family's needs. The thrust of structural family therapy is to restructure the system by creating interactional change within the session. The therapist actively becomes a part of the family, yet retains sufficient autonomy to restructure it. The techniques of structural therapy have been described in detail by Kaufman (1985). They include the contract, joining, actualization, marking boundaries, assigning tasks, reframing, the paradox, balancing and unbalancing, and creating intensity.

According to strategic therapists, symptoms are maladaptive attempts to deal with difficulties, which develop a homeostatic life of their own and continue to regulate family transactions. The strategic therapist works to substitute new behavior patterns for the destructive repetitive cycles. The techniques used by strategic therapists include the following:

1. Using tasks with the therapist responsible for planning a strategy to solve the family's problems.
2. Putting the problem in solvable form.
3. Placing considerable emphasis on change outside the sessions.
4. Learning to take the path of least resistance, so that the family's existing behaviors are used positively.
5. Using paradox, including restraining change and exaggerating family roles.
6. Allowing the change to occur in stages; the family hierarchy may be shifted to a different, abnormal one before it is reorganized into a new functional hierarchy.
7. Using metaphorical directives in which the family members do not know they have received a directive.

Stanton et al. (1982) successfully utilized an integrated structural-strategic approach with heroin addicts on Methadone Maintenance treatment.

Psychodynamic Therapy.

This approach has rarely been applied to substance abusers because they usually require a more active, limit-setting emphasis on the here and now than is generally associated with psychodynamic techniques. However, if certain basic limitations are kept in mind, psychodynamic principles can be extremely helpful in the family therapy of these patients.

There are two cornerstones for the implementation of psychodynamic techniques: the therapist's self-knowledge and a detailed history of the substance abuser's family.

Important elements of psychodynamic family therapy include the following:

countertransference —

The therapist may have a countertransference problem toward the entire family or any individual member of the family, and may get into power struggles or overreact emotionally to affect, content, or personality. The IP's dependency, relationship suction and repulsion, manipulativeness, denial, impulsivity, and family role abandonment may readily provoke counter-transference reactions in the therapist. However, family therapists view their emotional reactions to families in a systems framework as well as a counter-transference context. Thus they must be aware of how families will replay their problems in therapy by attempting to detour or triangulate their problems onto the therapist. The therapist must be particularly sensitive to the possibility of becoming an enabler who, like the family, protects or rejects the substance abuser.

the role of interpretation —

Interpretations can be extremely helpful if they are made in a complementary way, without blaming, guilt induction, or dwelling on the hopelessness of longstanding, fixed patterns. Repetitive patterns and their maladpative aspects for each family member can be pointed out, and tasks can be given to help change these patterns. Some families need interpretations before they can fulfill tasks. An emphasis on mutual responsibility when making any interpretation is an example of a beneficial fusion of structural and psychodynamic therapy.

overcoming resistance —

Resistance is defined as behaviors, feelings, patterns, or styles that prevent change. In substance-abusing families, key resistance behaviors that must be dealt with involve the failure to perform functions that enable the abuser to stay "clean."

Every substance-abusing family has characteristic patterns of resistant behavior, in addition to individual resistances. This family style may contribute significantly by resistance; some families may need to deny all conflict and emotion, and are almost totally unable to tolerate any displays of anger or sadness; others may overreact to the slightest disagreement. It is important to recognize, emphasize, and interpret the circumstances that arouse resistance patterns.

Bowen's Systems Family Therapy.

In Bowen's (1974) approach, the cognitive is emphasized and the use of affect is minimized. Systems theory focuses on triangulation, which implies that whenever there is emotional distance or conflict between two individuals, tensions will be displaced onto a third party, issue, or substance. Drugs are frequently the subject of triangulation.

Behavioral Family Therapy.

This approach is commonly used with substance-abusing Adolescents. Its popularity may be attributed to the fact that it can be elaborated in clear, easily learned steps.

Noel and McCrady (1984) developed seven steps in the therapy of alcoholic couples that can readily be applied to married adult drug abusers and their families:

1. Functional analysis. Families are taught to understand the interactions that maintain drug abuse.
2. Stimulus control. Drug use is viewed "as a habit triggered by certain antecedents and maintained by certain consequences." The family is taught to avoid or change these triggers.
3. Rearranging contingencies. The family is taught techniques to provide reinforcement for efforts at achieving a drug-free state by frequent reviewing of positive and negative consequences of drug use and self-contracting for goals and specific rewards for achieving these goals.
4. Cognitive restructuring. IPs are taught to modify self-derogatory, retaliatory, or guilt-related thoughts. They question the logic of these "irrational" thoughts and replace them with more "rational" ideation.
5. Planning alternatives to drug use. IPs are taught techniques for refusing drugs through role-playing and covert reinforcement.
6. Problem solving and assertion. The IP and family are helped to decide if a situation calls for an assertive response and then, through role-playing, to develop effective assertive techniques. IPs are to perform these techniques twice daily and to utilize them in situations that would have previously triggered the urge to use drugs.
7. Maintenance planning. The entire course of therapy is reviewed, and the new armamentarium of skills is emphasized. IPs are encouraged to practice these skills regularly as well as to reread handout materials that explain and reinforce these skills.

Families can also be taught through behavioral techniques to become aware of their nonverbal communication, so as to make the nonverbal message concordant with the verbal and to learn to express interpersonal warmth nonverbally as well as verbally.

FAMILY READJUSTMENT AFTER CESSATION

Once the substance abuse has stopped, the family may enter a honeymoon phase in which major conflicts are denied. They may maintain a superficial harmony based on relief and suppression of negative feelings. When the drug-dependent person stops using drugs, however, other family problems may be uncovered, particularly in the parents' marriage or in other siblings. These problems, which were present all along but obscured by the IP's drug use, will be "resolved" by the IP's return to symptomatic behavior if they are not dealt with in family therapy. In the latter case, the family reunites around their problem person, according to their old, familiar pathological style.

Too many treatment programs in the substance-abuse field focus their efforts on brief, high-impact treatment, neglecting aftercare. Many of these programs include a brief, intensive family educational and therapeutic experience, but have even less focus on the family in aftercare than on the IP. These intensive, short-term programs have great impact on the family system, but only temporarily. The pull of the family homeostatic system will draw the IP and/or other family members back to symptomatic behavior. The family must be worked with for months, and often years, after substance abuse first abates if a drug-free state is to continue. In addition, ongoing family therapy is necessary for the emotional well-being of the IP and other family members.

GROUP THERAPY

Group therapy varies with each of the three phases in the psychotherapy of substance abusers: achieving abstinence, early Sobriety, and late sobriety (achieving intimacy).

Early Phase: Achieving Abstinence.

In the first phase of psychotherapy, the type of group utilized will depend on the treatment setting: hospital, residential, intensive outpatient (also termed partial hospitalization), or limited outpatient.

In hospital settings, educational groups are an essential part of the early treatment process, and the subjects covered in these groups are quite similar to those in educational family groups (described in the first section of this article). The major difference of emphasis in patient educational groups is on the physiological aspects and risk factors of drugs and alcohol. Other important didactic groups cover in detail issues such as (1) Assertiveness Training; (2) other compulsive behaviors, such as sexuality, eating, working, and Gambling; (3) Relapse Prevention; (4) the prolonged abstinence syndrome; (5) leisure skills; and (6) cross addiction. All educational groups include appropriate coping strategies, some of which are developed from the experiences of recovering members.

One advantage of 28-day residential programs (now more often 7 to 21 days, followed by an intensive 6-hours-a-day outpatient program) is that group therapy can be started immediately after drinking or drug use stops. In the first few sober days, the addict or alcoholic is so needy that his/her resistance to groups is low. At this stage, the therapist and the group should show the substance abuser how to borrow the confidence that life without alcohol or drugs is possible and better than life with it. This hope is best offered by a therapist or cotherapist who is a recovering substance abuser with solid sobriety. Therapeutic groups in these settings will also deal with appropriate expressions of feelings, relationships with significant others, childhood molestation and abuse, building self-esteem, and development of strategies for self-care.

A critical aspect of early group therapy is for the patient to experience the sharing of a group of individuals struggling against their addiction. This helps to overcome the feelings of isolation and shame that are so common in these patients. The formation of a helping, sober peer group that provides support for a lifetime, in and out of twelve-step groups, is very helpful and dramatic when it occurs.

In outpatient programs there is less of an opportunity to perform uncovering therapy in the early phases because there is less protection and less of a holding environment than in residential settings.

Others, particularly Woody et al. (1986), have developed detailed group therapy techniques for methadone patients. Also, Brown and Yalom (1977) and Vanicelli (1992), with alcoholics, and Khantzian et al. (1990), with cocaine addicts, have adapted psychodynamic techniques for group work.

Ex-addicts and recovering alcoholics are valuable as cotherapists, or even as primary or sole therapist, particularly in the early stages of groups. Commonality of experience with the client, by itself, does not qualify an individual to be a therapist. Recovering persons should have at least two years of sobriety before they are permitted to function as group therapists. The techniques that help ex-addicts become experienced therapists are best learned gradually and under close supervision, preferably by experienced paraprofessionals and professionals.

Also helpful in cotherapy is male-female pairing, which provides a balance of male and female role models and transference.

During the early sessions of group therapy with substance abusers, the focus is on the shared problem of drinking or drug use, and its meaning to each individual. The therapist should be more active in this phase, which should be instructional and informative as well as therapeutic.

Alcoholics tend toward confessionals and monologues about prior drinking. These can be politely interrupted or minimized by a ground rule of "no drunkalogues." Romanticizing past use of drugs or alcohol is strongly discouraged.

Outpatient Groups.

The desire to drink or use drugs and the fear of slipping are pervasive, early concerns in outpatient groups. The patient's attitude is one of resistance and caution, combined with fear of open exploration. Members are encouraged to participate in AA and other relevant twelve-step groups, yet the "high support, low conflict, inspirational style" of AA may inhibit attempts at interactional therapy. Therapists should not be overly protective and prematurely relieve the group's anxiety because this fosters denial of emotions. On the other hand, the members' recognition of emotions and responsibility must proceed slowly because both are particularly threatening to substance abusers. Patients are superficially friendly, but do not show real warmth or tenderness. AA-type hugs are an easy way to begin to show physical support. They are afraid to express anger or to assert themselves. However, sudden irritation, antipathy, and anger toward the leaders and other members inevitably begin to become more overt as the group progresses.

Gradually, tentative overtures of friendship and understanding become manifest. There may be a conspiracy of silence about material that members fear could cause discomfort or lead to drug use or drinking. The therapists can point out to the members that they choose to remain static and within comfortable defenses rather than expose themselves to the discomfort associated with change. Patients usually drop out early if they are still committed to using drugs or drinking. Other patients who drop out early do so because they grow increasingly alarmed as they become aware of the degree of discomfort that any significant change requires.

Middle Phase: Early Sobriety.

In the middle phase of group therapy, the emphasis is quite similar to that of individual therapy. Therapists should continue to focus on cognitive behavioral techniques to maintain sobriety. Intensive affects are abreacted toward significant persons outside of the group but are minimized and modulated between group members. In this stage there evolves a beginning awareness of the role of personality and social interactions in the use of drugs and alcohol. Alcoholics are ambivalent about positive feedback. They beg for it, yet reject it when it is given. They repeatedly ask for physical reassurance, such as a warm hug, but may panic when they receive it because of fear of intimacy and a reexperiencing of their unmet past needs. There is a fear of success and a dread of competing in life as well as in the group. Success means destroying the other group members (siblings) and loss of therapist (parent).

Alcoholics are reluctant to explore fantasies because the thought makes them feel as guilty as the act. They view emotions as black or white. This makes them withhold critical comments because they fear their criticism will provoke upset and the resumption of drinking in other members. This withholding may be conscious or unconscious. Rage has been expressed either explosively or not at all. Its expression in the middle phase of group should be encouraged, but gradually and under slowly releasing controls.

The other crucial affect that must be dealt with is depression. There is an initial severe depression, which occurs immediately after detoxification. It appears to be severe but usually remits rapidly, leaving the substance abuser with a chronic, low-grade depression—frequently expressed by silence, lack of energy, and vegetative signs. These patients should be drawn out slowly and patiently. Ultimately, they are encouraged to cry or mourn, and a distinction is made between helping them deal with despair as opposed to rushing to take it away from them.

The success of the middle phase of group therapy with substance abusers depends on the therapist's and the group's ability to relieve anxiety through support, insight, and the use of more adaptive, concrete ways of dealing with anxiety. Alcohol and drugs must become unacceptable solutions to anxiety. In this vein, it is important not to end a session with members in a state of grossly unresolved conflict. This can be avoided by closure when excessively troubling issues are raised. Closure can be achieved by the group's concrete suggestions for problem solution. When this is not possible, group support, including extragroup contact by members, can be offered. Brown and Yalom (1977) utilize a summary of the content of each group that is mailed to members between sessions and helps provide closure and synthesis.

Final Phase: Late Sobriety.

In the final phase of therapy, substance abusers express and work through feelings, responsibility for behavior, interpersonal interactions, and the functions and secondary gain of drugs and alcohol. In this phase, reconstructive group techniques as practiced by well-trained professionals are extremely helpful and essential if significant shifts in ego strength are to be accomplished. Here, the substance abuser will become able to analyze defenses, resistance, and transference. The multiple transferences that develop in the group are recognized as "old tapes" that are not relevant to the present. Problems of sibling rivalry, competition with authority, and separation anxiety become manifest in the group, and their transference aspects are developed and interpreted. Conflicts are analyzed on both the intrapsychic and interpersonal levels. Ventilation and catharsis take place, and may be enhanced by group support. Excessive reliance on fantasy is abandoned.

Alcoholics who survive a high initial dropout rate stay in groups longer than neurotic patients, and thus a substantial number of middle-phase alcoholics will reach this final phase. By the closing phase, the alcoholic has accepted sobriety without resentment and works to free himself or herself from unnecessary neurotic and character problems. He or she has developed a healthy self-concept, combined with empathy for others, and has scaled down inordinate demands on others for superego reassurance. He or she has become effectively assertive rather than destructively aggressive and has developed a reasonable sense of values. More fulfilling relationships with spouse, children, and friends can be achieved.

When members leave the group, the decision to leave should be discussed for several weeks before a final date is set. This permits the group to mourn the lost member and for the member to mourn the group. This is true regardless of the stage of the group, but the most intense work is done in the later phases. In open-ended groups, the leadership qualities of the graduating member are taken over by others, who then may apply these qualities to life outside the group.

By the time substance abusers have reached this phase, they act like patients in highly functioning neurotic groups. Other forms of group treatment combine the principles of group and family work, such as multiple family group treatment and couples groups.

Multiple Family Group Treatment (MFGT).

This is a technique that can be used in any treatment setting for substance abusers but is most successful in hospital and residential settings, where family members are usually more available. In a residential setting, the group may be composed of all of the families or separated into several groups of three or four closely matched families. Most MGFTs now include the entire community because this provides a sense of the entire patient group as a supportive family. In residential settings these groups are held weekly for two or three hours. In hospitals, a family week or weekend is often offered as an alternative or adjunct to a weekly group.

Couples Groups.

There are two types of couples groups: one for the parents of young substance abusers and one for the significant other and the substance abuser.

Couples often have difficulty dealing with the role of their own issues in family or other couple therapy dysfunction when the children are present. This boundary is generally appropriate, and thus ongoing couples groups should be an integral part of any family-based treatment program.

When the presenting problem of substance abuse is resolved, content shifts to marital problems. It is often at this point that parents want to leave the MFGT and attend a couples group. In a couples group, procedures are reversed. Couples should not speak about their children but, rather, focus on the relationship between themselves. If material is brought up about the children, it is allowed only if it is relevant to problems that the couples have.

Couples must support each other while learning the basic tools of communication. When one partner gives up substance misuse, the nonusing partner must adjust the way he or she relates to the formerly using partner. There are totally new expectations and demands. Sex may have been used for exploitation and pacification so often that both partners have given up hope of resuming sexual relations and have stopped serious efforts toward mutual satisfaction. In addition, drugs and alcohol may have physiologically diminished the sex drive. Sexual communication must be slowly redeveloped. Difficulties may arise because the recovering abuser has given up the most precious thing in his or her life (drugs or alcohol) and expects immediate rewards. The spouse has been "burned" too many times (and is unwilling to provide rewards when sobriety stabilizes the spouse) to trust one more time; at the same time the recovering abuser is asked to reevaluate expectations for trust.

Couples groups in an adult or an adolescent program provide a natural means for strengthening intimacy. Spouses are encouraged to attend Al-Anon, Naranon, Coanon, and Coda to help diminish their reactivity and enhance their coping and self-esteem.

Couples groups have been used even more widely with alcoholics than with drug abusers, and the techniques are similar to those described above. Spouses of alcoholics are encouraged to attend Al-Anon, which facilitates an attitude of loving detachment.

Many studies have demonstrated that spousal involvement facilitates the alcoholic's participation in treatment and aftercare. It also increases the incidence of sobriety and enhanced function after treatment. Further, the greater the involvement of the spouse in different group modalities (Al-Anon, spouse groups, etc.), the better the prognosis for treatment of the alcoholic.

(See also: Causes of Substance Abuse ; Comorbidity and Vulnerability ; Contingency Contracts ; Families and Drug Use ; Sobriety ; Toughlove )

BIBLIOGRAPHY

Ablon, J. (1974). Al-Anon family groups. American Journal of Psychotherapy, 28, 30-45.

Anderson, C. M., & Stewart, S. (1983). Mastering resistance: A practical guide to family therapy. New York: Guilford Press.

Berenson, D. (1976). Alcohol and the family system. In P. J. Guerin (Ed.), Family therapy. New York: Gardner.

Bowen, M. (1974). Alcoholism as viewed through family systems therapy and family psychotherapy. Annals of the New York Academy of Sciences, 233, 114.

Brown, S., & Yalom, I. D. (1977). Interactional group therapy with alcoholics. Journal of Studies on Alcohol, 38, 426-456.

Cadogan, D. A. (1973). Marital group therapy in the treatment of alcoholism. Quarterly Journal of Studies on Alcohol, 34, 1187-1197.

Cahn, S. (1970). The treatment of alcoholics: An evaluative study. New York: Oxford University Press.

Fox, R. (1962). Group psychotherapy with alcoholics. International Journal of Group Psychotherapy, 12, 56-63.

Hoffman, H., Noem, A. A., & Petersen, D. (1976). Treatment effectiveness as judged by successfully and unsuccessfully treated alcoholics. Drug and Alcohol Dependence, 1, 241-246.

Johnson, V. E. (1980). I'll quit tomorrow (rev. ed.). San Francisco: Harper & Row.

Kaufman, E. (1994). Psychotherapy of addicted persons. New York: Guilford Publications.

Kaufman, E. (1985). Substance abuse and family therapy. New York: Grune & Stratton.

Kaufman, E. (1982). Group therapy for substance abusers. In M. Grotjahn, C. Friedman, & F. Kline (Eds.), A handbook of group therapy. New York: Van Nostrand Reinhold.

Kaufman, E., & Kaufman, P. (1992). Family therapy of drug and alcohol abuse (2nd ed.). Boston: Allyn & Bacon.

Kaufman, E., & Kaufman, P. (1979). Family therapy of drug and alcohol abuse. New York: Gardner.

Khantzian, E. J., Halliday, D. S., & Mc Auliffe, W.E. (1990). Addiction and the vulnerable self. New York: Guilford Press.

McCrady, B., et al. (1986). Comparative effectiveness of three types of spousal involvement in outpatient behavioral alcoholism treatment. Journal of the Studies of Alcohol, 14 (6), 459-467.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

Noel, N.E. &Mc Crady, B. (1984). Behavioral treatment of an alcohol abuser with a spouse present. In E. Kaufman (Ed.), Power to change: Family case studies in the treatment of alcoholism. New York: Gardner.

Stanton, M.D., et al. (1982). The family therapy of drug abuse and addiction. New York: Guilford Press.

Vanicelli, M. (1992). Removing the roadblocks. New York: Guilford Press.

Woody, G. E., et al. (1986). Psychotherapy for substance abuse. Psychiatric Clinics North America, 9, 547-562.

Wright, K.D., & Scott, T. B. (1978). The relationship of wives' treatment to the drinking status of alcoholics. Journal of Studies on Alcohol, 39, 1577-1581.

Yalom, I.D., et al., (1978). Alcoholics in interactional group therapy. Archives of General Psychiatry, 35, 419-425.

Edward Kaufman

Hypnosis

Hypnosis is a normal state of attentive, focused concentration with a relative suspension of peripheral awareness, a shift in attention mechanisms in the direction of focus at the expense of the periphery. Being hypnotized is something like looking through a telephoto lens. What is seen, is seen in great detail, but at the expense of context. The use of hypnosis has been associated with inducing a state of relaxation and comfort, with enhanced ability to attend to a therapeutic task, with the capacity to reduce pain and anxiety, and with heightened control over somatic function. For these reasons, hypnosis has been used with some benefit as an adjunct to the treatment of certain kinds of Drug and Alcohol Abuse and Addiction.

Therapeutic approaches involving hypnosis include using it as a substitute for the pleasure-inducing substance, taking a few minutes to induce a self-hypnotic state of relaxation (for example, by imaging oneself floating in a bathtub or a lake, or visualizing pleasant surroundings on an imaginary screen). In this strategy the hypnosis is a safe substitute for the pleasure-inducing effects of the drug. A second approach involves ego-enhancing techniques, providing the subject with encouragement, picturing himself or herself living well without the substance and able to control the desire for it. A third approach involves instructing subjects to reduce or eliminate their craving for the drug. A fourth involves cognitive restructuring, diminishing the importance of the craving for the drug by focusing instead on a commitment to respect and protect the body by eliminating the damaging drug. One widely used technique for smoking control, for example, has people in hypnosis repeat to themselves three points: (1) For my body, smoking is a poison; (2) I need my body to live; (3) I owe my body respect and protection. This approach places an emphasis on a positive commitment to what the person is for, rather than paying attention to being against the drug, thereby keeping attention on protection rather than on abstinence.

Hypnosis has been most widely used in the treatment of Nicotine dependence, and although the results vary, a number of large-scale studies indicate that even a single session of training in self-hypnosis can result in complete abstinence of six months or more by approximately one out of four smokers.

There are fewer systematic data regarding use of hypnosis with Cocaine, Opiate, or alcohol addiction. The success of the approach is complicated by the fact that the acute effects of substance intoxication and/or the chronic effects on cognitive function of alcohol and other drug abuse hampers hypnotic responsiveness, thereby diminishing the potential of addicted individuals to enter this state and benefit from it. Nonetheless, there may be occasional individuals who are sufficiently hypnotizable and motivated to use this approach as an adjunct to other treatment, diminishing the dysphoria and discomfort that can accompany Withdrawal and abstinence while enhancing and supporting their commitment to a behavior change. Hypnosis can be used by licensed and trained physicians, psychologists, dentists, and other health-care professionals who have special training in its use. The treatment is employed in offices and clinics as well as in hospital settings. It should always be used as an adjunct to a broader treatment strategy.

Hypnosis is a naturally occurring mental state that can be tapped in a matter of seconds and mobilized as a means of enhancing control over behavior, as well as the effects of withdrawal and abstinence, in motivated patients supervised by appropriately trained professionals.

BIBLIOGRAPHY

Childress, A. R. Et al. (1994). Can induced moods trigger drug-related responses in opiate abuse patients? Journal of Substance Abuse Treatment 11, 17&endash;23.

Haxby, D. G. (1995). Treatment of nicotine dependence. American Journal of Health Systems Pharmacists 52, 265&endash;281.

Orman, D. J. (1991). Reframing of an addiction via hypnotherapy: a case presentation. American Journal of Clinical Hypnosis 33, 263&endash;271.

Page, R. A., & Handley, G. W. (1993). The use of hypnosis in cocaine addiction. American Journal of Clinical Hypnosis 36, 120&endash;123.

Stoil, M. J. (1989). Problems in the evaluation of hypnosis in the treatment of alcoholism. Journal of Substance Abuse Treatment 6, 31&endash;35.

Valbo, A., & Eide, T. (1996). Smoking cessation in pregnancy: the effect of hypnosis in a randomized study. Addictive Behavior 21, 29&endash;35.

David Spiegel

Long-term Versus Brief

For many medical and psychiatric disorders that, like substance use disorders, have a chronic course, longer-term treatments are usually found to be much more effective than short interventions. For example, most patients with disorders such as hypertension, elevated cholesterol, diabetes, or schizophrenia have the best clinical course if they maintain lifestyle modifications and remain on their medications for extended periods of time. One would therefore think that individuals with substance use disorders who seek treatment would have better outcomes if they received longer, as opposed to shorter, episodes of care. However, research findings in the addictions have indicated that the relationship between length of treatment and outcome is not particularly straightforward.

There is considerable evidence that patients who stay in treatment longer have better outcomes. That is, when patients with similar demographic characteristics and pretreatment substance-use severity all enter the same treatment program, those who stay in treatment longer will on average have better treatment outcomes that those who leave early. The dividing line that predicts good versus poor outcome has frequently been retention for at least 90 days in treatment. However, it is not clear how much the better outcomes should be attributed to longer stays in treatment or to individual characteristics such as motivation and initial success in treatment. The most direct way to untangle treatment from motivation effects is to conduct studies in which patients are randomized to different lengths or intensities of treatment, and their outcomes examined over time. Studies of this sort have produced very little evidence to indicate that longer or more intense treatments produce better substance-abuse outcomes than shorter or less intense treatments. For example, a recent random assignment study compared 6- and 12-month therapeutic community programs, and 3- and 6-month residential programs with a relapse prevention focus. In both cases, the long and short versions of the same program did not differ in rates or patterns of drug use during six-month posttreatment followup periods. This suggests that the relationship between longer treatments and better outcomes is probably more a function of motivation and other patient characteristics than duration of treatment received.

However, it should also be stressed that many substance abuse treatment programs feature a continuum of care, in which patients spend a certain amount of time in an initial higher intensity treatment and then "step down" to a lower intensity level of care, such as aftercare. Perhaps participation in and completion of aftercare following initial treatment has greater prognostic significance than the duration of a single level of care? Surprisingly, research suggests it does not. In the majority of the relatively few studies that have examined this issue, patients who were randomly assigned to active aftercare treatments did not have better substance use outcomes than those who were randomized to either no aftercare or minimal aftercare conditions.

Is it therefore the case that duration of substance use treatment, whether in one level of care or a continuum of care, is not related to substance use outcome? Despite the results from randomized studies described here, duration might still be of some importance. For example, monitoring substance abusers with low-cost, low-intensity interventions over long periods of time and arranging for more intensive treatments if they appear to have resumed use or be at risk might produce better outcomes than simply discharging patients following an initial episode of care and maintaining no contact after that. However, this approach has yet to be evaluated in controlled research studies.

Although the research literature does not strongly support the use of longer-term treatment interventions, there is consensus among clinicians and clinical researchers that sustained recoveries from substance use disorders generally require ongoing efforts by those who have these disorders. Some of the behaviors that have been associated with good long-term outcomes include regular attendance at self-help groups such as Alcoholics Anonymous, treatment for family or marital problems, employment, involvement with religion, and commitment to new interests or hobbies. These findings are consistent with the notion that formal treatment, whether of short or long duration, is useful for beginning a process of change that must be sustained over long periods of time in order to be successful and that ultimately involves many areas of functioning.

BIBLIOGRAPHY

McCusker, J., et al. (1995). The effectiveness of alternative planned durations of residential drug abuse treatment. American Journal of Public Health, 85, 1426-1429.

McKay, J. R. (in press). The role of continuing care in outpatient alcohol treatment programs. In M. Galanter (Ed.), Recent developments in alcoholism, vol XV: Services research in the era of managed care. New York: Plenum.

Moos, R. H., et al. (1990). Alcoholism treatment: Context, process, and outcome. New York: Oxford University Press.

Simpson, D.D., et al. (1997). Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11, 4, 294-307.

James R. McKay

Minnesota Model

Origins of the Minnesota Model of drug abuse treatment are found in three independent Minnesota treatment programs: Pioneer House in 1948, Hazelden in 1949, and Wilmar State Hospital in 1950. The Hazelden Clinics are still in existence and are located in Minnesota and Florida. The original treatment programs recognized Alcoholics Anonymous (AA) as having success in bringing about recovery from Alcoholism. Unique to this early stage of the Minnesota Model was the blending of professional behavioral science understandings with AA's principles. Important in the development of the Minnesota Model is the way treatment procedures emerged from listening to alcoholics, from trial and error, from acknowledgment of the mutual help approach of AA, and from the use of elementary assumptions rather than either a well-developed theoretical position or a generally accepted therapeutic protocol. In many ways, the Minnesota Model may be seen as having come about in a grassroots, pragmatic manner.

Because of its evolutionary, noncentralized development, the Minnesota Model is not a standardized set of procedures but an approach organized around a shared set of assumptions. These assumptions have been articulated by Dan Anderson, the former president of Hazelden Foundation and one of the early professionals working with the Minnesota Model at Wilmar State Hospital. They are the following: (1) Alcoholism exists in a consolidation of symptoms; (2) alcoholism is an illness characterized by an inability to determine time, frequency, or quantity of consumption; (3) alcoholism is non-volitional—alcoholics should not be blamed for their inability to drink ethanol (alcohol); (4) alcoholism is a physical, psychological, social, and spiritual illness; and (5) alcoholism is a chronic primary illness—meaning, that once manifest, a return to nonproblem drinking is not possible. Although these assumptions are phrased as pertaining to alcoholism, early experience with the Minnesota Model demonstrated that drug abuse other than alcoholism can also be understood and treated within these assumptions. Chemical dependency is the term generally used by clients and treatment providers when referring to substance abuse. The Minnesota Model provides treatment for chemical dependency—for both alcohol and other drugs.

A twenty-four to twenty-eight day inpatient treatment stay, or approximately eighty-five hours in outpatient rehabilitation, characterizes the Minnesota Model treatment. Inpatient treatment may occur in hospital settings or free-standing facilities and may be run by for-profit or nonprofit organizations. Different treatment settings have different mixes of staff positions, but the multidisciplinary team of medical and psychological professionals plus clergy and focal counselors are frequently found—either in a close interacting network or a more diffuse working arrangement.

Primary focal counselors have either received specific training in the Minnesota Model approach to treatment or have learned their counseling skills in an apprenticelike placement. Most counselors are neither mental-health-degreed professionals nor holders of medically related degrees, but they are commonly working on their own twelve-step programs because of life experience with chemical dependency or other addictions. As in AA, this shared personal experience of both clients and counselors is important for the client/counselor relationship and the behavior modeling the counselor provides for the client.

Minnesota Model treatment programs vary in the centrality of counseling staff and the programmed autonomy of the treatment experience. Some treatment programs have the counselor facilitating the majority of the groups and visibly directing the treatment experience. Other programs have the treatment groups carrying out the treatment experience where the activity follows a prescribed format, but the group members are the visible actors while the counseling staff maintains a low profile as they seek to empower clients to acquire the insights and resources necessary for their recovery. Treatment also varies in the amount of confrontation, the presence of a family program requirement, the extent of assigned reading, the detail of client record documentation, and other attributes.

What Minnesota Model treatment has without exception is the use of AA principles and understandings (steps and traditions) as primary adjuncts in the treatment experience. Clients are provided with the AA "Big Book" (Alcoholics Anonymous ) and The Twelve Steps and Twelve Traditions. Both of these books are required reading. Spirituality is emphasized as important to recovery, which is consistent with the AA understanding. AA group meetings occur in the schedule of rehabilitation activities, and clients may visit a community AA meeting as part of their treatment experience. Clients will work on AA steps during their treatment experience; some programs focus on the first five steps while others emphasize all twelve steps.

Treatment it not just an intensive exposure to AA. It motivates treatment participants to develop mutual trust and to share and be open about how the use of chemicals has come to control their lives. Clients are told that they have the disease of chemical dependency. Their behavior has been directed by the disease, but they have been unable to see the reality of their behavior and the consequences because of the disease characteristic of denial. Treatment plans are individualized based on assessments by the multidisciplinary staff. Generally, the first goal of treatment is to break the client's denial and the second goal is for the client to accept the disease concept. Because treatment has clients ranging from new admissions to those ready to complete their program, senior peers are very influential in helping clients who are in the early stages of treatment to understand denial and the Disease Concept.

Acceptance and awareness that they are able to change if they take appropriate action to deal with their chronic condition is the message in the final treatment stage. The rehabilitation staff develops an aftercare plan with the client that will continue to support some of the changes that have taken place during treatment and it encourages changes that will promote ongoing recovery. Characteristically, clients comment on their increased awareness of simple pleasures and being with other people without trying to manipulate them. They are told that they must continue to work the AA steps, attend AA meetings, and address other problems of living if they are going to experience recovery because primary treatment is just one part of an ongoing continuum of care. Recovery is hard work made even more difficult by possible bouts of depression, problems of regaining trust from their family, and establishing new friends and activities not tied to alcohol and drug use.

Treatment outcome studies carried out by Hazelden for their treatment clients and for ten treatment programs in the Hazelden Evaluation Consortium are in general agreement with outcome evaluation findings reported by Comprehensive Assessment and Treatment Outcome Research for approximately one hundred hospital and freestanding treatment programs throughout the United States. About 50 percent of all clients treated, including noncompleters, are abstinent for one year following treatment discharge. This percentage is higher for treatment completers and for clients having fewer complications and more stability in their lives. Thirty-three percent of the clients have returned to heavy use patterns within the year, and the remainder have had slips or a period of resumed drinking/use but also have sustained periods of abstinence. Abstinent clients have fewer legal, health, interpersonal, and job-related problems, and about 75 percent attend AA and/or continuing care.

The Minnesota Model is a label that is applied to a broad range of programming. Nevertheless, it represents a highly visible treatment modality serving a large number of clients throughout the United States, although it is more dominant in certain regions. It has a counterpart known as the Icelandic Model, and both of these treatment models have influenced treatment in Sweden and other parts of Scandinavia. International interest in adopting the Minnesota Model appears to be growing, with scattered treatment programs appearing in many countries. Little research has been done on the diffusion of this treatment model to other cultures.

(See also: Alcoholism ; Treatment, History of )

BIBLIOGRAPHY

Anderson, D. J. (1981). Perspectives on treatment: The Minnesota experience. Center City, MN: Hazelden Educational Services.

Cook, C. C. H. (1988). The Minnesota Model in the management of drug and alcohol dependency: Miracle, method or myth? Part I. The philosophy and programme. British Journal of Addiction, 83, 625-634.

Cook, C. C. H. (1988). The Minnesota Model in the management of drug and alcohol dependency: Miracle, method or myth? Part II. Evidence and conclusions. British Journal of Addiction, 83, 735-748.

Laundergan, J. C. (1982). Easy does it: Alcoholism treatment outcomes, Hazelden and the Minnesota Model. Center City, MN: Hazelden Educational Services.

J. Clark Laundergan

Non-Medical Detoxification

The term 'detoxification' is used to refer to the management of two distinct types of problem resulting from excessive alcohol or other drug use. These are the symptoms and behavioral changes associated with extreme intoxication on the one hand and of withdrawal following extended use on the other. Although both involve recovering from the toxic effects of a drug while refraining from further use, the problems associated with each are quite different and require different methods to tackle them. In relation to Western society's favorite drug, alcohol, these problems are so common that the challenge is to develop methods which can be widely used without excessive cost. This requirement tends to rule out an exclusive reliance on expensive medical settings, medical personnel and medication—even though both problems carry with them a small but significant risk of death or serious injury. Despite this restriction, human ingenuity has devised a number of relatively safe and cost-effective alternatives to hospital care and which are frequently preferred by the clients in need of 'sobering up' or 'drying out'. These innovative services have usually been developed for people who run into problems with their use of alcohol and have later been emulated by services for people who use other dependence-inducing drugs.

The most visible problems associated with extreme intoxication concern public order, particularly in relation to the use of alcohol. Drunkenness is associated with violence, both to the self and to others as well as with 'public nuisance' offenses. The habitual drunken offender, who may otherwise be quite harmless, and the potentially dangerous disorderly 'drunk' present themselves in huge numbers to police forces the world over and, typically, then clog up already overburdened court and penal systems. In the past two decades several countries have experimented with having drunkenness 'decriminalized' i.e. made no longer a criminal offense. The aim of this has been to free up the courts and the police so that they can concentrate on more serious crimes. Another impetus for decriminalization of drunkenness has been a growing awareness that locking up drunk people in police cells puts them at risk of serious harm. In Australia, for example, the tragic deaths of many Aboriginal people while in police custody are thought to have been caused by the combined effects of alcohol and confinement.

Historically, the setting up of non-medical detoxification services occurred hand-in-hand with the decriminalization of drunkenness. Among the first experiments in the 1970s were by the Addiction Research Foundation in the Canadian province of Ontario and St. Vincents' Hospital in New South Wales, Australia. In both cases, services were set-up with the principal aim of diverting drunkenness offenders from the criminal justice system to a more humane setting where they might be also be counseled to seek help for their drinking problems. Both utilized a residential social setting staffed by non-medical personnel and provided no medical care or medication. To this day they successfully supervise thousands of problem drinkers, mainly self-referred, through sobering-up and/or alcohol withdrawal with an impressive record of safety. For example, in its first ten years of operation, the New South Wales facility has dealt with nearly 14,000 admissions and recorded only two fatalities among this high-risk population. Only 1 percent have required transfer to a nearby hospital for specialized medical care, often for reasons unrelated to alcohol withdrawal. These facilities have not been successful, however, in terms of attracting referrals from the police. In New South Wales, for example, the police have accounted for only 0.2 percent of referrals. It is possible that these facilities are diverting some potential offenders before they come to police attention, although this does not appear to be to a very significant extent.

SOBERING-UP SHELTERS

In an excellent review of detoxification services worldwide, Orford and Wawman (1986) suggest that the design of the above services confused the problems of intoxication and withdrawal. They should be seen as highly successful and cost-effective alternatives to hospital care for alcohol withdrawal but not the solution for what society should do with the habitual drunken offender. Australia's continuing concern to prevent Aboriginal deaths in custody has also prompted an increasing use of what have come to be called 'sobering up shelters'. These provide supportive non-medical settings where people can stay a few hours or, if necessary, overnight until, literally, they have sobered up. They have been found to provide an inexpensive alternative to prison and have succeeded in gaining the necessary support of the local police. Experience to date suggests that close liaison between shelter staff and police officers is necessary so that all concerned are clear about the specific aims of the project and how each can help the other. It is important that specialist treatment facilities are available to the sobering-up shelters so that people requiring urgent medical attention or longer-term help with a drinking problem can be referred on.

It should be noted that there are also potentially serious medical emergencies associated with extreme levels of drug intoxication. Poisoning through overdose, accidental or otherwise, is a common cause of admission to hospital emergency rooms the world over and all too frequently this may result in death. The most common of such instances are deliberate acts of self-poisoning, usually with prescribed medication, closely followed by cases of accidental alcohol poisoning. Over-dosing on heroin can also be quite common where that drug is widely used—especially as a result of users having lost tolerance to the drug's effects after a period of abstinence, if used with other CNS depressant drugs such as alcohol or benzodiazepines and/or if the heroin is unusually pure. It is for this reason that the staff of sobering up shelters, or of any facility which also caters for drug users, should be trained to identify the warning signs of overdose so that the sufferer may be taken to hospital with as little delay as possible. In some countries the opiate-antagonist drug Narcan is used in a variety of non-medical settings including by drug using peers at the scene of an overdose (Lenton and Hargreaves, in press). Similarly, there is a great educational need among the general drug-using and drinking public who all too often abandon their friends to 'sleep it off' and later find them asphyxiated.

DEALING WITH ALCOHOL AND OTHER DRUG WITHDRAWAL

Since the pioneering Canadian and Australian development of 'social setting' detoxification services to assist people safely through alcohol withdrawal, a variety of other non-medical approaches have been developed. Really, detoxification services should be seen as being on a continuum ranging from supervision by an informed 'lay person'—a relative, a recovered problem drinker or user or non-medical professionals—all the way to 24 hour nursing and medical care in a specialist hospital unit. Even in the latter case substantial variations exist regarding the amount of medication used during withdrawal—or even whether any medication is used at all. Detoxification services designed to minimize discomfort and the possibility of actual harm occurring during withdrawal may be 'non-medical' in several senses: by, variously, using non-medical settings (e.g. hostels, the client's home), non-medical personnel (e.g. relatives, ex-problem drinkers) or non-medical procedures. There is wide consensus that medical assistance needs to be available if required but the responsibility for accessing this need not be left only with medical personnel.

The Ontario model of non-medical detoxification was created following the results of a study reported in 1970. It found in the relative safety of an alcoholism treatment unit that only 5 percent of admissions required any form of medical assistance. In addition to the residential 'social setting' model of detoxification, 'ambulatory' or outpatient detoxification procedures were developed which relied on the drinker calling in daily to a clinic to collect their medication and receive a brief check-up. Evaluations of these types of service conducted in several countries have demonstrated that their success rate in terms of both safety and effectiveness is at least the equal of inpatient care—and is considerably cheaper.

A variation of this approach is 'home detoxification', an approach developed initially in the UK with problem drinkers and now widely used in many other countries. This usually involves a community alcohol worker (e.g. nurse, counselor or psychologist) assisting a family practitioner to assess a drinker who wishes to stop drinking alcohol but who may experience severe withdrawal symptoms in the process. Providing the home environment is deemed to be supportive and the client sufficiently motivated to stop drinking the detoxification then occurs in the patient's home with supportive visits from the alcohol worker. The family doctor's telephone number is provided to the client and any close relative or partner in case of emergency. A particular effort is made to screen out drinkers with a history of withdrawal fits, delerium tremens or Korsakoff's Psychosis. In order to reduce the real risk of overdose with some types of medication (notably chlormethiazole) either the alcohol worker or a relative holds the medication. An important reason for developing this service in the UK was the discovery that many family doctors were already prescribing chlormethiazole to cover alcohol withdrawal but in the absence of any supervision and frequently longer than the recommended maximum period—sometimes even indefinitely. It was found that this was the single most common method of managing alcohol withdrawal among a group of patients who, for many reasons, were loathe to attend a psychiatric hospital or specialized treatment unit. Later studies have found evidence that home detoxification is more acceptable to groups that are frequently under-represented in traditional settings such as the young, the elderly and women. Home detoxification therefore offered a safe alternative to completely unsupervised withdrawal on the one hand and a cost-effective alternative to inpatient hospital care. The cost of Home Detoxification per client has been estimated to be approximately a quarter that of inpatient hospital care. Formal evaluations of the UK service suggest that not only is there no loss in terms of either safety or efficacy but that the clients prefer to be treated at home and that many would refuse to attend a hospital facility.

CONCLUSIONS

Non-medical detoxification services have been developed to cope with the problems associated with alcohol withdrawal in chronic heavy drinkers and also with episodes of alcohol-induced intoxication. While such services are being developed for users of other mood-altering drugs, there is, as yet, only limited published research concerning their efficacy. Non-medical detoxification services need clear aims and objectives and should be part of a comprehensive range services for people with alcohol problems. Both intoxication and alcohol withdrawal are so common in Western society that, although they carry a small but significant risk of serious injury or death, it is too costly to attempt to provide specialist medical care in every instance. Safe and inexpensive alternatives have been developed in a number of countries, which are to be recommended over a laissez-faire or punitive approach to these major social problems. There is encouraging evidence that community-based detoxification services attract problem drinkers who are usually under-estimated in treatment services, such as women, young people and the elderly.

BIBLIOGRAPHY

Annis, H. (1985) Is Inpatient Rehabilitation of the Alcoholic Cost Effective? Advances in Alcohol and Substance Abuse, 5, 175-190.

Bennie, C. (1998) A comparison of home detoxicfication and minimal intervention strategies for problem drinkers. Alcohol and Alcoholism, 33, 2, 157-163.

Cooper, D. (1994) Home Detoxification and Assessment, Radcliffe Medical Press, Oxford, UK.

Fleman, N. (1997) Alcohol home detoxification: a literature review. Alcohol and Alcoholism, 32, 6, 649-656.

Lenton, S. and Hargreaves, K. (2000). Editorial: A trial of naloxone for peer administration has merit, but will the lawyers let it happen? Drug and Alcohol Review. [In Press]

Lenton, S. and Hargreaves, K. (2000). Should we trial the provision of naloxone to heroin users for peer administration to prevent fatal overdose?—For Debate. Medical Journal of Australia. [In Press]

Midford, R., Daly, A. and Holmes, M. (1994) The care of public drunks in Halls Creek: A model for community involvement. Health Promotion Journal of Australia, 4 (19):5-8.

Orford, J.&Wawman, T. (1986) Alcohol Detoxification Services: a Review. London: DHSS, HMSO.

Pederson, C. (1986) Hospital admissions from a non-medical alcohol detoxification unit, Drug and Alcohol Review, 5 ; 133-137.

Stockwell, T., Bolt, E.&Hooper, J. (1986) Detoxification from alcohol at home managed by General Practitioners. British Medical Journal 292, 733-735.

Stockwell, T., Bolt, E., Milner, I.et al. (1991) Home Detoxification for Problem Drinkers: It's safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism 26 (2), 207-214.

Tim Stockwell

Outpatient Versus Inpatient

With the rising cost of drug treatment and the growth of managed care, outpatient treatment is becoming a much more common form of treatment for substance abuse than inpatient treatment. Recent reviews of the scientific literature have supported this trend by showing that there is no strong evidence for the superiority of inpatient over less costly outpatient treatment. In fact, more recent investigations have focused on comparing various levels of intensities of outpatient treatment.

ALCOHOL TREATMENT

Finney et al. (1996) reviewed fourteen studies of Alcohol abuse and found that seven showed no significant differences in drinking outcomes between inpatient and outpatient treatment, five showed inpatient treatment to be superior, and in two studies a day hospital outpatient treatment was more effective. In the studies that found inpatient treatment to be more effective, patients in the comparative outpatient programs were less likely to receive an initial period of inpatient Detoxification and these studies were slightly less likely than those finding no treatment differences to randomly assign patients to treatment. Unless subjects are randomly assigned to each of the treatments, no way exists of knowing whether the findings were due to different kinds of patients volunteering for the different types of treatment. On the other hand, it could be argued that random assignment is an artificial selection process that makes it difficult to generalize findings to "real life" situation. Among the studies that compared costs, treatment in out-patient settings was less expensive than treatment in inpatient settings. Overall, the investigators concluded that there were no differences between in-patient and outpatient treatments. However, particular types of patients (e.g., those with medical/psychiatric impairments) may benefit more from inpatient treatment.

COCAINE TREATMENT

Alterman et al. (1994) found that a twenty-seven hour per week day hospital treatment was just as effective as more costly inpatient treatment for low SES male veterans. Both groups showed significant improvements in functioning at the seven-month follow-up evaluation. Although a greater proportion of subject assigned to inpatient treatment completed treatment, the day hospital treatment costs were 40 to 60 percent of inpatient treatment. Another randomized clinical trial comparing day and residential treatment programs for drug abuse (mostly Cocaine) found no overall differences in substance use problems between the two treatment conditions (Guydish et al., 1998).

Comparing Outpatient Treatment Intensities.

As a result of finding no superior effect of inpatient treatment and given the limited availability of inpatient care, researchers are now comparing various intensities of outpatient treatment. Coviello et al. (in press) found no differences between male veterans randomly assigned to either a 12 hour per week day hospital program or a six hour per week outpatient program for cocaine dependence. Both treatments were similar in therapeutic structure and only differed in level of treatment intensity. McLellan et al. (1997) found no differences between intensive outpatient programs of at least three sessions per week and traditional outpatient programs of one or two sessions weekly. In addition, Avants and colleagues (1999) have demonstrated that providing enhanced standard care for Opiate-dependent patients enrolled in Methadone maintenance treatment may be just as effective and less costly than intensive day treatment.

CONCLUSIONS

Research suggests that there are few differences between inpatient and outpatient treatment for substance abuse. Both treatments result in improvements in patient functioning. While inpatient treatment is more effective in retaining patients in treatment, it is much more costly than outpatient treatment. However, initial short-term inpatient treatment in the form of detoxification may be necessary to increase positive outcomes of later outpatient care. Recently, much more attention is being directed toward studying various levels of intensities of outpatient programs. Preliminary findings suggest that lower intensity outpatients treatments may be just as effective as similar higher intensity treatments. What seems to be more important is the content of the intervention rather than the setting in which the treatment is provided.

It should be noted that inpatient treatment is clearly indicated for patients with acute medical and psychiatric problems that can only be handled in an inpatient setting. Inpatient treatment may also be necessary for patients who continually fail in outpatient treatment, have few social sources, or whose recovery would be jeopardized in an outpatient program due to exposure to a social environment where substance use is prevalent. As a final cautionary note, much of the research in this area has been conducted with adult male clients. More research is needed with women and adolescent populations.

BIBLIOGRAPHY

Alterman, A. I., O'Brien, C. P., Mc Lellan, A. T., August, D. S., Snider, E. C., Droba, M., Cornish, J. W., Hall, C. P., Raphaelson, A. H., and Schrade, F.X. (1994). Effectiveness and costs of inpatient versus day hospital cocaine rehabilitation. Journal of Nervous and Mental Diseases, 182 (3), 157-163.

Avants, S.K., Margolin, A., Sindelar, J.L., Rounsaville, B. J., Schottenfeld, R., Stine, S., Cooney, N. L., Rosenheck, R. A., Li, S. H., Kosten, T. R. (1999). Day treatment versus enhanced standard methadone services for opioid-dependent patients: A comparison of clinical efficacy and cost. American Journal of Psychiatry, 156 (1), 27-33.

Coviello, D. M., Alterman, A. I., Rutherford, M. J., Cacciola, J. S., Mc Kay, J. R., Zanis, D. A., (in press). The effectiveness of two intensities of psychosocial treatment for cocaine dependence. Drug and Alcohol Dependence.

Finney, J. W., Hahn, A. C., Moos, R. H. (1996). The effectiveness of inpatient and outpatient treatment for alcohol abuse: The need to focus on mediators and moderators of setting effects. Addictions, 91 (12), 1773-1796.

Guydish, J., Werdegar, D., Sorensen, J. L., Clark, W., Acampora, A. (1998). Drug abuse day treatment: A randomized clinical trial comparing day and residential treatment programs. Journal of Consulting and Clinical Psychology, 66 (2), 280-289.

McLellan, A. T., Hagan, T. A., Meyers, K., Randall, M., Durrell, J. (1997). "Intensive" outpatient substance abuse treatment: Comparisons with "traditional" outpatient treatment. Journal of Addictive Diseases, 16, 57-84.

Arthur I. Alterman

Revised by Donna M. Coviello

Pharmacotherapy, An Overview

Pharmacological agents may be used for several purposes in the treatment of drug and alcohol addiction. These include the alleviation of acute withdrawal symptoms, the prevention of relapse to drug or alcohol use, and the blocking of the euphorigenic effects of drugs of abuse. The various medications are used in the treatment of addiction to alcohol, opiates, cocaine, tobacco, and sedatives.

ALCOHOLISM

Detoxificaton.

The use and abuse of Alcohol has been known to humankind for centuries, and alcohol is currently one of the most widely used of the mood-altering substances. Habitual alcohol use is associated with the development of Tolerance and physiological (Physical) Dependence. Tolerance refers to a decrease in susceptibility to the effects of alcohol following chronic alcohol use, which results in the user consuming increasing amounts of alcohol over time. Physical dependence may be conceptualized as a physiological state in which the recurrent administration of alcohol is required to prevent the onset of withdrawal symptoms. Symptoms of alcohol withdrawal include irritability, tremulousness, anxiety, sweating, chills, fluctuations in pulse and blood pressure, diarrhea, and, in severe cases, seizure. These symptoms generally begin within twenty-four hours following the last use of alcohol, peak within forty-eight hours, and subside over several days.

Pharmacotherapy for alcohol withdrawal includes the use of agents, such as Benzodiazepines and Barbiturates, that are cross-tolerant with alcohol. These agents attenuate the symptoms of withdrawal and result in decreased arousal, agitation, and potential for seizure development. Medication is provided in doses that are sufficient to produce mild sedation and physiological stabilization early in the withdrawal period; this is followed by a gradual dose reduction and then discontinuation over the next one to two weeks. Currently, benzodiazepines are the agents of choice for the treatment of alcohol withdrawal, because of the relatively high therapeutic safety index of these medications, their ability to be administered both orally and intravenously, and because of their anti-convulsant properties. Barbiturates may be used in a similar fashion, but they have a lower therapeutic index of safety than do benzodiazepines.

Recent additions to the pharmacotherapy of alcohol withdrawal include clonidine and carbamazepine. Clonidine is an antihypertensive agent (i.e., it lowers blood pressure) that has recently been used in the treatment of drug withdrawal states and chronic pain. This medication decreses autonomic hyperactivity (i.e., it lowers an increased pulse and blood pressure), but it does not have the anticonvulsant properties of the benzodiazepines or barbiturates. Carbamazepine has also been employed in the treatment of alcohol withdrawal and does have anticonvulsant properties. Neither medication is habit forming and thus may have potential in the treatment of alcohol withdrawal.

Maintenance Lithium.

Lithium is primarily employed in the treatment of bipolar mood disorder (previously termed manic-depressive disorder), but it may be beneficial in the treatment of other psychiatric disorders. It has received much attention in the investigation of pharmacologic agents for the treatment of alcohol dependence, and several studies have reported that its use had favorable effects on alcohol consumption. For example, after receiving doses of lithium comparable to those administered to human beings, laboratory animals demonstrated a significant reduction in alcohol consumption. In recovering alcoholics, lithium treatment has been associated with a decreased desire to continue drinking after alcohol use and, in several studies, with a higher rate of abstinence for those alcoholic patients who were compliant with therapy. Although these small studies on the efficacy of lithium for alcohol dependence appeared promising, a recent large placebo-controlled study failed to demonstrate a beneficial effect of lithium. At the present time, although lithium certainly has a place in the treatment of alcoholic patients with bipolar disorder, the indications for its use in other patients with alcohol dependence are less clear.

Antidepressants.

Depressive symptoms are noted in many alcoholics at the time that they enter treatment. Because of the frequent co-occurrence of depression and alcoholism, the use of antidepressants would appear to be potentially useful in this population. Several studies have demonstrated favorable effects of antidepressants on alcohol consumption. Tricyclic antidepressants such as imipramine and desipramine inhibit the re-uptake of norepinephrine and serotonin in nerve terminals. These medications have been associated with decreased ethanol consumption in laboratory animals and in human alcoholic subjects. The serotonin reuptake inhibitors (blockers) zimelidine, viqualine, fluvoxamine, and fluoxetine (Prozac) have also demonstrated favorable short-term results in the treatment of alcohol dependence. Although these medications are not routinely administered to all recovering alcoholics, many physicians consider the use of antidepressants in alcoholic patients if depressive symptoms do not resolve after several weeks of abstinence, or if a mood disorder was present prior to the onset of ethanol abuse.

Anxiolytics.

Used to decrease anxiety, anxiolyrics include benzodiazepines, such as chlordiazepoxide (Librium) and diazepam (Valium), and azaspirodecadiones, such as buspirone. Both classes of medication have been investigated for use in alcohol dependence. Early studies supported the use of benzodiazepines in recovering alcoholics with claims of decreased alcohol craving and consumption after chlordiazepoxide administration. Other controlled trials refuted this, however, and many physicians would question the use of benzodiazepines in this population. The azaspirodecadiones such as buspirone are nonaddictive medications that have been marketed for the treatment of anxiety. Although few controlled trials have been conducted that evaluated the effect of buspirone on human alcohol use, animal studies have demonstrated decreased alcohol consumption after treatment with this agent. Unlike benzodiazepines, buspirone is not known to be habit forming and thus may be a promising agent for additional controlled studies in human subjects.

Dopaminergic Agents.

The effects of dopaminergic agents on the consumption of alcohol in animal studies have been conflicting, since both agents that augment dopaminergic activity and those that diminish it have been noted to decrease alcohol consumption. In humans, controlled studies with apomorphine and bromocriptine, both of which increase dopaminergic activity, have revealed decreases in alcohol craving, anxiety, and depression, and increased abstinence among alcoholic depressed patients.

Opioid Antagonists.

Opioid antagonists are competitive antagonists of Opiods at opiate receptors. They include Naloxone, which may be used intramuscularly or intravenously to rapidly reverse opiate intoxication, and Naltrexone, which is prescribed orally to prevent or reverse intoxication from opioids. Unlike opioids, these medications are not habit forming and may have a place in the treatment of alcohol-dependent patients. A variety of studies have demonstrated a reduction of alcohol consumption or self-administration by experimental animals treated with these agents. In human subjects, naltrexone administered as an adjunct to substance-abuse treatment has resulted in a decreased rate of alcohol consumption. In addition, those patients who did experience a "slip" were less likely than those who were not treated with naltrexone to suffer a complete relapse to alcohol use.

Antidipsotropics.

Antidipsotropics are medications that are used to decrease alcohol consumption by creating an adverse reaction following alcohol use. They include Disulfiram, Calcium Carbimide, and Flagyl. Disulfiram use results in an accumulation of acetaldehyde following the consumption of alcohol. Acetaldehyde levels accumulate if patients who are receiving disulfiram ingest alcohol, with the result that the patients may experience symptoms of acetaldehyde toxicity. These include sweating, chest pain, palpitations, flushing, thirst, nausea, vomiting, headache, difficulty breathing, hypotension, dizziness, weakness, blurred vision, and confusion. Symptoms may begin within five to fifteen minutes following alcohol ingestion and may last from thirty minutes to several hours. The use of disulfiram is based upon the premise that the fear or actual experience of this adverse event may serve as a deterrent to alcohol use. Despite its toxicity, disulfiram has been used safely by thousands of recovering alcoholics since its introduction in 1948. Supervised voluntary use of the medication as an adjunct to other rehabilitative therapy has resulted in reduced alcohol consumption and decreased alcohol-related criminal behavior among alcohol-dependent patients.

Compliance is the key to successful use of disulfiram in alcohol dependence, since patients need only discontinue using disulfiram if they wish to resume drinking. Indeed, in an unsupervised setting, disulfiram administration shows no superiority over placebo on outcome measures related to alcohol use. Methods that have been investigated to improve compliance include surgical implants of disulfiram, reinforcement by providing a reward for compliance, and contingency management techniques. Although surgical implants have met with little success, the other two methods have demonstrated various degrees of efficacy.

OPIOID DEPENDENCE

The opioids include opiates, drugs derived from the opium poppy (Papaver somniferum ), as well as those synthesized to produce similar narcotic effects. Opium has been used as a medicinal substance for at least 6,000 years. Widespread abuse of opiates was noted by the eighteenth century, with the smoking of opium in Asia; currently, Heroin is a major opiate of abuse in the United States. Pharmacotherapy for opiate dependence may be employed both during the acute withdrawal syndrome and later to maintain abstinence from illicit opioids (e.g., heroin).

Acute Opioid Withdrawal.

The syndrome of acute withdrawal from opiates varies in regard to the opiate of abuse. The time of onset, intensity, and duration of withdrawal symptoms depend on several factors, including the half-life of the drug, the dose, and the chronicity of use. Heroin is a relatively short-acting agent; symptoms of withdrawal often begin within eight to twelve hours after the last use. Early symptoms include craving, anxiety, yawning, tearing, runny nose, restlessness, and poor sleep. Symptoms may progress to include pupil dilation, irritability, muscle and bone aches, piloerection (the goose bumps—thus the term cold turkey ), and hot and cold flashes. Peak severity occurs 48 to 72 hours after the last dose and includes nausea and vomiting, diarrhea, low-grade fever, increased blood pressure, pulse, and respiration, muscle twitching, and occasional jerking of the lower extremities (which explains the term kicking the habit ). The opiate withdrawal syndrome following chronic heroin use may last seven to ten days, but with longer-acting agents such as Methadone, a similar constellation of symptoms may occur; they begin later, peak on the third to eighth day, and persist for several weeks.

A variety of medications may be used in the treatment of acute opiate withdrawal. The most common method is to use opiates alone. A dose high enough to stabilize the patient is administered on the first day and then gradually tapered over one to two weeks. Generally, long-acting opiates such as methadone are employed, but any opiate may be used.

Other medications used for opiate withdrawal are Clonidine and Buprenorphine. Clonidine is an alpha-2 adrenergic agonist that is commonly employed as an antihypertensive medication. It is active on central nervous system (CNS) locus coeruleus neurons in the same areas at which opiates exert their effects. Clonidine appears most effective in decreasing symptoms such as elevation of pulse and blood pressure and may be less effective in relieving other symptoms of withdrawal. The major side effects of clonidine are orthostatic hypo-tension and sedation. A recent development in the pharmacotherapy of opiate withdrawal is rapid detoxification through the combined use of clonidine with opiate antagonists such as naltrexone. This treatment may decrease the time required for the detoxification process to two to three days. Opiate addicts may be stabilized on buprenorphine, a mixed opioid agonist/antagonist, with minimal discomfort and then withdrawn over five to seven days with less severe withdrawal symptoms than those associated with methadone withdrawal.

Antagonists.

Opiate antagonists such as naloxone and naltrexone compete with opiates for CNS opioid receptors. Naloxone has a short half-life (two to three hours) and is generally employed on a short-term basis to reverse acute opiate intoxication. Naltrexone has a longer duration of action (approximately twenty-four hours) and is used as a long-term maintenance medication to inhibit euphoria in opioid addicts. Both medications have been used with relative safety for several years, and maltrexone has been successfully employed as an adjunct to other therapies in the treatment of opioid addicts. Clinically, side effects of naltrexone may include mild dysphoria and elevation in cortisol and beta-endorphin levels; no withdrawal syndrome has been noted following its discontinuation. Naltrexone is generally administered three to four times a week at an average dose of 50 milligrams per day. Despite its advantages, many opioid addicts resist therapy with this medication, and even in the most successful of programs, six-month retention rates may range from only 20 to 30 percent. The addition of psychosocial interventions such as counseling and contingency-management programs is helpful. When these interventions are added, naltrexone has been noted to be particularly effective in selected groups, such as those made up of health care professionals, business people, and prisoners on work-release programs.

Methadone Maintenance.

Methadone has been used as a safe and effective treatment for opioid dependence for over twenty years. Heroin addicts easily adapt to using this long-acting opiate that possesses all of the physiological characteristics of heroin. When taken orally, methadone may have less abuse potential than heroin, but the onset of its CNS effects are slower and its tendency to induce euphoria is generally less than that of intravenous or inhaled heroin. In addition, it has a longer half-life than heroin and if it is administered daily, tissue levels accumulate, thereby decreasing interdose withdrawal symptoms that may lead to repeated opiate use. Methadone maintenance may be helpful for addicts who have difficulty adjusting to a drug-free lifestyle or for those who have been unsuccessful with other forms of treatment.

During maintenance therapy, methadone is initiated at a low dose and then gradually increased to higher doses, which are associated with decreased opiate craving and secondary illicit opiate use. With methadone maintenance treatment, many patients show significant decreases in illicit drug use, depression, and criminal activity, and they demonstrate increased employment. Therapy that is provided for extended periods of time and in the context of other psychosocial services has been associated with the highest success rates.

Another maintenance medication currently under investigation is levo-alpha-acetylmethadol (LAAM). LAAM is a long-acting form of methadone that requires administration three times per week instead of daily as with methadone. Although LAAM has been associated with a reduction in illicit opioid use, its slower onset of action may lead to decreases in treatment retention compared to the use of methadone. The initiation of treatment with methadone and subsequent conversion to LAAM therapy may improve compliance with this medication. LAAM is not yet routinely used in the treatment of opioid dependence, and additional studies will be necessary to determine the appropriate use of this agent.

Buprenorphine.

Buprenorphine is a mixed opioid agonist/antagonist that has been used for several years as a possible maintenance medication for opioid dependence. Although it has only recently been available within the United States, preliminary studies indicate that it may be a promising agent for the treatment of opioid dependence. As with methadone, maintenance treatment consists of daily administration of buprenorphine, but the optimal daily dose of medication remains under investigation. At low doses, buprenorphine has agonist effects at opioid receptors, but at higher doses antagonistic effects may occur. Buprenorphine maintenance has been associated with good treatment retention, decreased illicit opiate use, and a relatively mild withdrawal syndrome. On the basis of early studies, buprenorphine was thought to be a promising agent in the treatment of both cocaine and opioid dependence, but significant benefits have not been confirmed by better-controlled studies.

COCAINE DEPENDENCE

Cocaine abuse has increased markedly since the 1970s, and by 1984, more than 20 million Americans reported that they had tried cocaine. In addition to psychotherapy and other traditional approaches to substance-abuse treatment, a variety of pharmacotherapeutic interventions may be of benefit to cocaine abusers.

Pharmacotherapy for cocaine abuse may be employed to address specific symptoms that occur during the cocaine-withdrawal syndrome. Gawin and Kleber identified three phases in the cocaine abstinence syndrome. The crash phase generally begins soon after cocaine use ends and may last up to four days. Symptoms experienced at this time may include depression, suicidal ideation, irritability, anxiety, and intense cocaine craving. Sedatives such as alcohol and heroin may be used by addicts to alleviate these symptoms. The second or withdrawal phase may last two to ten weeks and is characterized by anxiety, depression, inability to experience pleasure, and increased cocaine craving. The third or extinction phase may last three to twelve months; during this phase, cocaine craving may continue as well as increased susceptibility to relapse in response to environmental cues.

Pharmacotherapy for cocaine dependence may be used to alleviate symptoms experienced during the cocaine abstinence syndrome. During the crash period, early symptoms such as anxiety and insomnia may be relieved by benzodiazepines such as Chlordiazepoxide. Neuroleptics (Antipsychotics) may also be helpful during this period to alleviate psychotic symptoms such as paranoia.

Other agents that may be used on a short-term basis include dopaminergic agents such as bromocriptine and Amantadine. Some investigators postulate that CNS dopamine may be depleted by chronic cocaine use. Dopaminergic agents may be used to augment CNS dopaminergic function, and various dopaminergic agents such as amantadine, bromocriptine, and L-dopa have been employed for this purpose. Although few long-term, double-blind, placebo-controlled studies have been conducted, several studies have supported the use of dopaminergic agents such as amantadine as anticraving medications during withdrawal.

Antidepressants may be helpful during the withdrawal and extinction stages of cocaine abstinence. One controlled and several uncontrolled studies in recovering cocaine addicts suggested that the tri-cyclic antidepressant desipramine might decrease cocaine use and craving. Other antidepressants investigated in pilot studies include fluoxetine, imipramine, doxepin, and trazodone. Antidepressants may take several weeks to begin to alleviate symptoms of depression or craving, however, and some cocaine addicts may drop out of treatment during this period. These patients may benefit from initiation of treatment with a short-term agent (such as a dopaminergic agent) followed by long-term treatment with an antidepressant. As with every treatment, however, no firm conclusions are warranted about any agent until it has been tested in a controlled clinical trial that has been replicated at least once.

Pharmacotherapy may also be helpful for patients with psychiatric diagnoses other than cocaine dependence. In some patients, cocaine abuse may be an attempt at self-medication to address the discomfort of depression or other psychiatric disorders. Patients with major depressive disorder and bipolar disorder may respond to therapy with anti-depressants or lithium, and those with attention deficit disorder may benefit from the cautious use of low doses of stimulant medication.

In summary, antipsychotics and benzodiazepines may be used to alleviate symptoms of acute cocaine withdrawal, whereas tricyclic antidepressants and dopaminergic agents may be helpful in the long-term treatment of cocaine withdrawal. Pharmacotherapy should be considered an adjunct to other forms of rehabilitative therapy during the long-term treatment of the cocaine-dependent patient.

TOBACCO DEPENDENCE

One commonly used pharmacological treatment for tobacco dependence is a nicotine-containing gum called Nicorette. The main reason to quit smoking cigarettes is its powerful association with lung cancer, emphysema, and other medical problems. Yet nicotine, the active ingredient in cigarettes, is another drug that is associated with pleasant effects and with withdrawal discomfort, thereby making it an extremely addicting drug. Providing cigarette smokers with nicotine replacement in the form of a gum will help them avoid the health risks associated with smoking cigarettes. One problem with Nicorette is that it is difficult to chew correctly and therefore people need to be trained in how to chew it in order to derive the therapeutic effect. Recently, a patch has been developed that is placed on the arm and automatically releases nicotine. A method that shows good potential as a treatment, the patch was made available in the early 1990s. Detoxification from nicotine may also be facilitated with the medication clonidine, the same agent used to help alleviate opiate withdrawal symptoms.

SEDATIVE DEPENDENCE

Current treatments for sedative dependence include detoxification agents rather than anticraving agents. Detoxification is accomplished by tapering the dosage of benzodiazepines over two to three weeks. More recently, carbamazepine, an antiseizure medication, was shown to relieve alcohol and sedative withdrawal symptoms, including seizures and delirium tremens. Future work with agents that block the actions of benzodiazepines may hold promise as a maintenance or anticraving agent used to help the sedative abuser abstain from drug abuse.

CONCLUSIONS

Medications must be accompanied by psychological and social treatments and support; they do not work on their own. Moreover, medications to block illicit-drug effects in the brain may be of little use if the patient does not take them. More research in many fields is needed to identify potential medications, but this research must recognize the psychosocial as well as the neurobiological areas of therapy. Without this integration, the work to develop more effective treatments for the difficult problem of drug abuse and dependence cannot begin.

(See also: Causes of Substance Abuse ; Complications ; Disease Concept of Alcoholism and Drug Abuse ; Nicotine Delivery Systems for Smoking Cessation )

BIBLIOGRAPHY

Frances, R. J., & Franklin, J. E. (1990). Alcohol and other psychoactive substance use disorders. In J. A. Talbott, R. E. Hales & S. C. Yudofsky (Eds.), The American Psychiatric Press textbook of psychiatry. Washington, DC: American Psychiatric Press.

Gawin, F. H., & Kleber, H. D. (1986). Abstinence symptomatology and psychiatric diagnosis in chronic cocaine abusers. Archives of General Psychiatry, 43, 107-113.

Jaffe, J. H. (1989). Drug dependence: Opioids, non-narcotics, nicotine (tobacco) and caffeine. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry (5th ed.). Baltimore: Williams & Wilkins.

Jaffe, J. H. (1985). Drug addiction and drug abuse. In A. G. Gilman et al. (Eds.), Goodman and Gilman's the pharmacological basis of therapeutics, 7th ed. New York: Macmillan.

Kosten, T. R., & Kleber, H.D. (Eds.). (1992). Clinician's guide to cocaine addiction. New York: Guilford Press.

Lowinson, J. H., Ruiz, P., & Millman, R.B. (Eds.). (1992). Baltimore, MD: Williams & Wilkins.

Schuckit, M. A., & Segal, D. S. (1987). Opioid drug use. In E. Braunwald et al. (Eds.). Harrison's principles of internal medicine, 11th ed. New York: McGraw-Hill.

Elizabeth Wallace

Thomas R. Kosten

Psychological Approaches

Psychological treatments of drug dependence assume that drug abuse is a learned behavior. As such, it is not different from other less controversial and more healthful behaviors in its development. That is, a psychological perspective suggests that drug abuse is, for the most part, learned in many of the same ways as behaviors such as reading or driving a car. This perspective also suggests that drug abuse can be changed in the ways that other behaviors are changed. Forces for change include rewards (reinforcers) and unpleasant events (punishments); cues that signal the need for specific actions (discriminative stimuli); and training in new ways of thinking about oneself and the world that lead to ways of living that do not involve drugs.

Operant Learning Models.

Psychological treatments for drug abuse can be grouped into three categories, based on the models of behavior that they represent. The first are those that draw from operant learning models. These models suggest that many important behaviors, including those many behaviors that end with the use of an illegal drug are controlled by environmental events, rather than events inside the individual. Internal events may come into play but, ultimately, these are caused by external events. These models suggest that the important factor in determining drug use is the balance between the rewards and the punishments of use. Contingency management, a system of rewards for abstinence and punishment for drug use, is an example of an operant-based treatment.

Classical Conditioning.

A second model used is classical conditioning. A neutral event is paired repeatedly with another important event, one that usually evokes a response for the organism. A man who has experienced heroin withdrawal many times may eventually find that certain rooms of his apartment itself have come to cause him to crave drugs, because the apartment itself has become associated with withdrawal. A treatment based on classical conditioning, for example, is an attempt to remove the craving induced by the sight of drug paraphernalia, by repeatedly presenting pictures of those paraphernalia with no drugs, and therefore with lack of a reinforcing response.

Social Learning Models.

Other treatments draw from social learning models. These assume that behaviors, such as drug abuse, are learned in many ways, including operant conditioning, classical conditioning, imitation (learning by watching someone else), and learning certain ways of thinking. These models also usually assume that imitation and learning new ways of thinking are more important for humans than other ways of learning. An example of a treatment based on a social learning model is cognitive behavioral psychotherapy, where the drug abuser is taught new ways of viewing old situations, as well as new social skills, in the hope that these new thoughts and skills will lead to a less troubled life, which does not demand drug abuse to make it tolerable.

OPERANT MODELS: CONTINGENCY MANAGEMENT

Contingency management has been incorporated into many drug-treatment programs as a way of assisting people in reducing drug use. In contingency management, reinforcers or punishers are applied depending on the patient's behavior. Often, contingencies are formalized in a contract. In contingency contracting, a treatment plan is developed and agreed to by treatment staff and patient. As part of the contract, both agree that certain consequences will occur as a result of certain behaviors on the part of the patient.

Early work indicating the usefulness of contingencies was completed largely at Johns Hopkins University. Working in a methadone-maintenance program, investigators at Johns Hopkins found that money and the opportunity to raise dose levels all served to decrease drug abuse. Work at the University of California in detoxification treatment programs also indicated that payment for drug abstinence was an effective adjunct to short-term detoxification treatments, where methadone is used for only about three weeks, to help drug abusers in their transition from heroin use to a drug-free state. Both of these experimental programs focused on rewards for desired behavior, rather than punishments for drug use. Contingencies also have been used to help clients conform to other treatment demands, including attending counseling sessions (Stitzer & Kirby, 1991).

Even though early work focused on providing positive reinforcers for desired behavior, the adaptations of this work in most clinics around the country has involved negative consequences. For reasons not clear, most clinical sites that have adopted the contingency contracting procedures use punishers, not reinforcers. A common example is the use of a detoxification contract in methadone-maintenance treatment. Frequently, patients who are using illegal drugs sign a contract with treatment staff indicating that if they do not terminate all unapproved drug use within a certain period of time, their methadone dose will be reduced. If they continue to use drugs, their dose is incrementally reduced until they are no longer receiving methadone. At any point in the sequence, however, that the patient shows evidence of discontinuing drug use, the methadone dose can be raised and the person continued on the treatment program. Usually, the contract indicates that patients are given a certain amount of time to decrease the number of drug-positive urines or they are gradually detoxified from the program.

Contingency management has been used with practically every addiction, both by itself and in conjunction with other treatments. The evidence is now convincing that contingencies, especially positive contingencies, are effective in decreasing drug abuse. Work is needed to train clinic staff in using contingency programs, especially those employing positive contingencies (Stitzer & Kirby, 1991).

CLASSICAL CONDITIONING: AVERSIVE CONDITIONING

A form of behavioral therapy once widely used is Aversion Therapy. Here, the drug or the cues that remind drug users of it are paired with unpleasant events. The notion is that by pairing this very desirable substance with an unpleasant event, the association with the substance will become negative. The most successful of these has been rapid smoking, a treatment for tobacco dependence. In rapid smoking, the smoker smokes and inhales at a rate about 6 times that of normal. During this process, the therapist points out negative things about smoking, including the smell of the smoke, burning eyes, racing heart, and pounding head. Over time, the poisonous elements of the smoke itself (usually an amount of Nicotine that exceeds the smoker's tolerance) may make the smoker nauseated. Thus, the cues associated with a cigarette (its appearance and smell) rather than calling forth pleasant reactions in the smoker, come to call forth unpleasant ones. Aversive-conditioning treatments have been attempted with other drugs, most notably Alcohol and Cocaine. Usually, for example, a chemical that induces vomiting is given so that nausea and vomiting occur at about the same time the patient is drinking in a controlled setting. However, aversion treatments for drug abuse other than Tobacco abuse have had limited success or, at least, limited popularity. There are at least two reasons for this. First, with other drugs, the dose of the problem drug needed to produce unpleasant reactions may be physiologically dangerous. Second, rapid smoking is unique in that it is the actual drug, tobacco smoke, that is used to form the aversion. There is evidence in the psychological literature that such aversions are especially potent.

Aversive smoking has been evaluated in several well-controlled studies. It appears that when it is done correctly, abstinence rates can be as high as 60 percent after one year—a very high abstinence rate indeed—since the average abstinence rate after treatment for cigarette smoking is about 20 percent. The data for aversion for alcoholics using chemicals is not so clear. There are few comparisons with other treatments or with no treatment. Individuals who choose aversion treatment may be especially motivated to change, and they might have achieved high abstinence rates even without treatment.

One variant of aversion conditioning is covert conditioning. In covert conditioning, the drug abuser, with the help of a therapist, imagines both the drug use and the unpleasant consequences of it. For example, alcoholics might picture a cold beer, prepare to savor it, took at it, sip it, then slowly feel increasingly nauseated until they become violently ill. Thus, both the aversive events and the unpleasant consequences are imagined, rather than real. This has advantages if the drug of choice is illegal or quite dangerous, because it avoids drug use at all. Also, patients who might refuse to participate in actual aversive conditioning may feel able to do so when the aversion experienced is imagined. Unfortunately, however, there is not a great deal of evidence to support the usefulness of this approach (Council on Scientific Affairs, 1987).

The use of aversion conditioning has decreased recently, except in a limited number of private psychiatric hospitals. There are several reasons contributing to its demise. The first is the lack of demonstrated efficacy in controlled clinical trials with drugs other than tobacco. The second is its expense when compared with other treatments. Last, because of its intrinsically unpleasant nature, it has low acceptability.

SOCIAL LEARNING MODELS

Skill Training.

In skill training, drug abusers, and others at risk for drug abuse, are taught skills that will help them not to use drugs. These can be simple and direct; for example, teaching junior high school students effective ways to refuse a cigarette. The skills learned may also be complex. Consider, for example, a smoker who knows the temptation to smoke when angry, because in the past anger-provoking situations have resulted in relapse. A therapist working with such a person in skill training would first review the situations that produce anger. These might be as diverse as incorrect charges on a credit card bill to a fight with the boss. After identifying the situations, the smoker and therapist would then discuss the details of the situation. For example, they might imagine what the boss would say to smokers to elicit anger. They would attempt to find ways of handling the situation that would leave the smokers feeling satisfied after it was over. They would discuss the usual response that would culminate in smoking. They would then identify alternative responses. Finally, they would role-play the alternative responses. The therapist would play the role of both the boss and the smoker, to give the smoker a model of different ways to handle the situation. In this way, the smokers would learn to handle anger in a better way, would be satisfied with the new responses, and be less likely to smoke. The smoker would also have ready responses other than smoking. Skill-training programs have been studied with smokers, alcoholics, cocaine abusers, and abusers of multiple drugs. Skill training is closely related to the recovery training and self-help that is discussed below. Recent data indicate skill training may be an especially useful treatment for heroin and/or cocaine abusers and alcoholics when used in the context of a large therapy program (Carroll, Rounsaville, & Gawin, 1991).

Skill training has been shown to be especially useful as an ancillary to other treatments. For example, one program developed a workshop to train drug-treatment patients in job-finding skills. There was a great deal of practice in new ways to interview for jobs. Patients were taught how to fill out a job application to maximize their strengths—also how to handle the existence of prison records or long lapses in employment. They practiced their interviews and saw themselves in practice interviews on videotape. The rationale was that if drug abusers could be taught to present themselves positively in a job interview, they would be more likely to get jobs. And, were they to become employed, they would be less likely to use drugs, for several reasons. These reasons include increased general life satisfaction and making new friends and social contacts who are not drug abusers. Studies using this technique found that it was helpful in increasing employment rates in both Methadone-Maintenance clients and former addicts recruited from the criminal-justice system. These studies did not address the length of time the job was held, however. It may be that a separate set of skills is needed to maintain employment. This set should be the object of further study (Hall et al., 1981).

Some programs have attempted to combine several approaches, so that abstinence is supported in multiple ways. Among the most successful of these is the community-reinforcement approach to alcoholism treatment developed by Azrin (1976). The original community-reinforcement approach incorporated (1) placement in jobs that interfered with drinking; (2) marriage and family counseling; (3) a self-governing social club; and (4) encouragement to engage in hobbies and recreational activities that could substitute for drinking. This procedure was found to decrease time spent drinking alcohol, increase rates of employment, increase time spent with families, and decrease the time spent in the hospital being treated for alcoholism. A later revision of the program also encouraged patients to take Disulfiram, a drug which produces unpleasant reactions if one drinks after taking it; taught alcoholics how to identify and handle danger signals so that they did not lead to drinking; provided patients with a "buddy" in the client's neighborhood; and switched from individual to group counseling. This procedure produced even more strikingly positive results than the original program. It can be argued that subjects in these studies had resources available to them that many drug abusers and alcoholics do not have, including the opportunity to receive inpatient treatment, a local economy that provides a choice of job opportunities, and supportive families. Recent work with cocaine abusers has replicated these positive results. The finding is especially impressive because the cocaine abusers were treated on an outpatient basis, and they traditionally have fewer resources than alcoholics.

Psychotherapy.

Psychotherapy has also been useful in treating drug addicts, especially those with social and psychological problems that complicate their drug abuse. The assumption behind providing psychotherapy to drug abusers is that drug abuse is motivated by the problems that abusers have with other people, as well as their feelings about themselves. Early workers in the field attempted to provide psychotherapy as the sole treatment for drug abuse. Most found that it was not successful; they assumed that this was because the personality characteristics of addicts were not those that allowed people to succeed in psychotherapy—that is, addicts are often distrustful of nonaddicts and may not easily reveal their feelings to professionals. Also, they may not be especially reliable and often appear to have shaky to no motivation to change. Nevertheless, a large-scale study at the University of Pennsylvania—using clients who were already in methadone maintenance—found that, in the context of a larger treatment program, drug-treatment clients with other or extensive psychological problems do benefit from the addition of psychotherapy. The forms of psychotherapy available included one focusing on feelings and emotions (supportive—expressive) and one focusing on thought and behaviors (cognitive—behavioral). These researchers found that the type of therapy was not important, just participating in therapy was important (Woody et al., 1983).

The Recovery Training and Self-Help Model.

Researchers at Harvard University studied a model that combined skill training in Relapse Prevention with Self-Help Groups. In their study, opiate addicts attended a recovery-training session once a week and a self-help group led by a former addict. Members also met informally outside the treatment meetings and in group-sponsored recreation and community activities. In the professionally led recovery meetings, leaders addressed a variety of topics, including high-risk situations, friendships, physical illness, and relations with family; they developed new ways of handling these situations that would be less likely to lead to drug use. The self-help groups supported these changes and further reinforced them. In two studies, one in the United States and one in Hong Kong, this treatment led to higher rates of abstinence or infrequent use than was found in a control condition, to increases in employment, and to fewer reports of criminal behavior. These differences were quite long-lasting—occurring six months to one year after entrance into treatment (McAuliffe & Ch'ien, 1986).

Twelve-Step Programs.

The most well-known Twelve-Step program for helping substance abusers is Alcoholics Anonymous (AA). AA, founded in 1935 by a group of recovering alcoholics, is a fellowship of men and women who are committed to helping other alcoholics. Narcotics Anonymous (NA), founded in 1953, was adapted from AA principles to include all substance abusers, not only alcoholics.

AA and NA programs focus on alcoholism and substance abuse as a disease for which there is no cure—therefore recovery becomes a lifetime commitment. These programs emphasize the personal powerlessness of individuals in combating their illness and get individuals to recognize that they must give themselves to a greater power so that they may be saved.

The guiding tenets of AA and NA programs are called the Twelve Steps. Each step is a passage through recovery, combining self-discovery with spiritual guidance. They involve five psychological tasks: (1) recognition and admission of powerlessness over alcohol; (2) acceptance of a high power as a source of strength and guidance during recovery; (3) self-help appraisal and self-disclosure in the service of personal change; (4) making amends for past wrongs; and (5) carrying the AA message to others (Anderson & Gilbert, 1989).

One can argue that aspects of AA parallel psychological approaches. For example, similar to psychotherapy, AA and NA members are encouraged to "work through" problems and to change the attitudes and actions associated with an alcohol- or drug-using lifestyle. These programs also use principles common to other self-help groups. Members are encouraged to attend meetings on a daily or weekly basis, at which the steps are discussed and made relevant, speakers recount their lives, and connections with support networks and role models are made.

Nevertheless, despite the facility with which psychological models might explain such approaches, they are not psychological approaches. They were developed from a spiritual approach, not from psychological principles.

SUMMARY

There are many psychological treatments that appear to be useful in aiding drug abusers to stop using drugs, no matter whether the drug be an illegal one, or alcohol or nicotine. Positive results come from contingency-contracting programs and multifaceted-reinforcement programs that are offered in the context of complex treatment programs or from skill-training programs that address several facets of the drug abuser's life. Also, there is evidence for the usefulness of different forms of psychotherapy for drug abusers, especially for those who have psychological and social problems. Drug abuse is increasingly becoming identified as a complicated problem that involves both biological and psychological factors. Because of this and the clear usefulness of psychological intervention, we can expect to see the development of new psychological treatments for drug abuse.

(See also: Addiction: Concepts and Definitions ; Adjunctive Drug Taking ; Causes of Substance Abuse ; Disease Concept of Alcoholism and Drug Abuse ; Prevention ; Vulnerability ; Wikler's Pharmacologic Theory of Drug Addiction )

BIBLIOGRAPHY

Anderson, J.G., &Gilbert, F. S. (1989). Communication skills training with alcoholics for improving performance of two of the Alcoholics Anonymous recovery steps. Journal of Studies on Alcohol, 50, 361-367.

Azrin, N. H. (1976). Improvements in the community-reinforcement approach to alcoholism. Behavior Besearch and Therapy, 14, 339-348.

Carroll, K. M., Rounsaville, B. J., & Gawin, F.H. (1991). A comparative trial of psychotherapies for ambulatory cocaine abusers: relapse prevention and interpersonal psychotherapy. American Journal of Drug and Alcohol Abuse, 17 (3), 229-247.

Council on Scientific Affairs. (1987). Aversion therapy. Journal of the American Medical Association, 258, 2562-2566.

Emrick, C. D. (1987). Alcoholics Anonymous: Affiliation processes and effectiveness as treatment. Alcoholism, 11, 416-423.

Hall, S. M., et al. (1981). Increasing employment in ex-heroin addicts II: Criminal justice sample. Behavior Therapy, 12, 453-460.

McAuliffe, W. E., & Ch 'ien, J. M. (1986). Recovery training and self-help. Journal of Substance Abuse Treatment, 3, 9-20.

Ogborne, A. C., & Glaser, F. B. (1981). Characteristics of affiliates of Alcoholics Anonymous: A review of the literature. Journal of Studies on Alcohol, 42, 661-675.

Sheeren, M. (1988). The relationship between relapse and involvement in Alcoholics Anonymous. Journal of Studies on Alcohol, 49, 104-106.

Stitzer, M. L., & Kirby, K. C. (1991). Reducing illicit drug use among methadone patients. In Improving Drug Abuse Treatment (National Institute on Drug Abuse Research Monograph 106). Rockville, MD: National Institute on Drug Abuse.

Woody, G. E., et al. (1983). Psychotherapy for opiate addicts. Archives of General Psychiatry, 40, 639-645.

Sharon Hall

Meryle Weinstein

Self-Help and Anonymous Groups

Self-help groups for drug and alcohol abuse, often called mutual-help groups, are of two basic types. First are the long-standing anonymous groups closely patterned after Alcoholics Anonymous (AA). An alternative type also has a group context, but rejects the spiritual aspects (such as reliance on "higher power") of AA and urges members instead to take personal responsibility for gaining sobriety. The AA-like anonymous groups embrace the Twelve Steps, applying them to their own particular disorder. In some instances, they also adapt the AA Twelve Traditions. Narcotics Anonymous, Emotions Anonymous, Overeaters Anonymous, Gamblers Anonymous, Al-Anon, Cocaine Anonymous, and Nicotine Anonymous are prominent examples. Examples of the alternatives to AA are Rational Recovery (RR), Secular Organization for Sobriety (SOS), and Women for Sobriety (WFS). Numerous members of these groups have been dropouts from AA.

In embracing AA's Twelve Steps, the first type of organization teaches powerlessness over their malady, reliance on the group or on some entity as a "higher power," catharsis via self-inventory, confession and amends, and a commitment to search out and tell others suffering from the same disorder about their programs for recovery. The rationale is that members have deep-seated denials that must be blunted by admitting helplessness and invoking the group and a higher power to help them. Moreover, this powerlessness is seen as a lifetime condition and the Twelve Steps are seen as providing a mechanism for ensuring a lifetime cessation of the compulsive behavior. The steps were devised in the late 1930s by Bill W., the major cofounder of AA, in conjunction with a small group of his earlier followers.

The Twelve Steps of Alcoholics Anonymous.

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to others, and to practice these principles in all our affairs.

Source: The Twelve Steps are reprinted with permission of Alcoholics Anonymous Word Services, Inc. Permission to reprint this material does not mean that AA has reviewed or approved the contents of this publication, nor that AA agrees with the views expressed herein. AA is a program of recovery from alcoholism only —use of the Twelve Steps in connection with programs and activities patterned after AA, but which address other problems, does not imply otherwise.

The second type of organization emphasizes that individuals, as individuals, must use their own resources and, in effect, "Save Our Selves" (SOS). The founder of WFS has written Thirteen Statements of Acceptance around which meetings are anchored: For example, number 5 is "I am what I think," and number 13 is "I am responsible for myself and my actions." The other statements encourage in women alcoholics a strong feeling of self-worth even though they have symptoms of a serious disease (Kirkpatrick, 1989).

The two types of organizations differ on basic treatment strategies. One difference is their divergent views of the permanency of their obsessive behavior. AA, and the many AA-like groups, view their problems as lifetime conditions over which they are powerless. In short, they will never recover; they are permanently "recovering" from a disease. In contrast, RR, for example, plays down the disease concept, and the higher-power notion that goes with it, and appeals to forces within a member's own intellect and willpower. Self-reliance is taught. WFS targets the development of self-value, self-esteem, and self-confidence as a way to meet the emotional needs of modern women, thereby, members believe, reducing significantly the basic roots of alcohol abuse for them.

The success rates of the AA fellowship have been assessed at two points in time. Of those initially attracted to AA, a large proportion drop out—somewhere between 35 and 65 percent. Of those who become active members, 65 to 70 percent "improve to some extent, drinking less or not at all during A.A. participation" (Emrick, 1989:45). Membership in AA seems to be associated with relatively high abstinence rates, but with fairly typical improvement rates (Emrick, Lassen, & Edwards, 1977). It appears that AA is effective only with some 25 to 30 percent of the population with alcohol-related problems. AA, then, is a highly selective treatment source—attracting and holding those alcohol-troubled persons with severe alcohol problems who have high affiliative needs, conformist tendencies, proneness to guilt, and need for external controls (Trice & Roman, 1970; Ogborne & Glaser, 1981).

Unfortunately, the alternative type of organization has yet to be scrutinized by objective researchers. But subjective estimates of the number of groups and members have been put forward. SOS claims 1,000 groups with 2,000 members (Christopher, 1992); Hall (1990:1,46) has estimated that RR has meetings in 100 cities, "with perhaps two thousand members at any one time," and Hall (1990) estimated 5,000 members in 32 groups for WFS. Assuming that, like AA, there are dropouts and misfits for each type of group, these numbers must be sharply discounted. Nevertheless all three have demonstrated some staying power. SOS even publicizes itself as a demonstrated and proven alternative to AA. As yet no reliable data support this contention, but the fact that sizable numbers have been attracted to it suggests that it, or groups like it, are realistic contenders for some of AA's approximately 1 million members.

(See also: Alcoholism ; Disease Concept of Alcoholism and Drug Addiction ; Ethnic Issues and Cultural Relevance in Treatment ; Women and Substance Abuse )

BIBLIOGRAPHY

Christopher, J. (1992). The S.O.S. story. S.O.S. National Newsletter, 5 (1), 1, 2.

Emrick, C. (1089). Alcoholics Anonymous: Membership characteristics and effectiveness as treatment. In M. Galanter (Ed.), Recent developments in alcoholism: Treatment and research (pp. 37-53). New York: Plenum Press.

Emrick, C. D., Lassen, C.L. &Edwards, M. T. (1977). Nonprofessional peers as therapeutic agents. In A. S. German & A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 120-161). New York: Pergamon Press.

Hall, T. (1990). New way to treat alcoholism shuns spirituality. New York Times, December, 4, 1, 46.

Kirkpatrick, J. (1990). Women for sobriety. The Counselor, January/February: 9.

Ogborne, A. C., & Glaser, F. B. (1981). Characteristics of affiliates of Alcoholics Anonymous: A review of the literature. Journal of Studies on Alcohol, 42 (7), 661-675.

Trice, H.M., &Roman, P.M. (1970). Sociopsychological predictors of affiliation with Alcoholics Anonymous: A longitudinal study of "treatment success." Social Psychiatry, 5, 51-59.

Harrison M. Trice

Therapeutic Communities

Therapeutic communities (TCs) are drug-free residential treatment facilities for drug and/or alcohol addiction. TCs emerged in the 1960s as a self-help alternative to the conventional medical and psychiatric approaches being used at that time.

Most traditional TCs have similar features, including their organizational structure, staffing patterns, perspectives, rehabilitative regimes, and a twelve- to eighteen-month duration of stay. They differ greatly, however, in size (30-600 beds) and client demography. Most people entering TCs have used multiple drugs-including Tobacco, Marijuana, Alcohol, Opiods, pills, and, recently, Cocaine and Crack-cocaine. In addition to their substance abuse, most TC clients also have a considerable degree of psychosocial dysfunction (Jainchill, 1994). In traditional TCs, 70 to 75 percent of clients are men, but admission for women is increasing. Most community-based TCs are integrated across gender, race/ethnicity, and age. Primary clinical staff are usually former substance abusers who were rehabilitated and trained. Other staff are the professionals who provide medical, mental health, vocational, educational, family-counseling, fiscal, administrative, and legal services.

Traditional TCs share a defining view of substance abuse as a deviant behavior, which may be attributed to psychological factors, poor family effectiveness, and, frequently, to socioeconomic disadvantage. Drug abuse is thus seen as a disorder of the whole person and recovery as a change in lifestyle and personal identity. As part of the recovery process, TCs seek to eliminate antisocial attitudes and activity, develop employable skills, and inculcate prosocial attitudes and values. This TC view of recovery is based upon several broad assumptions: the client's motivation to change, the client's main contribution to the change process (self-help ), the mediation of this recovery through peer confrontation and sharing in groups (mutual self-help ), the affirmation of socially responsible roles through a positive social network, and the understanding that treatment is a necessarily intense "episode" in a drug user's life.

Diverse elements and activities within the TC foster rehabilitative change. Junior, intermediate, and senior peer levels stratify the community, or the family. The TC's basic program elements, consisting of individual counseling and various group processes, make up the therapeutic and educative elements of the change process. The daily activities, including morning meetings, seminars, house meetings, and general meetings facilitate assimilation into the community as a context for social learning. Clients are oriented into the program during the orientation-induction stage. They progress through the primary treatment stage of the program by achieving plateaus of stable behavioral change. Client development reflects their changing relationship with the community, characterized as compliance, conformity, and commitment. Finally, reentry represents the final program stage where the skills needed in the greater social environment are fostered through increased self-management and decision making.

The effectiveness of the traditional long-term residential TC, as described here, has been well-documented (De Leon, 1997, 2000). Today, TCs include a wide range of programs serving diverse clients who use a variety of drugs and present complex social/psychological problems. Client differences, clinical requirements, and funding realities have all encouraged the development of modified residential TCs with shorter stays (3, 6 and 12 months) as well as TC-oriented day treatment and outpatient models. Most traditional TCs have expanded their social services or incorporated new interventions to address the needs of special populations such as adolescents, mothers and children, homeless, mentally ill chemical abusers, and prison inmates. In these modifications the cross-fertilization of personnel and methods from the traditional TC, mental health, and human services portends the evolution of a new therapeutic community.

BIBLIOGRAPHY

De Leon, G. (2000). The therapeutic community: Theory, model, and method. New York: Springer Publishing Company.

De Deon, G. (Ed.). (1997). Community as method: Therapeutic communities for special populations and special settings. Westport, CT: Greenwood Publishing Group, Inc.

Jainchill, N. (1994). Co-morbidity and therapeutic community treatment. In F. M. Tims, G. De Leon, & N. Jainchill (Eds.), Therapeutic community: Advances in research and application. National Institute on Drug Abuse Research Monograph 144. Publication no. 94-3633 (pp. 209-231). Rockville, MD: National Institute on Drug Abuse.

George DeLeon

Traditional Dynamic Psychotherapy

Dynamic psychotherapy is the term for the various psychological treatments, primarily talking treatments, intended to modify and ameliorate behaviors based on inner conflicts (e.g., "Should I study for the test or cheat?") and/or interpersonal conflicts (difficulties with others). These techniques range from those intended primarily to support individuals, lending them the therapist's strength or understanding ("If you do that you'll get in trouble. Have you thought of handling it this way?"), to helping patients reach their own understanding of the origins and implications of their behaviors. The application of these techniques to the treatment of alcoholics and substance abusers is supported by the high incidence of cooccurrence of psychiatric illness—in several studies, 70 percent—some of which may play a role in initiating or maintaining the behavior. It has been suggested that for some substance abusers, the use of illicit compounds is a misguided attempt at self-medication. Often, psychotherapy must be provided in conjunction with other treatments—pharmacologic, such as Disulfiram for alcoholics or Methadone for Heroin abusers; Self-Help groups, such as Alcoholics Anonymous; or family or group psychotherapy.

Psychotherapy is based on the assumption that the patient will think and talk about ideas and feelings rather than acting upon them. This may prove particularly difficult for substance abusers who often have little sense of what they feel, other than generalized pain, and who are used to action and immediate gratification. Therefore, treatment, particularly at the beginning, must take place within a structure that both supports and helps control impulsive behavior. Sometimes, treatment starts in a hospital or other residential setting; often, it is accompanied by regular drug testing. After the agreement to start therapy and setting goals, therapist and patient meet once to several times a week. As trust is developed between patient and therapist, the therapist can expect less lying and less denial of difficulties; treatment can, if indicated, begin to move from support toward expression of feelings—toward identification of conflicts and the understanding of their origins. Initially the therapist listens, struggling to understand the patient's inner experience and its meaning. The therapist then attempts to help patients to understand what they have presented, with appropriate changes and qualifications based on further information provided by the patient. Important issues to be explored in treatment include current relationships (with spouse, children, friends, coworkers), past relationships (with parents and other family), and the relationship within the treatment between the patient and the therapist. Often, the difficulties and distortions within this relationship mirror past and current relationships and may be used to help the patient see the nature and impact of the past on current behaviors.

Treating substance abusers can be frustrating for therapists; there are many slips with return to drug use, and patient behavior is often calculated to make the therapist angry and to give up. It is essential that therapists who make the attempt carefully monitor their own feelings so that they do not interfere with the treatment itself. It is also important to remember that when properly done, treatment can make the difference between suffering with chronic problems and successful adaptation. This is particularly true when substance abuse is accompanied by other psychiatric disease and/or disability.

(See also: Causes of Substance Abuse: Psychological (Psychoanalytic) Perspective ; Disease Concept of Alcoholism and Drug Abuse ; Epidemiology )

BIBLIOGRAPHY

American Psychiatric Association. (1989). Treatments of psychiatric disorders: A task force report of the American Psychiatric Association. Washington, DC: Author.

William A. Frosch

Twelve Steps, The

The heart of the Alcoholics Anonymous (AA) is a program called the Twelve Steps set forth by cofounder Bill W. and his early followers. The Twelve Steps establish a suggested, unfolding process for becoming, and remaining, sober. The process begins with an admission of powerlessness over alcohol, along with unmanageable lives, and builds momentum gradually into a commitment to carry the AA program via the Twelve Steps to active alcoholics. Newcomers are not pressed to follow all the steps if they feel unwilling or unable to do so. This suggested policy seems to be followed. Thus, Madsen (1974) found that 41 of the 100 AA members he studied had gone through all the Twelve Steps. And Rudy (1986:10) reports that "in Mideast City, A.A. members talk about and emphasize steps 1, 2, 3, 4, and 12 more than others." This pragmatic view of the Twelve Steps can be heard in an AA saying—"Take the best and leave the rest." The steps are:

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs [Alcoholics Anonymous World Services, 1976:59].

Step one meant for Bill W., the founder of AA, "the destruction of self centeredness" (Alcoholics Anonymous, 1939:16). In informal talk, AA members often urge everyone "to leave their egos at the door." Trice (1957:45) found that affiliation with AA was initially encouraged among those newcomers who reported that they had no willpower models among their friends or relatives for quitting alcohol abuse. Many observers have noted the strong tendency among alcoholics toward an "exaggerated belief in the ability to control their impulses, especially the impulse to use alcohol… that they are in charge of themselves, that they are autonomous and able to govern themselves" (Khantzian & Mack, 1989:74). AA teaches that until alcoholics accept the first step they will continue to believe a fiction—that they are clever enough and strong enough to control their drinking. In any event, by taking the first step, newcomers to AA dramatically change their conception of self from believing they can control their drinking to believing they cannot ever do so.

In step one, AA taps into the repentant role in U.S. tradition. Redemptive religions emphasize that one can correct a moral lapse, even one of long duration, by public admission of guilt and repentance. AA members can assume this repentant role, beginning with step one, and it becomes, along with the other steps, a social vehicle whereby they can reenter the community (Trice & Roman, 1970).

This role is strengthened by step two and step three, wherein alcoholics agree there is a power greater than themselves who will help and agree to turn their destiny over to this higher power as they conceive of it. In essence, members believe that one does not have to stand alone against alcohol abuse and the strains of life; AA offers the group itself and its collective notion of a higher power to help the powerless.

By accepting and executing step four and step five, AA members believe they are engaging in a realistic self-examination of the factors of fear, guilt, and resentment that cause their drinking. In step four, new members list all people they now resent or have resented in the past. Along with this list, newcomers note what they believe to be the substance of the resentment. Following this exercise, new members work out ways to try to alter conceptions of these resented persons. They also attempt an inventory of their own behaviors that have contributed to their fears, guilts, and resentments. In step five, alcoholics acknowledge these inventories to a higher power and confess them to some other individual. for example, a friend, pastor, therapist, or sponsor. Members believe that this moral inventory and its reduction in resentments enable them to live through emotional experiences that in the past were managed by the abuse of alcohol.

Steps six and seven are reinforcements of the changes produced by acting out steps four and five. In step six, members indicate and reaffirm a readiness to respond to help from a higher power. In step seven, with as much humility as possible, members actually request that the higher power help them eliminate the inventory of "shortcomings" assembled by the member. In steps eight and nine, members seek to make further changes and reinforce past changes by providing restitution to those they have hurt in the past. Members list those actually harmed by their past behaviors and then do as much as they can to make amends and try to cancel out the harm caused. Most members agree that some amends might actually do harm to either themselves or others and caution against them. For example, the member might grievously damage a spouse by confessing in detail sexual infidelities. Step ten is a repetition and a reinforcement of steps four and five. In this step, members continue to "take my moral inventory" and admit their wrongs to themselves, others, and the Greater Power. Step eleven also acts as an implementer, but this time for step three, in which through meditation and prayer they again decide to turn over their willpower and their lives to a higher power.

Step twelve is the culmination of all these steps. Members are urged to carry their experiences and stories to active alcoholics in treatment centers, hospitals, even homes—in effect, to offer the redemptive model of AA sobriety to them. AA participants argue that, by becoming helpers, they help themselves at the same time and that they derive new commitments to the truths believed to be manifest in the other eleven steps. Furthermore, in twelfth-step work, there is a one-on-one, often a two-on-one (two AA members and one active alcoholic) meeting that often results in a sponsor-sponsoree relationship between a newcomer and older (in AA "birthdays") members. The group wisdom of AA teaches that new members are more likely to join during a crisis. Consequently, twelfth-step workers do not press for an admission of alcoholism during initial contacts. Rather, they try to be nonjudgmental, accepting, and reassuring, while nevertheless trying to help the prospect define the problem and what he or she will do about it. Members do, however, briefly describe their recovery via AA and invite the prospect to come to their meetings. If there is a positive response, they will promise to take the prospective member. According to Bales (1962:575), the sponsor-sponsoree relationship, along with the actual twelfth-step work itself, is "the heart of the therapeutic process" in AA.

The use of these steps is supported by basic assumptions: that intense self-examination and confession are cathartic; that alcoholics cannot control even moderate drinking and therefore are incapable of drinking at all. In other words, "once an alcoholic, always an alcoholic." According to the first step, "We admitted we were powerless over alcohol." The assumption of being powerless has been the focus of considerable controversy outside AA. The controversy centers around a follow-up study of 11,000 alcoholics whose drinking patterns were obtained 6 months and 18 months after experiencing one of a variety of treatment programs. The study, which contained numerous flaws (e.g., short follow-up time), showed that the majority of former alcoholics (who drank, on average, more than 8 ounces a day of ethanol [alcohol]) who had experienced a treatment program could drink moderately (2.5 ounces per day) at levels that many believe to be no problem (Armor, Polich, & Stambul, 1976).

A competing assumption is that Alcoholism is a disease—that alcoholics suffer from an "allergy." This belief has also been controversial. An alternative has been the concept of the "problem drinker," the heavy drinker who gets into trouble, directly or indirectly, because of drinking alcohol. This bypasses the debate about alcoholism being a disease and about the amount drunk; it focuses instead on the "problem" correlates of drinking, that is, a role-impairment definition—financial problems and problems with family, police, friends, and neighbors. For example, Trice (1966:29) suggests that role impairment—such as job impairment—would be one of the performance criteria for the definition of alcoholism: alcoholics differ from those around them because the performace of their adult roles becomes clearly impaired by their recurrent use of alcohol. In the United States, most alcoholics are very poor husbands and fathers or wives and mothers; on the job, they falter and disappoint their coworkers. In addition, their unreliable behavior makes for doubts and confusion in intimate friendships. In sum, drinking behavior that significantly damages the performance of basic roles is the phenomenon, and it is not necessarily a disease as AA claims. Calahan and Room (1974) reported significant correlations between heavy drinking and impairments in the performance of these elementary roles. Such a definition opens the door for other therapies that assume that moderate drinking is possible. It even assumes that there may be "spontaneous recovery," that no therapy of any kind may be involved in some recoveries.

Finally, it should be noted that the Twelve Steps of AA are, in many members' minds, inevitably associated with AA's Twelve Traditions, which are aphorisms for the maintenance and continuity of AA itself at the group level. Examples are: Tradition 1—Our common welfare should come first; personal recovery depends upon AA unity. Tradition 10—We need always maintain personal anonymity at level of press, radio, and films (Alcoholics Anonymous World Services, 1965).

(See also: Alcoholism ; Disease Concept of Alcoholism and Drug Abuse ; Rational Recovery ; Sobriety ; Treatment, History of ; Vulnerability As Cause of Substance Abuse )

BIBLIOGRAPHY

Alcoholics Anonymous World Services. (1976). Alcoholics Anonymous: The story of how thousands of men and women have recovered from alcoholism (3rd ed.). New York: A.A. Publishing.

Alcoholics Anonymous World Services. (1965). Twelve steps and twelve traditions. New York: Author.

Alcoholics Anonymous World Services. (1939). Alcoholics Anonymous (1st ed.). New York: Author.

Armor, D. J., Polich, J. M., & Stambul, H. B. (1976). Alcoholism and treatment. Santa Monica, CA: Rand.

Bales, R. F. (1962). The therapeutic role of Alcoholics Anonymous as seen by a sociologist. In D. Pittman & C. R. Snyder (Eds.), Society, culture, and drinking patterns, pp. 573-578. New York: Wiley.

Khantzian, E. J., & Mack, J. E. (1989). Alcoholics Anonymous and contemporary psychodynamic theory. In M. Galanter (Ed.), Recent developments in alcoholism: Treatment research, Vol. 7, pp. 67-89. New York: Plenum Press.

Madsen, W. (1974). The American alcoholic. Spring-field, IL: Charles C. Thomas.

Rudy, D. R. (1986). Becoming alcoholic: Alcoholics Anonymous and the reality of alcoholism. Carbondale: Southern Illinois University Press.

Trice, H. M. (1966). Alcoholism in America. New York: McGraw-Hill.

Trice, H. M. (1957). A study of the process of affiliation with Alcoholics Anonymous. Quarterly Journal of Studies on Alcohol, 18, 39-54.

Trice, H. M., & Roman, P. M. (1970). Delabeling, relabeling and Alcoholics Anonymous. Social Problems, 17 (4), 538-546.

Harrison M. Trice