Counseling and Methadone in Treatment of Substance Abuse - Essay Example

Counseling and Methadone in Treatment of Substance Abuse 2008 Counseling and Methadone in Treatment of Substance Abuse Introduction Substance abuse is currently one of the most challenging and disturbing health issues in the US. Almost 100 thousand of US citizens die annually as a result of illicit drug and alcohol abuse, and approximately 12 thousand more die of AIDS, which is strongly related to substance abuse. An estimated 14 million people in the US either have been diagnosed with or currently continue to abuse alcohol, drugs and other illicit substances (Austin, 2005). The almost epidemic situation with substance abuse and dependency has negative health consequences and impressive economic costs. Substance abuse, including tobacco use and nicotine addiction, is associated with a wide range of serious health and social problems. Recent epidemiological evidence demonstrates that 72 conditions requiring inpatient treatment are wholly or partially attributable to substance abuse. Consequently, the estimated annual cost for health care, law enforcement, motor vehicle crashes, crime, and lost productivity due to substance abuse is nearly 1 thousand dollars for every American citizen, including children (Austin, 2005). Such disturbing situation with substance abuse can not but appeal for immediate and effective actions from the government and local authorities. Although the problem is not new, the search for the most effective methods of coping with substance abuse is far from being over. Many different prevention and treatment options have been proposed up to date, but none of them can be addressed as the most effective. Partially this is due to the fact that substance abuse is a condition with extremely complex and often controversial etiology; partially due to lack of serious scientific research exploring specific mechanisms of recovery. The increasing use of psychotherapeutic interventions in both prevention and treatment of substance abuse suggests that modern researchers and practitioners are taking efforts to deal with the problem more effectively than before. This paper provides an overview of the most widely used type of interventions in treatment of substance abuse, namely psychological counseling. Counseling Despite the long history of use a lot of issues related to psychological counseling in treatment of substance abuse still remain poorly explored or unknown. There is one major reason for such situation listed in the substance abuse literature: counseling research projects have often been denied funding due to inability of the researchers to convince the funding authorities that their research standards for scientific investigation meet the conventional standards. Unfortunately, specifics of psychological research makes this task extremely complex: even the most fundamental traditional standard of experimental investigation, the double-blind method, is a "virtual impossibility in comparative psychotherapy research" (Onken & Blaine, 1990: 1). Instead, most of the research in the field has focused on medication treatments for substance abuse even despite the fact though non-pharmacological interventions (such as psychotherapy) are used more frequently, either alone or in combination with other methods of treatment (Carroll, 1998). However, the lack of funding have not prevented the researchers and practitioners from designing a number of psychological and psychosocial intervention strategies for treatment of substance abuse. Although the philosophies underlying various kinds of treatment are vastly different, almost all of them include, in some or other form, psychological counseling that has been used in substance abuse recovery and prevention programs since long ago. Thus, already in the early 1980s individual psychotherapy or psychological counseling were available in a stunning 99 % of the drug-free, methadone-maintenance, and multiple-modality drug abuse treatment units and almost 97 percent of the detoxification units in this United States (National Drug and Alcoholism Treatment Unit Survey, 1982). Counseling is a process that involves taking measures that help create certain conditions to make the client understand and solve the problem. It also helps the patient understand and improve his behavior, character, values and life as a whole. Normally counseling is perceived as a remedy for mental problems, but it can also be helpful at any point of life because its essence is the positive attitude towards personal development (Woods, 2005). The methods of outpatient counseling are versatile, and such versatility is probably the most essential advantage of this kind of intervention because the multiple etiology of substance abuse, coupled with variety of symptoms and patterns associated with this condition and different substances involved require much flexibility in treatment. Outpatient counseling includes a number of therapeutic approaches such as behavior therapy, skill development, family therapy, cognitive-behavioral and relapse prevention therapy, and is found to yield outcomes similar to those in inpatient treatment programs in terms of treatment completion rate, reduction in substance use, improvement in behavior and functioning (Lowinson, Ruiz, Millman & Langrod, 2004). These therapies are based on different theoretical approaches and different vision of the nature of substance abuse, but all of them demonstrate high effectiveness in helping patients cope with the problem. Family Systems Therapy (FST), also referred to as Family Therapy and Couple and Family Therapy, is a relatively new counseling strategy that is used to treat substance abuse and other psychological problems in the family context. FST perspective relies upon the assumption that psychological problems developed in the social context of families. Such view implies that the therapist should pay attention to the entire family of the patient instead of focusing almost exclusively on the individual needs and symptoms of the patient. Modern forms of FST employ a wide range of methods and techniques from the field of psychotherapy, systems theory, systemic coaching, and communication theory and tend to incorporate several psychotherapeutic approaches including cognitive therapy, narrative perspectives, social constructionist approach, intergenerational theory, etc. (Nichols & Schwartz, 1998). Such variety of paradigms incorporated in FST is due to exceptionally complex, multilateral and multilevel nature of human interactions within the family setting. Various types of family therapy are effectively used to treat substance addiction and other serious psychological disorders such as schizophrenia and anorexia nervosa. However, family therapy is not considered an adequate option in several cases: when family members, one or both, have serious mental disorder; physical or life-related limitations that does not allow to regularly take part in family therapy; when excessively rigid structure of personality is observed in one or both members of the family, when cultural/religious background of the family does not allow conducting any kind of psychotherapeutic intervention; unstable families (Nichols & Schwartz, 1998). Relapse Prevention is the classic form of the increasingly popular cognitive-behavioral therapy. This approach relies on the learning perspective in etiology of substance abuse which implies that unhealthy behaviors including substance abuse are learned. Therefore, the core idea underlying this therapy is empowering abusers to learn how to identify and correct their maladaptive behavioral patterns. Relapse prevention therapy incorporates several cognitive-behavioral strategies that provide help in stopping substance abuse and minimizing the chances of relapse. The counseling methods used within the framework of relapse prevention approach include exploring the consequences, both positive and negative of continued substance use, strict self-monitoring to recognize and identify situations which put the patient in high risk of abuse, and developing strategies for coping with and avoiding such situations. The basic idea of this therapy is to anticipate the difficulties patients will face and to help them develop effective strategies to cope with them (Carroll, Rounsaville & Keller, 1991). Research shows that positive results brought about using these strategies remain after the intervention is over. Thus in one study majority of patients participating in cognitive-behavioral program maintained the treatment outcomes throughout the following year (Carroll et al, 1994). Other popular types of cognitive-behavioral therapy include Cognitive Therapy (Beck et al. 1993) and the Community Reinforcement Approach (Meyers & Smith 1995). Cognitive therapy "is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions" (Beck et al. 1993: 21). This therapy focuses on functional analysis of substance abuse and identification of cognitions associated with substance abuse. In cognitive therapy, the therapist's approach to focusing on cognitions is based on leading the patient through a series of questions, and the treatment is believed to reduce substance use by changing the patient's way of thinking (Carroll, 1998). Motivational Enhancement Therapy (MET) is another popular counseling strategy that produces behavioral change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. This approach uses techniques to produce rapid and internally motivated change in the patient instead of guiding him step by step through the process of recovery. The therapy employs motivational interviewing principles to reinforce motivation and build a plan for targeted change. This approach has demonstrated high effectiveness in treatment of alcohol and marijuana abusers (Miller, 1996). Supportive-Expressive Therapy (Luborsky, 1984) and Interpersonal Psychotherapy (Rounsaville & Carroll, 1993) represent a different approach in treatment of substance abuse as compared with cognitive-behavioral interventions. These two therapies rely on the idea that substance abuse and dependence, are ".intimately related to disorders in interpersonal functioning which may be associated with the genesis or perpetuation of the disorder. IPT, as adapted for cocaine dependence, has four definitive characteristics: (1) adherence to a medical model of psychiatric disorders, (2) focus on patients' difficulties in current interpersonal functioning, (3) brevity and consistency of focus, and (4) use of an exploratory stance by the therapist that is similar to that of supportive and expressive therapies" (Carroll, 1998: 11). These are more exploratory approaches that view substance abuse a symptom of other problems and conflicts and, therefore, deal with the problem less directly than cognitive-behavioral approaches. Gestalt Therapy (GT) is a holistic approach in treatment of psychological problems which seeks to integrate the whole variety of factors that relate to human mind, body and spirit. Integration of feelings, behaviors, and thinking is the main purpose in this approach (Latner, 1990). GT is a 'present-centered' approach: it stresses the value present subjective experiencing, the therapeutic relationship, personal responsibility and autonomy (O'Leary, 1997). Patients who receive counseling within GT perspective are viewed as potentially empowered to recognize how their previous experiences might have affected their lives. They are made aware of personal responsibility, how to avoid problems, to finish things which must be finished, to experience life issues in a positive light, and in the awareness of the present moment. The basic goal of the counselor is to make the patient accept this awareness and the responsibility of taking care of him instead of trying to find the empowerment outside. The arsenal of methods and techniques the therapist may employ to achieve this goal - either individually or in groups - ranges from dimple dialogue to role plays and dream analysis, while the problems that can be treated using GT are multiple too: deviant behavior in children and adolescents, psychosomatic disorders, and couples and family problems (Latner, 1992). Another popular model of substance abuse treatment, the 12-step model strongly relies on the notions and concepts proposed by Alfred Adler. The relationship between the key concepts and ideas of the Adlerian perspective has been explored and verified by credible research. Thus, Carroll (1999) argues that, "tenets of Adlerian theory and practice are compatible with the philosophy and practices of Alcoholics Anonymous. Counselors can expect treatment approaches based on Adlerian counseling theory to be congruent with 12-step practices of individuals who are in recovery from alcohol dependence" (p. 50). This relationship is multiple and difficult to remain unnoticed. Improvement in self-acceptance and self-esteem of the patients is the core goal and idea of the 12-step model, which clearly shows that this therapy is, in fact, built on the foundations of Adlerian teaching. Similarly to Freud and other representatives of the psychodynamic paradigm, Adlerian psychology implies excavation of the patient's past and using the results to modify his or her future in the positive direction: improving the self-worth, restoring or increasing the patient's integration into community, etc. Adlerian philosophy focuses on encouraging and empowering people to remember situations and events that occurred in the past when their unconscious need for self-worth remained unmet, and using these memories to improve their self-worth through putting changed values and beliefs into their unconscious (Brigham, 2003). Methadone Maintenance Treatment The essence of Methadone Maintenance Treatment (MMT) is using a synthetic compound methadone to stop substance abuse and return the patient to normal life conditions. Methadone is an agent that occupies the brain sites affected by the abuse of substances. It prevents the sedative effects of drugs and relieves the craving for the same. Thus the individual does not tend overcome relapsing conditions. Methadone also relieves patients from the withdrawal symptoms experienced. It is not an intoxicating agent itself when used at a controlled dose once a day. MMT program involves providing the patient with a fixed dose of methadone everyday along with some resocialization programs. The dose is determined on the basis of the addiction level and condition of the patient. On the average, length of MMT is one year though the actual period is determined based on the specific conditions of the patient. Through the regulated use of methadone the patient reduces or stops using drugs. The risk of diseases is also reduced resulting in reduced mortality rate. Criminal behavior reduces and family stability and employment potential increase. Pregnancy outcome also improves with the use of methadone (Wechsberg, Berkman, Kasten & Roussel, 2007). MMT is the most comprehensively studied and most effective drug treatment modality as compared with other similar treatments such as chemical dependency treatment, drug-free outpatient treatment and therapeutic communities. However, it is also surrounded by some controversy associated first of all with the nature of methadone. The problem is that methadone is classified as a drug and its use as a substitute of another substance contradicts the principles of drug free society. Secondly, since the length of MMT is rather long many patients fail to complete it which results in high relapse rates. Sometimes patients continue using drugs despite undergoing treatment and can not control their addiction. Thus the treatment is not quite effective for them. Critics also state that use of methadone may increase criminal activities as patients may engage in selling it to others experiencing withdrawal symptoms (Breslin and Malone, 2006). Conclusion Both counseling and MMT are effective treatment methods for substance abuse. However, their effectiveness depends upon several factors with nature and severity of problem being the key ones among them. Some kinds of counseling or therapy are reported to be more effective for specific problems. For example, cognitive behavioral therapy is probably the most effective option for the treatment of substance abusers. Counseling can help patients cope with the withdrawal symptoms produced by the drugs. It can also teach the individuals the appropriate behavior and attitude that make them acceptable to the society. The follow up sessions provide necessary assistance to the patient to help stop the incidence of relapse. Precisely, counseling helps to rehabilitate the patient. However, one of the drawbacks of counseling is that effectiveness of intervention mainly depends up on the willingness of the patient. Unwilling or uncooperative patient will not be able to draw benefit from counseling, the simple reason being that a fair amount of effort is needed at patient's end to be successful in the treatment. A behavioral change cannot be brought about forcefully in an individual. It was found that when a patient was engaged forcefully against his/ her own will in any sort of mental treatment the results were not as good as expected. In many cases it produced adverse results also. Another drawback of counseling is that it can not prevent the patient from experiencing withdrawal symptoms. Thus patients with severe problems need to be administered with medications. Despite its impressive effectiveness in treatment of substance abuse, MMT is also not without its drawbacks. The key problem is that methadone is also a drug that produces less severe effects compared to cocaine or heroin but the patient may find it difficult to stop taking it: it produces withdrawal effects similar to other drugs but a little less severe. Studies showed that patients undergoing methadone treatment do suffer from addiction to quite some extent. They may show relapse of substance abuse and may not recover from the addiction of methadone. In view of the above discussion it can be said that for successful treatment of substance abuse a combination of both outpatient counseling and methadone maintenance treatment may be more effective. Methadone can take care of the withdrawal symptoms and counseling can improve the behavioral and psychological disorders. Counseling can help reduce the tendency to drop out, i.e. it can convince the patient about the benefit of the treatment and can strengthen the mentality to cope with the withdrawal symptoms produced by methadone during dose reduction. Thus the risk of the patient of being addicted to methadone may be reduced and s/he may progress towards normal drug free life more effectively. Reference Austin, G. D. (2005). Substance Abuse & Problem Gambling. Iowa Department of Public Health Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press. Breslin, K.T., Malone, S.,(2006) "Maintaining the viability and safety of the methadone maintenance treatment program", Journal of Psychoactive Drugs, 38(2), pp.157-160 Brigham, G. S. (2003). 12-Step participation as a pathway to recovery: the Maryhaven experience and implications for treatment and research. Science and Practice Perspectives, 2, 43-51. Carroll, K. (1998). 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Rockville: National Institute on Drug Abuse Wechsberg, W.J., Berkman, N.D., Kasten, J.J. & Roussel, A.E., (2007), Methadone Maintenance Treatment in the U.S.: A Practical Question and Answer Guide, USA, Springer Publishing Company Woods, D., (2005), "What is counseling", retrieved June 17, 2008 from http://www.dougwoods.com/counselling.html Read More