What is treatment?
Treatment implies something being done to help someone get better, to reach recovery. Ideally it is a psychosocial intervention which may be packaged with other interventions such as medication and harm reduction advice. Help seekers bring with them their substance use history, their mental health and their social circumstances and so it is important to be realistic about what difference treatment can make. Some people have all they need to get better without help, others need a lot of help.
Choosing an effective intervention
It turns out that apparently dissimilar talking therapies often have crucial ingredients in common. This means that the particular treatment matters less, as long as it is recognised as effective, than feeling good about the way it is delivered. Treatment is invariably some form of psychosocial intervention, which may be enhanced with medication, and which should build resilience into the future. The prescribing interventions are usually specific to each substance and work only for as long as they are given.
Good outcome predictors...
✔︎ Having supportive family and friends
✔︎ Being ready to make lifestyle changes
✔︎ Having employment or a satisfactory occupation and income
✔︎ Having housing or at least reasonable accommodation
✔︎ Understanding that dependence can be undone
✔︎ Being in reasonably good mental health
✔︎ A readiness to move away from others with addiction problems
Rudi Moos. Professor Emeritus, Stanford University, USA
Four components of treatment
A good treatment is fashioned collaboratively by the practitioner and their service user. Preparation is important so that everybody knows what to expect and so that the right support can be put in place. All treatments have essentially the same elements…
Detoxification or stabilisation
Before any real treatment can take place a person’s substance use needs to be under some degree of control - it is very difficult to move forward with someone who is repeatedly intoxicated. A period of abstinence is preferable because people will be more able to follow the treatment plan. A medication assisted detoxification may be indicated if a person is experiencing significant withdrawal symptoms or is using a mix of drugs. People feel better very quickly, which is rewarding but also a risky time for relapse.
Relapse prevention
Relapse prevention is about looking for triggers for drinking or drug taking and starts as soon as a treatment programme starts. Deep-seated traumas are the job of mental health teams to resolve. Triggers occur everyday: people who you drink or take drugs with, places that are high risk, wanting to celebrate, feeling saddened by something, overconfidence after days of abstinence. The list is endless but it matters to identify accurately where relapse risks lie.
Lifestyle change
The absolute key to successful treatment is to make lifestyle changes. This can be a difficult and long process especially for someone who has been embedded in a drinking or drug-taking culture for many years. Simply accepting that big changes are needed is daunting. Of course, there may well be some things that cannot be changed. Regrets for things in the past that cannot be undone is not going to help, rather set out a plan for enjoyable and more healthy activities.
Harm reduction
Harm reduction happens all the way through contact with helping agencies. It is about improving the quality of life without necessarily stopping substance use. It is a way of engaging people with helping agencies and of helping those who are unable or choose not to work towards recovery. Examples are:
✔︎ needle and syringe exchange ✔︎ substitute prescribing ✔︎ dietary advice and nutritional supplements ✔︎ coping strategies for partners, friends and children ✔︎ immunisations ✔︎ naloxone for opiate overdose ✔︎ housing support
How good is treatment?
The short answer is ‘It all depends’. There are good treatments for addiction problems, but the one thing that makes the most difference to treatment outcome is where the person is starting from. 50-60% of how well people do is down to social capital: education, family and friends, employment, health. A useful way of thinking about ‘where somebody is at’, where are they starting from, is the stages of change model originally described by Prochaska and DiClemente…
In the precontemplation stage, the person is either unaware of a problem that needs to be addressed or aware of it but unwilling to change the problematic behaviour.
This is followed by a contemplation stage, characterised by ambivalence regarding the problem behaviour and in which the advantages and disadvantages of the behaviour, and of changing it, are evaluated, leading in many cases to decision-making.
In the preparation stage, a resolution to change is made, accompanied by a commitment to a plan of action.
This plan is executed in the action stage, in which the individual engages in activities designed to bring about change and in coping with difficulties that arise.
If successful action is sustained, the person moves to the maintenance stage, in which an effort is made to consolidate the changes that have been made.
Once these changes have been integrated into the lifestyle, the individual exits from the stages of change. Relapse, however, is common, and it may take several journeys around the cycle of change, known as “recycling”, before change becomes permanent.
Here is a brief summary of effective and commonly used treatments…
What works
Effective therapies include these specific strategies...
✔︎ Set and keep checking goals
✔︎ Provide rewards as goals are achieved
✔︎Set clearly described take-home tasks and monitor their achievement
✔︎ Involve family and friends
✔︎ Find alternative activities unlikely to trigger substance use
✔︎ Rehearse ways of dealing with risky situations
✔︎ Create flexibility in the recovery plan
Psychosocial interventions...
CBT :: Cognitive behaviour therapy is probably the most researched and effective treatment. CBT works by i) identifying risks of drinking or taking drugs ii) working out ways of dealing with these situations - developing 'coping skills' iii) practising these 'coping skills'.
CM :: Contingency management, which works by rewarding abstinence or some other goal, typically with vouchers, medication take-away privileges and prizes.
RP :: Relapse prevention, which is the same as CBT but with a relapse prevention focus.
MI :: Motivational interviewing is more of a method than an intervention. It works by helping service users to become aware of what they most want to change in their behaviour.
NT :: Network therapy works by recruiting family and friends willing to give practical and emotional support to help people make changes to their substance use.
CN :: Counselling is something of an umbrella concept but typically means allowing a person to talk about their problems and feelings in a confidential and safe environment.
Social support :: Includes help with housing, employment, rewarding occupations, leisure activities, relationships and so forth.
Prescribing interventions...
Substitution :: Some drugs of misuse can be 'substituted' with a safer prescribed medication. This is most commonly the case for heroin and other opiates.
Detoxification :: Medication can help relieve the cravings and withdrawal symptoms that occur when people addicted to alcohol or a drug either stop suddenly or rapidly reduce their intake.
Relapse Prevention :: For some addictions there are medications that help prevent slipping back into drinking or drug use.
Nutritional :: Dietary advice and nutritional supplements may be needed because a person has neglected their diet due to their substance use or because of specific deficiencies.
