When A Single Approach Isn't Enough: Treating Mental Health Issues and Substance Abuse by Nina Bingham

                                                Introduction:
 This article reviews various treatments of Addiction Disorders for co-morbid and multimorbid clients, found in a combination of Eastern and Western Psychotherapeutic applications and Psychopharmaceutical interventions. It will show that clients with both Substance Abuse Disorders and Mental Illnesses require a more comprehensive treatment plan than substance abuse clients. Etiology foundational to Substance Abuse and Mental Disorders will be discussed: trauma, stress and neuroadaptations. A synthesis of information presented in this paper concludes that use of Eastern and Western Psychotherapeutic best-practices, along with Psychopharmaceuticals, may be the best hope for treatment of co-and multimorbid clients. This paper suggests an agenda for future clinical integrative interventions for such clients. 

         Psychotherapeutic clients suffering from mental illness and addiction can benefit from a comprehensive and integrative treatment plan, combining Western and Eastern psychotherapeutic methods, including the use of psychopharmacology. The respective branches of Medicine and Psychotherapy have historically approached treating psychopathology differently. The medical model employs an arsenal of neurological agents which work to supplement neurotransmitter imbalances. Psychotherapists use cognitive and behavioral therapies to effect emotional, thought and behavioral regulation. While these two “camps,” the medical psychiatrists, and talk-therapy psychologists and psychotherapists, will often work collaboratively on the client’s behalf, there is a certain type of client which may go underserved, despite therapeutic “best practices” of both these approaches. An analysis of co-and multimorbid Substance Abuse Disordered clients reveals serious challenges facing mental healthcare practitioners: First, clients who are mentally ill are also likely to suffer from a co-morbid substance abuse disorder, and while Cognitive-Behavioral Therapy has a modest rate of success with treating addiction disorders, most therapists are not prepared by Universities to treat dual-diagnosis cases which include Substance Abuse. Second, chronically mentally-ill clients can present in counseling with multiple mental illness diagnosis, as well as many substance abuse problems. These clients are referred to herein as multimorbid individuals. Thirdly, expecting an alcohol and drug treatment program which has had success among single-diagnosis substance abuse disorder clients to be as effective for co-morbid or multimorbid clients may lead to lapse and relapse. Research shows that the current system of treating co- or multimorbidity with a single clinical approach (either medical, psychotherapeutic or addiction treatment) is shortsighted. Before exploring solutions to these complex cases of addiction, one must first consider the effects of three often-concealed addiction etiologies: trauma, stress, and neuroadaptations.

    Substance Abuse Disorders develop often in patients with mental illness, particularly in those with exposure to trauma in childhood. Therefore, mental illness and trauma are risk factors in development of substance abuse disorders. Co-morbid clients exceed 50% among younger, chronically mentally ill clients (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). This high percentage of younger clients would especially benefit from a multi-therapeutic, integrated-care approach. While clients use drugs to self-medicate, alcohol and drug use has been found to hinder almost every aspect of care for young adults with chronic mental illness (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). If the cycle of drug dependency could be resolved among co- or multimorbid young adults, both their mental and physical health would improve. Unfortunately, these clients may not view their addiction as part of the psychological problem, and may be reluctant to engage in drug treatment. Clients may prefer not to present with a Substance Abuse complaint to a clinician, and why should they? After all, it is their coping mechanism! Instead, they often present to the counselor or medical physician complaining of depression or anxiety, or another mental health condition. This is when the clinician is in a position to effect important intervention in the client’s life. “An educational format and approach is a promising way to engage reticent clients in treatment. With a psychoeducational framework, the client does not feel “singled out” (Brown, Ridgely, Peppe, Levine, & Ryglewicz, 1989). By gently yet honestly informing the client of the duality or multiplicity of his mental illness and addiction, by showing him how mental illness can understandably lead to substance abuse, the client who is building a therapeutic relationship with the counselor or physician can begin the process of accepting the truth about his condition. I believe it is the therapeutic alliance that the client has with the clinician, and the support of his family, which will enable him to accept treatment. Even among those clients with the best clinical psychoeducation and family support, the chronic dual or multimorbid client may fear the two giants looming on the horizon of his recovery: the thought of dealing with memories of trauma, and his mountain of perceived stress. What he may not realize is that in addition, his brain has been changing to accommodate and adapt to his addiction; he has developed neurology which may now support his addiction.

    As mentioned earlier, addictive behaviors are coping mechanisms. Experiments in operant conditioning proved that humans will, to their detriment, continue unhealthy and dysfunctional behaviors if there is a positive enough reinforcer. That reinforcing agent for addicted clients is the alcohol or drugs. “An operant model posits that drug abuse disorders stem from deficiencies in the environmental contingencies of reinforcement rather than from defects within the individual. That is, the individual’s environment does not contain adequate sources of positive reinforcement, and drug use, which results in immediate and powerful rewards, becomes a frequent source of reinforcements” (Bigelow, 2001). When the addict’s environment and support system is not a positive enough reinforcer, he finds his reward via the addictive payout. Further bolstering his addiction are the negative consequences of physical and psychological withdrawal he suffers when he attempts to stop: “Although positive reinforcement may play a particularly important role during initial exposures to drug effects, the role of negative reinforcement assumes increasing importance as the individual learns that the drug alleviates unpleasant affective states, including aversive states associated with drug deprivation (i.e., withdrawal)” (Bradizza & Stasiewicz, 2009). The brain becomes conditioned to expect its pleasant rewards, and to avoid cessation of the drug. Neuroadaptions occur as a result of the drugs themselves, leading to development of habitual use. What should have been self-directed goal attainment becomes habitual, compulsive substance use instead. These neuroadaptations can affect two areas of cognitive functioning: inhibitory control and decision-making (Schwabe, Dickinson, &Wolf, 2011). Common brain circuitry is involved in the development of both mental illness and addiction. As an example, chronic use of illicit drugs results in changes in the amygdala which in turn may cause chronic depression. Substance abuse disorders often occur in patients with other psychiatric illnesses, yet few such individuals receive comprehensive treatment for their dual conditions (Kuehn, 2010).

    An explanation of why substance abuse is frequently paired with mental illness is the strong association between exposure to stress during childhood or adolescence (Kuehn, 2010). Post-Traumatic Stress Disorder (PTSD) has been associated with poorer Substance Abuse Disorder (SUD) outcomes. Poorer alcohol and drug outcomes appear specific to PTSD rather than to greater psychopathy in general. “The comorbidity of PTSD and substance abuse disorders has been documented, especially in women” (Marich, 2010). Women with PTSD were found to relapse more quickly than women who did not have PTSD, and patients relapsed faster, drank more, and drank more heavily post-treatment. It has been speculated that PTSD patients fare worse than their non-PTSD counterparts because they do not receive adequate treatment for PTSD: “Only1 in 4 of the PTSD patients had received any type of psychiatric treatment. This study speculates that SUD-PTSD patients were not referred for psychiatric treatment” (Brown, Stout, & Mueller, 1999).

               In addition to trauma being correlated to SUDs, the effects of stress cannot be underestimated in the development of psychopathology and addiction. Among 2,784 clients of an outpatient program at a comprehensive addiction treatment facility, multimorbidity (a combination of multiple mental disorders combined with multiple substance use disorders), was significantly correlated with female gender, unemployment, less social support, cannabis problems, and increased treatment engagement (Costel, Rush, Urbanoski, & Toneatto, 2006). This large study shows that environmental stressors such as unemployment and low social support can contribute to multimorbidity and SUDs. “It is well known that stress is a significant risk factor for the development of drug addiction and relapse” (Schwabe, Dickinson, & Wolf, 2011). Acute stressors trigger habitual coping methods which can, without intervention, lead to relapse. Chronic stress may encourage re-emergence of the addiction, or development of a new addiction. Trauma, stress, and neuroadaptations due to addictive behaviors are at the root of the problem of addictions. How a client manages stress is at the heart of substance abuse recovery therapy. The way in which an individual processes stress can either perpetuate the addiction, or prevent a relapse. How then should a Psychotherapist proceed to effectively treat co- and multimorbid addicted clients?

    Research studies have shown that unmodified Psychoanalysis is not an effective treatment for addictions, because traditional Psychoanalysis ignored the addiction and the client’s dangerous behavior. They proceeded in this way because they were taught to treat the underlying condition first, and in so doing the addictive behavior would be “cured.” Today we know that ignoring dysfunctional behaviors is not in the client’s best interest, nor will the addictive behaviors dissolve once the root psychological problem has been treated (Yalisova,1989). While traditional Psychoanalysis ignored the substance addiction and treated the client’s underlying cognitive distortions, today’s substance abuse clinicians may be making the reverse error: treating the behavioral symptoms of addiction while not attending to the underlying psychopathology of trauma/PTSD and stress. An eclectic way of psychotherapeutic practice, where both Western and Eastern Psychotherapeutic approaches are utilized may be the best hope for treatment of co-and multimorbid clients.

    The Western medical model utilizes medication in conjunction with counseling, and consistently ranks among the most effective substance abuse treatment interventions. However, pharmacotherapy remains underutilized and presents one of the greatest implementation challenges for community-based treatment programs. Staff attitudes towards addiction medications varied significantly between treatment units (Fitzgerald, & McCarty, 2009). While some recovery programs are equipped to treat dual or multimorbid clients, others are not. A good share of clients being seen on an out-patient basis or in Psychotherapy are co- or multimorbid, and will be looking to the clinician for comprehensive answers. Several Western psychotherapeutic approaches have shown promise in treating clients suffering from comorbid trauma/PTSD and addictions: Western Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive-Behavioral Therapy treating trauma (Marich, 2010).

               Traditional substance abuse programs may not have fully understood the dramatic and leading role that trauma plays in the lives of the addicted. Moreover, because the brain has adapted neurologically to the addiction, stimulation of the brain’s information processing system through Eye Movement Desensitization and Reprocessing (EMDR) can access suppressed or repressed memories, allowing the trained EMDR Therapist to navigate the painful, emotional and dreaded trauma memories to a safe and peaceful resolution. “Unfinished traumatic business” as well as symptoms of depression and anxiety can be effectively treated through this psycho-neural process (Marich, 2010). An additional Western Cognitive Behavioral Therapeutic modality that has been proven effective in complex cases of Substance Abuse Disorder is Acceptance and Commitment Therapy.

              Acceptance and Commitment Therapy (ACT) was used to study the effect that shame has on substance abuse disorders. The results showed that both Eastern Mindfulness techniques and ACT produced better attendance in treatment, as well as reduced substance use (Louma, Kohlenberg, Hayes, & Fletcher, 2012). Shame is a common experience among substance abusers; one might describe it as feelings of failure and worthlessness. These powerfully painful feelings can trigger substance use and relapse. Shame stigmatizes the individual, making them more prone to: treatment-seeking delays, treatment drop-out, and social withdrawal. Curiously, few substance abuse treatments comprehensively address the problem of shame. When Acceptance and Commitment Therapy (ACT) was applied to reduce feelings of shame, researchers Louma, Kohlenberg, Hayes, & Fletcher (2012) reported that the ACT group participants evidenced less days of substance use, had higher treatment attendance, and as shame was gradually reduced so were the substance abuse rates. While advances in Western neuropsychology have given clinicians the relatively new therapy of EMDR, and while Cognitive Behavioral Therapy and Acceptance and Commitment Therapy offers answers to the puzzle of addiction, there is another ancient therapy from the East which is finding renewed popularity and effectiveness for co- and multimorbid clients, and it comes to us from Buddhism.

    Psychotherapeutic clients suffering Addiction Disorders can benefit from Eastern Buddhist Mindfulness training; Dialectical Behavioral Therapy being one such successful therapeutic application of this training in the West. Mindfulness training, a 2,500 year old Buddhist tradition, has been shown to be effective in treating addictions (Brewer, Elwafi, & Davis, 2012). While traditional Western behavioral treatments for smoking have been mildly successful, with abstinence rates between 20% and 30%, mindfulness training has only recently been empirically “put to the test” for treatment of addictions. The results show that gradually, if the student continues to practice, mindfulness training can disrupt the addictive cycle of smoking and drug usage through the use of distraction from the drug stimulus, and concentrated focus on the here and now. By teaching individuals to more objectively observe the craving body and breathe through it, and to recognize triggers and cognitive distortions, habitual reactions to addictions eventually lose their grip and give way to a more self-determined way of life.

                At this time, due to Psychology’s relatively short history as a science, we may understand more of what doesn’t work in treatment of complex Substance Abuse Disorders than what is effective for the co-morbid or multimorbid client. Individuals who suffer from trauma, stress, and a shame-based self-concept, and who are substance users or abusers may benefit by a carefully constructed treatment plan which takes into account the history of trauma, PTSD, environmental stress and shame-based beliefs. By applying simplistic methods of substance treatment to complex cases of mental illness and substance abuse, we may be supplying a therapeutic “band-aid,” in which case the client may lapse and relapse due to the underlying psychological trauma, stress, and shame he is carrying. While modern Psychotherapy doesn’t condone ignoring addictive behavior any longer, clinicians may be overlooking the perplexing complexities of co- and multimorbidity. “Clients with multimorbidity have been neglected, and assuming that knowledge about comorbidity can be transferred to the population with multimorbidity is in error” (Costel, Rush, Urbanoski, & Toneatto, 2006).

                 This article suggests that a careful and thorough investigation of the clients past and present  be initiated through psychological assessment, and should alert the Psychotherapist to possible underlying deeper issues of dysfunctional thought and self-assessment which the client is evidencing through substance abuse. “It would come as no surprise to mental healthcare professionals that co-morbidity is common. Indeed, co-morbidity is the rule rather than the exception in clinical settings. Yet when formulating a treatment plan for people who present with co-morbid problems, it is difficult for clinicians to know where to start” (Thornton et al, 2012). In the past, existing treatment strategies have been applied unilaterally, instead of tailoring the treatment plan specifically for co-morbid clients (Kay-Lambkin, Baker, Lewin, & 2004). Co-morbid and multimorbid clients require a more comprehensive treatment plan, and could include psychopharmaceuticals, as well as a blend of Eastern and Western psychotherapeutic best-practices.

                 While Universities are doing their all to equip counselors with evidence-based methods of psychotherapeutic training for mental illness and substance abuse, there is a work to be done to unite these two schools of training within the University systems. If counselors are to practice treating the psychopathological issues in whole instead of only the presenting issue, an integration of substance abuse and mental illness curriculums should be the future foci of counselor training programs. “Clinicians and clinicians-in-training must not only acquire skills in accurate assessment and diagnosis but also be alert to the patterns of co-morbidity. At this point, clinicians have more information about the existence, patterning, and sequencing of co-morbidity than they do about effective treatment strategies. The next generation of treatment manuals for clinical trials will need to address this issue specifically” (Clarkin, & Kendall, 1992).

                To bridge the gap between research and clinical treatment of co-morbidity, the medical and psychological clinicians who are on the “front lines” of intervention of complex substance abuse disorders can strive to become more eclectic and integrative in their approaches to what remains a very difficult psychological puzzle. “Clearly,” states Berman, Jobes, & Silverman (2006), “one-size treatment does not fit all, and there is tremendous value in judiciously combining theoretical perspectives, treatments, and interventions from across the spectrum of options.” Norcross, Karpiate & Lister (2005) studied self-identified eclectic psychologists and found that, “Between one quarter and one-third of contemporary psychologists identify themselves as eclectic or integrative.” One psychologist in their study wrote, “People are different and have different diagnosis and needs as well as viewing therapy differently. Therefore, I suit the therapy to the patient.”

                In conclusion, while research has suggested an integrated treatment approach to co- and multimorbid clients, the clinical reality is structured in such a way that Substance Abuse Counselors and Psychotherapists treat complex cases of substance abuse and mental illness differently. Among Western approaches to psychotherapy, effective neurological and cognitive treatments have been proven effective, and Eastern mindfulness techniques are experiencing a resurgence of popularity in treating substance abuse and mental illness. In the future, both Substance Abuse Counselors and Psychotherapists would benefit by being equipped with a broad range of therapeutic skills, so clients can be treated in a holistic and integrative manner. As co- and multimorbid cases increase, so must our clinical response to them.

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