Abstract
This article reviews
various treatments of Addiction Disorders for co-morbid and multi-morbid
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 article suggests an agenda for future clinical integrative
interventions for such clients.
This article presents how Psychotherapeutic
clients suffering from mental illness and addiction can benefit from a more
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 comorbid
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 comorbid 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” (Kay-Lambkin, Baker, & Lewin, 2004).
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 “frontlines” 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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