Psychological processes and treatment implications

One of the most influential models in addiction treatment is known as the stages of change model.(13 !4) The stage of change that a person can be identified as being at determines the therapeutic approach and type of treatment offered. Thus at the precontemplation stage where there is no recognition of a need for treatment, there is no point in offering intensive treatment interventions. Similarly, at the contemplation stage when treatment is being considered, the appropriate intervention is to help the person clarify their views and build their motivation to change rather than offering active treatment. Indeed, it is only in the decision and action stages that treatment should be actively offered and facilitated.

The brief counselling technique of motivational interviewing (!5!6) has been proved to improve outcome effectively, and ties in well with the stages of change model. In the early stages the therapy is focused on encouraging the patient to reduce or resolve their ambivalence which acts as their psychological barrier to treatment. The patient in a client-centred but focused therapy is facilitated to discover the solutions to their own problems themselves. This approach of accepting the client' current level of thinking (rather than offering ready-made solutions, or confronting them, or trying to argue them into the solution) has been shown to be surprisingly effective in the clinical trials.(17> The effectiveness of this technique has resulted in a new understanding of motivation, which is seen as a dynamic state rather than as a fixed state, and one which can be influenced by the therapeutic stance.

Other cognitive therapies also make significant contributions to treatment. Relapse prevention involves the teaching of cognitive and behavioural strategies for dealing with high-risk situations and mental states.(1B!9) Other cognitive-behavioural therapies, including extinction of conditioning, contingency management, community reinforcement techniques/20 and indeed Beck's cognitive therapy, (2!> have been effectively applied to substance misuse. The recent very large Project MATCH (matching alcoholism treatments to client heterogenity) study of alcohol treatments compared three types of treatment and found that motivational enhancement, 12-step facilitation, and cognitive-behavioural therapy were equally effective overall, although each therapy excelled in certain subgroups. (2,23) Based on these results it seems likely that specific therapies targetted at specific issues of importance in patients with addiction are roughly equally effective overall, but that we do not yet know enough to confidently match specific patient subtypes to specific therapies.

A number of other therapies have also been shown to be effective, particularly in the alcohol field, including self-control training, self-help groups, marital and family therapy, coping and social skills training, anxiety and stress management, aversion therapies, and brief intervention strategies. (2 25)

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