Excerpt
Chapter 4:
Ingredients of the Integrated Treatment Approach


OVERVIEW
The integrated approach to treating SUDs is a model we have evolved over many years of working with patients in institutional settings and in our office practices. Regrettably, and despite the fact that studies on the treatment of SUDs have demonstrated convincingly that no one method of treatment is better than all others, the addiction field continues to be split into opposing factions, each claiming superiority of their own approach. Our clinical experiences have taught us to steer clear of dogmatic approaches claiming to be the single best method for treating SUDs. We are by no means the first to acknowledge or write about the importance of a more flexible, integrated approach (e.g., (Kaufman, 1994; Margolis & Zweben, 1998; Shaffer & Gambino, 1990), but the addiction treatment system in some parts of the country has been slow to move beyond rigid adherence to the disease model and reliance on harsh confrontational tactics. Although in recent years motivational and other individualized client-centered approaches have been incorporated increasingly into addiction treatment programs in both public and private sectors, a welcomed change indeed, many individuals who make contact with traditional treatment programs still encounter a confrontation-of-denial “one size fits all” approach.

The integrated approach neither requires nor recommends adherence to one theoretical model or method of treatment. To the contrary, this approach is nondogmatic and encourages clinicians to exercise creativity, flexibility, and reasonableness in treating SUDs as they would in addressing other types of mental health problems. The approach is integrated in the sense that it blends together many seemingly disparate and competing treatment approaches including: addiction counseling, supportive psychotherapy, cognitive-behavioral therapy, Rogerian client-centered therapy, psychodynamic insight-oriented therapy, motivation-enhancement therapy, harm reduction therapy, 12-step facilitation therapy, interpersonal therapy, patient education, and pharmacotherapy- all of which are brought together to meet the individual and changing needs of patients at different stages of treatment.

We view abstinence as the preferred treatment goal, especially for patients whose pattern of substance use provides clear evidence of impaired control and puts them at significant risk of suffering severe consequences if use continues. Nonetheless, we do not mandate abstinence or make it a precondition for patients to receive our help. And we do not convey disappointment or disapproval to those who do not choose abstinence as their goal. Developing individualized treatment goals as part of engaging patients “where they are” is an essential aspect of the integrated approach, as discussed more fully in Chapter 9.

In this chapter, we discuss certain ingredients and distinguishing features of the integrated approach: (a) the centrality of the therapeutic relationship; (a) application of the stages of change model to enhance patient-treatment matching (b) application of motivational interviewing techniques to engage patients and enhance readiness for change; (c) dividing treatment into successive stages focusing on specific tasks and goals; (d) using the self-medication hypothesis to understand and address certain psychodynamic aspects of the addiction; (e) using aspects of the disease model to justify a request for total abstinence; (f) using on-site urine drug testing as a clinical tool to support and reinforce behavior change; (g) facilitating patient engagement in self-help programs; (i) avoiding certain therapeutic traps and dilemmas.


Centrality of the Therapeutic Relationship
A central feature of the integrated approach that permeates all aspects of treatment is its emphasis on developing and maintaining a therapeutic relationship between patient and therapist. Of particular value in this regard are motivation-enhancement techniques (described below) that are designed to facilitate patient engagement and enhance readiness for change. Regardless of what particular issues or tasks are being addressed during a given phase of treatment, the therapist’s style, stance, and overall attitude toward to the patient are often the most critical determinants of treatment engagement, retention, and outcome. Unfailing respect for the patient’s autonomy and freedom of choice is essential. The therapist must maintain vigilant self-awareness especially with regard to controlling behaviors and other countertransference reactions that can alienate patients and lead them to drop out of treatment. Aggressive confrontation and not giving patients the benefit of the doubt, the mainstay of traditional addiction counseling, are seen as counterproductive and antithetical to the integrated approach. It is essential for therapists to maintain unfailing respect for the patient’s autonomy, sensitivities, defenses, and personal strengths. And clinicians must remain ever-mindful of the power of the therapeutic relationship to engender both benefit and harm. The therapeutic relationship is by far the most important ingredient of the integrated approach and, as in all other forms of good psychotherapy, it is the primary vehicle for facilitating positive change.


Phases of Treatment
Treatment within the integrated model is divided into different phases, each focusing on a specific set of tasks and goals. There are no rigid or clear cut dividing lines between the different phases as they often blend gradually and sometimes imperceptibly from one to the next. Also, all patients do not necessarily progress in linear or stepwise fashion through the different phases. Patients can and do enter treatment at different phases, progress through them at different rates, and move back and forth between phases or straddle more than one phase at a given point in time.

Assessment. The primary tasks of this phase are to engage the patient in a therapeutic relationship and to perform a multidimensional assessment of the patient’s substance use and related problems. This is often the most critical phase because it sets the tone for just about everything that follows and has a profound impact on whether or not the patient becomes engaged in the therapeutic process or drops out. Effecting a positive outcome rests heavily on creating a safe environment in which patients feel they can be open, honest, and forthcoming with you about details of their substance use and related difficulties without fear of being judged or rejected. The assessment explores in detail the nature and extent of the patient’s past and present substance use, negative consequences associated with use, its functional role and significance in the person’s life including how it may continue to serve some positive function, and the patient’s motivation and readiness for change. Techniques for conducting a multidimensional assessment of substance use are discussed in Chapter 7.

Individualized Goal Setting and Treatment Planning. Completing the multidimensional assessment paves the way for establishing individualized treatment goals and collaboratively developing a treatment plan with your patients to help them work toward achieving those goals. An essential ingredient of this process is to match treatment interventions to the patient’s level of motivation and stage of readiness for change. The stage-of-change (SOC) model informs and guides the process of finding the “best fit” between where the patient is and what the therapist should be doing to engender positive change at each stage of the process (Connors, Donovan, & DiClemente, 2001; DiClemente, 2003; Prochaska, DiClemente, & Norcross, 1992).

Taking Action. This phase focuses on helping patients change their substance use behavior and achieve their initial treatment goals of reducing or stopping their alcohol and drug use. While this phase focuses primarily on changing substance use behavior, other presenting problems and ongoing issues also are addressed.

Preventing Relapse. This phase concentrates primarily on doing what is necessary to maintain and solidify positive gains and prevent relapse to the former pattern of substance use. The development of relapse prevention strategies emanates from recognition that the types of clinical interventions needed to initiate changes in substance use behavior differ from those needed to maintain these changes and prevent relapse over the longer term (Marlatt, 1985; Marlatt & Gordon, 1985). A wide variety of relapse prevention strategies are discussed in Chapter 10.

Psychotherapy in Ongoing and Later-Stage Recovery. This is not a specific treatment phase, but a thread that runs throughout the treatment, with the focus and timing of psychotherapeutic interventions being based on individual needs. The types of issues that need to be addressed at any given point in therapy are difficult to specify in advance for all patients because of wide variation among individuals with SUDs with regard to how and why they present for treatment, and the complex psychological and sociological context within which alcohol and drug problems are often embedded. For example, some patients who present with alcohol and drug problems want to focus immediately on some of the psychological issues (e.g., poor self-esteem, relationship conflicts and failures, etc.) that they feel are connected to their ongoing substance use, whereas other patients want to focus only on changing their substance use behavior whether or not they are aware of other psychological factors that may be present.