The term, ‘psychotherapy,’ describes a psychological treatment that aims to change problematic thoughts, feelings, and behaviors by creating a new understanding of the thoughts and feelings that appear to be causally related to the problem(s). The patient is led to ask, ‘Why do I use drugs?’ The psychotherapy addresses the underlying addictive behaviors and the thoughts and feelings that appear to promote, maintain, or occur as a result. A goal is to help the patient resolve some of the associated problems so that he/she will no longer need to self-medicate to feel relief. Along with the goal of ceasing drug self-administration, psychotherapy addresses issues related to other problematic aspects of patients’ lives, both past and present, whether these problems contribute to drug abuse or not.

Addiction counseling, rather than psychotherapy, is the most widely used psychosocial intervention in substance abuse treatment. It differs from psychotherapy by being fairly directive and focusing on managing current problems related to drug use rather than exploring internal, intrapsychic processes. The client would ask, ‘Which people, places, and things make me feel like using drugs?’ ‘How can I avoid those people, places, and things?’ ‘How can I change my life so that I reduce the urge to use drugs?’ ‘Who can I turn to when I feel the need to use drugs?’ ‘Addiction counseling’ is the management of addiction, by giving support, structure, monitoring behavior, encouraging abstinence, and providing concrete services such as referrals for job counseling, medical services, or legal aid. This approach often uses the language and concepts of the 12-step program developed by Alcoholics Anon-ymous.

Increasingly, some methods used in addiction counseling and psychotherapy have merged in the actual practice of treatment. Effective therapists and counselors employ similar basic counseling skills, regardless of therapeutic orientation. These would include among other things active listening, empathy, and support. In addition to basic counseling skills, there are strategies or tools that are associated with specific theories of therapy. For example, identifying the precipitants to relapse is basically a cognitive intervention, while practicing refusing an offer of drugs is skill building, which is a behavioral intervention yet each of these techniques is often used in both psychotherapy and counseling.

Many addicts will self-administer drugs to reduce stress. This same constellation of symptoms can be more appropriately addressed with psychotherapy. For example, opioids have potent sedative and analgesic effects, stimulants can enhance mood and benzodiazepines reduce anxiety. In this sense, psychological factors such as anxiety, anger, and depression may encourage drug use as an attempt to escape from painful subjective experiences (Khantzian and Khantzian, 1984; Khantzian, 1985).

Studies have consistently shown that high levels of comorbidity exist between substance use and a wide range of other psychiatric problems, many of which meet symptomatic and duration criteria for DSM (Diagnostic and statistical manual of mental disorders)-III-R or DSM-IV diagnoses (American Psychiatric Association, 1987, 1994) (Rounsaville et al., 1982, 1991; Woody et al., 1983, 1990a,b; Khantzian and Treece, 1985; Weiss et al., 1986; Kessler et al., 1996). Major depression, dysthymia, posttraumatic stress disorder, and generalized anxiety disorder commonly co-occur with addiction. Because chronic use of most abused drugs (with the possible exception of opioids and nicotine) will magnify or even produce psychiatric symptoms, it is often difficult to determine which symptoms represent independent psychiatric disorders and represent substance-induced conditions.

However, whether emotional symptoms are drug related or represent independent disorders, studies have shown that they have prognostic significance (Woody et al., 1985, 1990a,b; Carroll et al., 1995). This finding is especially relevant to psychotherapeutic approaches for treating substance use disorders, because the psychotherapies were developed specifically to address such emotional symptoms. When viewed in this way, the presence of psychiatric symptoms in the context of a substance use disorder identifies a subgroup of patients that may benefit from a combination approach that includes a drug-focused intervention such as methadone maintenance, and psychotherapy.

Knowledge of the pharmacological effects of the various drugs of abuse is basic to treating addiction, regardless of the therapeutic approach or orientation. Nonmedically trained clinicians need to become aware of these effects, their routes of administration, drug combinations that are commonly used, and the typical patterns of use. Clinicians need to recognize the clinical presentations of intoxication and the withdrawal syndromes for the major categories of abused drugs. They also need to know the effects of common drug combinations such as ‘speedballing’, which is taking an opiate with cocaine or amphetamines, or the popular pairing of cocaine with alcohol. Clinicians also need to know the potential health consequences, both emotional and physical, of using the different drugs of abuse. For example, clinicians should recognize the risk for paranoia and depression among cocaine users, the heightened risk of HIV among injection drug users from sharing injection equipment, and the increased risk for HIV among users of cocaine or amphetamines that is associated with their tendency to engage in high levels of unprotected sex.

Studies have shown that 12-step participation is associated with improved outcomes. Twelve-step programs, such as Alcoholics Anon-ymous and Narcotics Anon-ymous, are abstinence oriented and foster a network of healthy social support. In addition, their philosophy imparts ideas that many recovering persons find helpful in dealing with everyday life and that appear to help establish and maintain a sober life-style. Also, they are widely available and free of charge.

Key aspects of the 12-step philosophy for therapists treating addiction are: (1) the belief that addiction is a disease, rather than bad behavior; (2) addiction damages the whole person, physically, mentally, and spiritually and that recovery must address all of those domains; (3) healing or recovery comes from connecting to something larger than oneself; (4) the paradox of surrendering power in order to ultimately be empowered to attain sobriety; (5) the idea that interpersonal support is critical for recovery; and (6) the belief that recovery is a lifelong process that encompasses continued personal growth.

Research has shown that frequency of attendance (Hoffman et al., 1983; Etheridge et al., 1999) and degree of participation (Weiss et al., 1996) in 12-step meetings is positively associated with treatment outcome, including preventing relapse (Fiorentine, 1999). As a result, these programs are strongly recommended by most addiction treatment programs (Fiorentine and Anglin, 1996). Furthermore these programs can easily be combined with psychotherapy or counseling, which seems to have an additive effect on enhancing outcomes (Fiorentine and Hillhouse, 2000). A recent study found that belief in the philosophy of the 12-step program improved drug use outcomes for patients receiving addiction counseling (Crits-Christoph et al., in press). There are other models of self-help programs, such as Rational Recovery and Women for Sobriety, but these tend to be less widely available and less well known. However, they also appear to foster continued recovery, and they may be a better ‘fit’ for some people than the 12-step programs.

There are six common settings for the provision of substance abuse treatment, and any one can use psychotherapy or counseling. These are: (1) inpatient (within psychiatric or general hospitals); (2) penal institutions; (3) outpatient (clinics or private practice settings); (4) intensive outpatient programs (IOPs); (5) halfway houses; and (6) therapeutic communities. The philosophy of treatment varies by setting, and particular psychotherapeutic approaches may fit better into some programs than others but drug counseling would likely be part of the program in each setting. Some programs would also integrate psychotherapy, particularly for patients with additional psychiatric problems.

Urine drug testing, is traditionally associated with drug counseling but not with psychotherapy; however, it is recommended by most addiction treatment programs because it appears to increase program effectiveness, regardless of the setting. Urinalysis encourages honesty, and it helps hold the patient accountable for his or her behavior. It may also lead the recalcitrant patient to seek ways to evade detection of drug use and thus should be observed or monitored for urine temperature to ensure compliance. Prompt results and feedback on drug-positive and drug-negative urine samples often help the patient feel that the therapist is knowledgeable and concerned with his or her progress in recovery. Positive feedback given for negative urine samples reinforces continuing abstinence and recovery. In the case of a positive test or self-report, analysis of what led to the drug use combined with ways to avoid it in the future can be an important component of psychotherapy or counseling.

Drug treatment programs vary greatly in basic aspects of service delivery such as availability of psychiatric and medical services, control of behavior problems, level of illicit drug use, type of physical facilities, use of psychotropic drugs, level of staff morale, educational level of staff, and types of patients receiving treatment (Ball et al., 1986). These programmatic qualities may play a major part in the feasibility, efficacy, or relative importance that psychotherapy may have in different settings.

The ‘dose’ of psychotherapy or counseling necessary to produce improvement is unclear. Research looking at three different levels of counseling in methadone-maintained opiate addicts found that when the standard methadone maintenance was combined with enhanced psychosocial treatment, patients maintained a greater reduction in drug use (McLellan et al., 1993). Furthermore, the results showed a stepwise effect, such that the more psychosocial services provided, the greater the reduction in drug use. In other words, more treatment equated to a better result provided that the treatment was not just all the same (for example, 6 hours a day of just drug counseling) and that the services were useful and addressed specific, identified problem areas such as family interventions, vocational services, or psychiatric services delivered on site.

According to research on psychotherapy for methadone-maintained patients addicted to opioids, therapy has typically been offered once a week, but patients attend, on average, only once every 2 weeks (Woody et al., 1983). However, patients also received daily doses of methadone, so the intensity of the combined pharmacotherapy plus psychotherapy treatment was quite high involving daily or near daily visits.

For cocaine-dependent patients, Kleinman et al. (1990) attempted once-a-week outpatient treatment, of several different modalities, and found that attrition was high and there was no evidence of any treatment effect for any of the modalities implying that once a week therapy was insufficient for these cocaine users. Hoffman et al. (1991) combined individual, family, and group therapies at different frequencies for treatment of cocaine dependence. The results showed a better outcome with group and individual conditions, which provided intensive day treatment compared with weekly outpatient therapy. The NIDA Cocaine Collaborative study (Crits-Christoph et al., 1999) looked at outpatient treatments and found that the combination of group and individual therapy or counseling, with group offered once-a-week and individual offered twice-a-week to start and tapering down to once-a-week was successful in assisting cocaine addicts to reduce or eliminate their cocaine use. Alterman (1990) reported a 50–60% abstinence rate at 6-month follow-up among cocaine-abusing patients receiving 12-step-oriented drug counseling in either inpatient or intensive day treatment (5 days per week) for 1 month, followed by twice-weekly therapy. These studies suggest that for cocaine-dependent patients, participation in drug treatment should be relatively intense, at least initially, and can decrease over time as the patient progresses.

Two controlled trials of psychotherapy for marijuana dependence showed benefits from once a week counseling. One study on group treatment (Stephens et al., 1994) and another on individual treatment (Grenyer et al., 1996) found substantial reduction in marijuana use and related problems with once-weekly therapy in the individual treatment study, as well as reductions in the group therapy condition that began with once-weekly therapy and decreased to once every other week.

For treating alcohol dependence, Project MATCH, found once a month motivational enhancement therapy as effective as other more intensive interventions, thus suggesting that certain therapeutic approaches can be effective at relatively low doses, at least for some types of addictions (Project MATCH Research Group, 1997).

Overall, these data suggest that the intensity of treatment needed varies with the specific drug, the severity of the dependence, and the nature of the patient's associated problems, particularly psychiatric conditions. For most patients, opioid or cocaine dependence appears to require more intense treatment than marijuana or alcohol dependence. In Woody and colleagues’ methadone studies, psychotherapy was most useful for patients who had moderate to high levels of psychiatric symptoms in addition to their substance use disorders. However, in the two largest studies for other substance dependence (Project MATCH Research Group, 1997; Crits-Christoph et al., 1999), psychotherapy provided no advantage over drug counseling, even for patients with high levels of psychiatric symptoms. Reasons for this disparate finding might be that the methadone maintenance patients were receiving an effective pharmacotherapy in combination with psychotherapy and counseling while the alcohol and cocaine studies did not have this advantage. The therapists in the methadone program may have been better able to focus on the co-occurring psychiatric symptoms and behavioral problems rather than focusing entirely on stopping drug use because the methadone was doing much of that work for them.

Other studies have shown that the mix of drug-focused treatments versus treatments that address associated problems may be important. These studies show that it is helpful to provide services that address associated concerns, such as family, employment, and psychiatric, in addition to drug-focused treatments, and these services are especially important for patients with difficulties in these areas (McLellan et al., 1993, 1997).

Family member involvement is generally felt to be associated with better outcomes, and programs usually try to involve other family members or significant others in treatment. This may be through individual family therapy, a multifamily group or occasional family workshops, which are psychoeducational rather than psychotherapeutic in nature. Through these interventions family members can be informed of the nature and consequences of addiction and the treatment process with the intent that it will enable families to more effectively support their addicted member through the process of recovery. Also, family involvement allows the therapist to explore historical or relationship factors in the family that can undermine and frustrate treatment. Such factors might include addiction in other family members, codependency and enabling behaviors, or the development of family crises in response to the patient's improvement. Lastly, family involvement in treatment may help family members access treatment and/or the support that they need to reduce adverse effects of the addiction on other family members.

One newer intervention model, behavioral couples counseling or behavioral family counseling, has been used in combination with individual counseling for drug-addicted men and their spouses or other family members. This approach is demonstrating positive outcomes in two dimensions. One is reduction of spousal abuse in abusive relationships (Fals-Stewart et al., 2002); the other has been better attendance, greater compliance with naltrexone and more days abstinent, and fewer legal and family problems as compared with individual treatment alone for opioid-dependent men (Fals-Stewart and O'Farrell, 2003).

Therapist qualities appear to have an effect on success in therapy (Luborsky et al., 1985, 1986). Three qualities appear to be generally predictive of outcome in psychotherapy: overall adjustment, skill, and interest in helping patients (Luborsky et al., 1985). For crack- and cocaine-abusing patients, Kleinman et al. (1990) found some therapists reliably retained patients better, and retention is a generally a critical measure of success in addiction treatment. Presumably this relates to the qualities of the therapists, although specific qualities were not explored in this study. Despite the apparent significance of therapist differences in treatment effectiveness, research has not identified which ‘types’ of therapists tend to be more or less effective in treating addiction (Crits-Christoph et al., 1990). Thus, there may not be specific ‘types’ of therapists who will be more effective. Rather, there appears to be something in the therapist–patient relationship that is related to outcome. This is often referred to as the therapeutic alliance or the helping alliance and scales have been developed to measure it.

These measures have found that therapists who can establish a positive connection with patients and are perceived by the patient as ‘helpful’ are more likely to achieve successful outcomes (Luborsky et al., 1985). This therapeutic alliance to outcome relationship holds across different therapeutic modalities (Horvath and Symonds, 1991) and a variety of psychiatric problems, including substance abuse (Conners et al., 1997). Patients’ and therapists’ ratings of the therapeutic alliance tend to be consistent, but where there are differences, patients’ ratings are better predictors of outcome than therapists’ ratings (Horvath and Symonds, 1991). In addiction treatment, these outcomes translate to better retention and greater reduction in drug use.

According to Project MATCH data, a national multisite study of psychosocial treatments of alcoholism, in an outpatient sample (n = 952) rating of the alliance by the therapist or the patient predicted treatment participation, days abstinent, and drinks per drinking day (Conners et al., 1997). These changes were all in the expected direction, that is, a positive alliance predicted greater participation in treatment and greater reduction in alcohol use. However, the study also looked at patients after discharge from inpatient rehabilitation and found that client's ratings of the aftercare therapist were not significant predictors of treatment participation or drinking-related outcomes. The lack of a correlation between alliance and outcome for the aftercare group following an inpatient stay could be because these patients had already achieved some degree of abstinence, and were compliant and/or motivated enough to continue treatment. Also, aftercare patients may have established a positive alliance with members of the inpatient treatment staff, and it was the strength of this alliance (which was not studied) that promoted their continued treatment participation and recovery.

Therapists’ emotional reactions to substance abusers may be important determinants of outcome as well. While true to some extent in all psychotherapy, these emotional reactions are considered to be particularly significant in the treatment of substance abuse because they are presumed to be more intense and negative (Imhof, 1991). Negative feelings can be particularly problematic because many addicts have feelings of shame and guilt over the addiction and its associated behaviors. Thus, we might expect addicted patients to be particularly sensitive to negative therapist reactions. In one early study of alcoholism treatment (Milmoe et al., 1967), the more anger and anxiety in the clinician's voice in the initial session, the less likely the patient was to follow through on getting treatment.

A good general principle for psychotherapy or counseling is that the therapist should be interested in and comfortable with addiction-related problems and behaviors. These include the manipulative, impulsive, or demanding behaviors that are sometimes observed, and the self-abusing aspect of the condition that may create negative countertransference feelings. An ability to accept the patient where they are, not pass judgment, and convey respect for the individual and the severity of his/her problem can strengthen the therapeutic alliance. Along these lines, Washton and Stone-Washton (1990) recommended that therapists working with addicted patients have a high degree of empathy, confidence, and hope, and a low wish to control the patient.

To promote a positive alliance, therapists should refrain from being judgmental and should occasionally extend themselves a little more with addicted patients than with other types of psychiatric patients. The dependency needs of addicted patients often express themselves in the therapist–patient relationship, and occasional appropriate, concrete, supportive responses are probably useful, especially in the early phases of treatment. This therapeutic posture may involve greeting the patient in a friendly manner on entering the office, actively seeking to reestablish contact when an appointment is missed, being generous with reinforcement for abstinence, and agreeing to see or speak with the patient occasionally at unscheduled times if necessary.

Drug users are at increased risk of HIV infection as well as other infections transmitted by blood and body fluids such as hepatitis B and C. Drug treatment has been found to be associated with sustained reductions in HIV risk and a lower incidence of HIV infection among drug users. This is true for methadone maintenance (Metzger et al., 1998) and cocaine treatment (Shoptaw et al., 1997). In the National Institute on Drug Abuse (NIDA) cocaine collaborative treatment study, in which treatment consisted entirely of psychotherapy and counseling, treatment was associated with a 49% decrease in HIV risk across all treatment, gender, and ethnic groups, due mainly to fewer sexual partners and less unprotected sex (Woody et al., 2003). Shoptaw and Frosch also reviewed a number of studies of treatment and its relationship to HIV risk among men who have sex with men and concluded that substance abuse treatment has significant value as an HIV risk reduction intervention to reduce sexual risk among men who have sex with men. Motivational interviewing (Yahne et al., 2002) used in an outreach approach successfully encouraged high-risk women sex workers who were using drugs to reduce their drug use and HIV risk behaviors and increase lawful employment. This underscores the role of counseling and psychotherapy in substance abuse treatment to reduce HIV risk.

NIDA has sponsored research testing a number of individual psychotherapy and counseling approaches for efficacy. The key concepts of the approaches that currently appear most promising are seen in the following.

Psychosocial components of drug abuse treatment have been the subject of formal research only in the past two decades. Most research has concluded that psychotherapy can be an effective treatment for substance use disorders (Resnick et al., 1981; Woody et al., 1983; Carroll et al., 1991, 1994, 1999; Stephens et al., 1994; Grenyer et al., 1996) though it has not outperformed standard drug counseling except for a few studies done in methadone programs. These studies and reviews have examined individual and group psychotherapies in the treatment of opioid, cocaine, alcohol, and marijuana dependence. The comparison of specific models of therapy for substance use disorders has become the focus of much interest.

Early experience with psychotherapy for opioid dependence showed that in the absence of methadone-maintenance, psychotherapy was not effective (Nyswander et al., 1958). Dropout rates were extremely high, and few patients improved. The introduction of methadone reduced opioid use and kept patients in treatment, and this changed the results significantly.

One early study compared supportive-expressive psychotherapy and cognitive-behavioral therapy plus drug counseling with drug counseling alone for opioid-addicted methadone maintenance patients in a Veterans Affairs treatment program (Woody et al., 1983). All patients showed improvement but the addition of professional psychotherapies to the drug counseling benefited patients more who had higher levels of psychopathology than drug counseling alone. Both drug counseling and the combined treatment were equally helpful for patients with low levels of psychopathology. A parallel study did not find a beneficial psychotherapy effect (Rounsaville et al., 1983). The differing outcomes may be the result of the low enrollment in the Rounsaville et al. study and other programmatic differences (Woody et al., 1998). A follow-up study in three community-based methadone programs also showed that patients with high levels of psychiatric symptoms did better with counseling plus psychotherapy than with counseling alone (Woody et al., 1995). Other investigators have found evidence for the efficacy of psychotherapy for opioid dependence when it is used in conjunction with methadone maintenance or naltrexone (Resnick et al., 1981).

A recent study of naltrexone for opioid dependence found that contingency management improved naltrexone compliance and opioid use outcome relative to standard naltrexone treatment (Carroll et al., 2001). Unlike methadone, which is an opioid agonist and thus creates effects that are similar to heroin, naltrexone is an opiate antagonist, produces no physiologic dependence, and has no opioid effects. Naltrexone makes it very difficult, if not impossible, to get the desired effects of ingested opiates. Consequently, many patients do not like to take naltrexone as much as they like methadone or other substitution drugs, so medication compliance can be problematic. In the Carroll et al. study, 127 opioid-dependent patients who completed outpatient detoxification were randomized to three conditions: standard naltrexone treatment, naltrexone treatment plus voucher-based contingency management, or naltrexone treatment plus voucher-based contingency management and significant other involvement. It was found that contingency management enhanced the outcomes of treatment retention, medication compliance and reduction in drug use when compared with standard naltrexone treatment. Significant other involvement did not improve outcomes over contingency management.

Another study of naltrexone treatment for opioid-dependent patients showed that a manualized psychosocial intervention designed to enhance the clinical value of naltrexone treatment showed greater retention with the more naltrexone taken, the more psychosocial services received, and the greater reduction in opioid use (Rawson et al., 2001). This study, like several mentioned earlier that were done in methadone programs, showed that pharmacological and behavioral treatments can be effectively combined to provide improved outcomes.

A NIDA multisite study investigated the efficacy of four psychosocial treatments when delivered in outpatient settings: (1) cognitive therapy plus group drug counseling; (2) supportive-expressive therapy plus group drug counseling; (3) individual drug counseling plus group drug counseling; and (4) group drug counseling alone (Crits-Christoph et al., 1997). All groups showed substantial reductions in cocaine use; however, patients in the individual drug counseling plus group drug counseling condition had a greater reduction than those in the other three groups. Patients with higher levels of psychiatric symptoms had poorer outcomes, but unlike the methadone studies and like the findings of Project MATCH, psychotherapy did not provide additional benefits to this more psychiatrically symptomatic group.

In another study, relapse prevention (a cognitive-behavioral model) showed better results than interpersonal psychotherapy, provided once per week for 12 weeks, in the treatment of cocaine abuse in ambulatory patients (Carroll et al., 1991). Fifty-seven percent of the relapse prevention subjects achieved greater than 3 weeks of abstinence during the 12 weeks, whereas only 33% of the interpersonal psychotherapy subjects met the same criterion. Also, relapse prevention appeared to be slightly more effective than interpersonal psychotherapy among patients with severe levels of cocaine dependence, although this finding was not statistically significant.

Higgins et al. (1993) compared community reinforcement with standard drug counseling. Community reinforcement, sometimes referred to as contingency management, involves positively reinforcing abstinence with a tangible reward that is usually given in the form of a voucher within the context of a psychosocial intervention. Sixty-eight percent of patients in the community reinforcement condition achieved 8 weeks of abstinence compared with 11% of the standard drug counseling patients. Research examining treatments for cocaine dependence in methadone maintenance patients has also shown support for voucher-based reinforcement for abstinence (Silverman et al., 1996; Rawson et al., 2001) or for treatment plan-related tasks (Iguchi et al., 1997).

Although psychotherapy and counseling alone have shown moderate efficacy, their dropout rates have often been high. This has fostered interest in developing combined psychotherapeutic and pharmacotherapeutic approaches to the treatment of cocaine dependence. One study compared relapse prevention plus desipramine, clinical management plus desipramine, relapse prevention plus placebo, and clinical management plus placebo to treat cocaine abuse in ambulatory patients (Carroll et al., 1994). All groups showed improvement, but there were no main effects for medication or psychotherapy. However, there was a significant interaction effect in that relapse prevention was associated with better outcomes for higher-severity cocaine users than was clinical management. Further analysis of these data (Carroll et al., 1995) suggests differential symptom reduction in depressed versus nondepressed cocaine patients. The depressed patients tended to have better retention and better cocaine outcomes than did the nondepressed patients. Desipramine was effective to reduce depressive symptoms, but not to reduce cocaine use. This points to the importance of comprehensive evaluation of drug-dependent patients and psychiatric problems, with the need for psychiatric treatment in drug treatment for those with dual diagnoses.

Project MATCH found no significant difference in outcome by type of treatment when comparing cognitive-behavioral therapy, to 12-step facilitation therapy (Nowinski et al., 1992), and motivational enhancement therapy (Miller et al., 1992) for the treatment of alcohol dependence. Patients decreased their alcohol use significantly and maintained improvement at 1-year posttreatment in all treatment conditions. Although higher levels of psychiatric severity were associated with worse outcome, the psychiatrically focused treatments did not alter this relationship.

Several studies have examined psychotherapy for marijuana abuse and dependence. Grenyer et al. (1996) compared a modification of supportive-expressive therapy (Grenyer et al., 1995) with a brief (one-session) intervention for treatment of marijuana dependence. The supportive-expressive therapy was offered for 16 weeks. At 16 weeks, the supportive-expressive group showed significantly larger decreases in marijuana use, depression, and anxiety and significantly larger increases in psychological health than did the brief intervention group.

In a study of group treatment of marijuana dependence (Stephens et al., 1994), patients were randomly assigned to either a relapse prevention (Marlatt and Gordon, 1985) group or a social support group. All groups were conducted weekly for the first 8 weeks, and then biweekly for the next 4 weeks for a total of ten 2-hour sessions. Patients in both treatments achieved and maintained reductions in marijuana use and related problems; however, outcomes did not differ between the two treatments.

Adding vouchers to behavioral therapies improved outcomes among heavy marijuana users (Budney et al., 2000). Sixty heavy marijuana users were randomly assigned to one of three treatments: motivational enhancement therapy, motivational enhancement plus behavioral coping skills therapy, or motivational enhancement plus behavioral coping skills therapy plus voucher-based incentives. During the 14-week study, 40% of patients in the incentives group achieved at least 7 weeks of continuous abstinence from marijuana compared with 5% of patients in each of the other groups. At the end of the 14-week treatment, 35% of the incentives group had stopped using marijuana, as compared with 10% of the motivational enhancement plus coping skills group, and 5% of the group receiving motivational enhancement alone.

Although the relative benefits of psychotherapy versus counseling vary in the studies reviewed here, most agree that psychotherapy and counseling can be effective in the treatment of substance abuse and addiction (Resnick et al., 1981; Woody et al., 1983; Carroll et al., 1991; Crits-Christoph and Siqueland, 1997) and moreover that some type of psychosocial intervention is a necessary component of substance abuse treatment. However, it appears that other conditions must be met in order for positive outcomes to occur.

The chemically dependent patient usually requires more structure and greater frequency of visits than traditional psychotherapy provides. An intensive treatment program, with sessions twice a week to everyday depending on the patient and the drug, is usually needed in the beginning. Then the intensity can be decreased as progress is achieved. Psychotherapy appears to be most effective when combined with drug-focused treatment services, either within the context of a structured addiction treatment program or when organized as needed by the individual psychotherapist. Additional services, such as vocational counseling, are very helpful for patients who have employment problems. Family involvement tends to support retention and compliance in treatment. In the case of outpatient treatment for opioid dependence, methadone maintenance or some other type of substitution therapy is essential for psychotherapy or counseling to have an effect. This combined approach, offering both psychotherapy and/or counseling and medication for addictive disorders for which an appropriate medication exists is probably the optimal treatment in many cases. The more traditional psychotherapies, such as cognitive-behavioral, supportive-expressive, and interpersonal, may be more helpful for patients experiencing clinically significant psychiatric symptoms, but this interaction has only been shown to exist in the context of methadone maintenance (Woody et al., 1985).

Research has not clearly indicated that one kind of psychotherapy is superior to any other for the treatment of addiction. However, among psychosocial approaches, the current frontrunners are probably cognitive-behavioral therapy, individual addiction counseling, contingency management, and motivational enhancement. It is important to recognize that we are in a dynamic period in this field and new approaches are developed all the time that improve upon previous work. There is much current interest to combine psychosocial and pharmacological treatments as it appears to be a valuable approach for many addictions. This approach recognizes the value of self-help participation, whether it be 12-step or another model. It is also important to view treatment of addiction as a long-term process that extends well beyond the end of formal treatment and involves continuing personal commitment and growth on the part of the patient.

The following guidelines may be helpful for the clinician treating chemical dependence with psychotherapy.

• Be familiar with the pharmacology of abused drugs. One should know the pharmacological effects of specific drugs of abuse (including their adverse and dangerous effects), the common drug combinations used and why addicts prefer these combinations, the signs and symptoms of intoxication and withdrawal from the various drugs of abuse, and the medical complications associated with various drug classes (including interactions that may occur with other medications that the patient is taking for medical or psychiatric problems). Much of this information can be found in the Treatment Improvement Protocols that are published by the Substance Abuse and Mental Health Administration.

• Be knowledgeable about the subculture of addiction in your area. This includes such information as which drugs are easily available, how they are typically ingested, if there are common combinations, how they are purchased and what they cost the buyer.

• Be knowledgeable about places the patient can go to receive help for the addiction and its associated problems, including 12-step programs, other self-help groups, vocational training and educational programs, legal assistance, and public assistance programs.

• Be prepared to provide education on the nature of addiction and the process of recovery. It is not recommended that the therapist do more talking than listening, but it is usually helpful to educate the patient about important aspects of the disease.

• Form clear goals (a treatment plan) early in treatment. Initially, these goals should be simple and should include abstinence from all nonprescribed drugs and alcohol, attendance in treatment, compliance with prescribed medications as appropriate, and participation in a program of self-help. Keep abreast of the patient's progress with these goals but review them, however briefly, in each session.

• Establish a positive, supportive alliance with the patient. Sometimes addicted patients may transfer some of their dependency needs on to the therapist so it can be helpful to offer more concrete support if necessary, such as calling to follow-up if a session is missed and being willing to schedule an extra session for the patient if they are feeling as if they might relapse.

• Incorporate direct, drug-focused interventions into the treatment program. Such interventions include advising patients to attend a self-help program and monitoring abstinence by self-report and urine drug screens or breathalyzer, preferably at each visit. Provide prompt feedback on drug screens regarding the presence or absence of drugs.

• Explore pharmacotherapeutic options, when they are available, in combination with psychotherapy and other behavioral treatments.

• Recognize that because the recovering addicted patient usually requires structure in addition to psychotherapy or counseling.

• Be prepared to refer the patient to other services as needed.

• Communicate to the patient that you appreciate the difficulty involved in abstaining and breaking the addictive cycle. Be accepting of where they have been and where they are now and be generous with positive reinforcement for gains.

• Be prepared to work with the patient on areas of their life adversely impacted by addiction. These may include financial problems, employment problems, relationship, and parenting difficulties, etc.

• Target the mental health interventions to patients with high levels of associated psychiatric or psychological problems, and address those difficulties simultaneously in the treatment.

This section describes some common difficulties the clinician treating addiction will most likely face: addressing ambivalence, dealing with relapse after a period of abstinence, and depression.