Marc Galanter, MD, FASAM
Helen Dermatis, PhD CHAPTER
60

CHAPTER OUTLINE

Psychotherapy for people dependent on alcohol and other drugs presents unique problems for the office-based practitioner. Among these are the ever-present vulnerability to relapse to substance use and high dropout rates. In order to address this problem, we can consider how engaging the input of people close to an addicted person can help in achieving a stable abstinence and deal with the vulnerability to dropout from treatment. To understand this option, it is first important to understand that certain conditioned drug-seeking behaviors may be extinguished if appropriate aversive stimuli are interposed after triggers to drug use are presented.

A drug user can become entangled in an interlocking web of self-perpetuating reinforcers that contribute to the persistence of drug abuse, despite compromising consequences, and the user’s imperviousness to a traditional, psychodynamic psychotherapeutic approach does not necessarily take such conditioning factors into account. This is because neither the user nor the therapist is typically aware of his or her existence due to the unconscious nature of the conditioned response of drug seeking. The therapist’s attempt to alter the course of the stimulus–response sequence is therefore often not viable, even with the aid of a willing patient, as neither party is necessarily aware that a conditioned sequence is taking place.

Sufficient exploration, however, can reveal the relevant stimuli and their effect through conditioned sequences of drug-seeking behavior. I initially described a technique for guided recall of relevant conditioned stimuli in a psychotherapeutic context, whereby the alcoholic or addict may become aware of the sequence of circumstances that can precipitate relapse (1). Once this is done, the patient’s own distress at the course of the addictive process, generated by the patient’s own motivation for escaping the addictive pattern, may be mobilized. This motivational distress then serves as an aversive stimulus. The implicit assumption behind this therapeutic approach is that the patient in question wants to alter his or her pattern of drug use and that the recognition of a particular stimulus as a conditioned component of addiction will then allow the patient, in effect, to initiate the extinction process. If a patient is committed to achieving abstinence from an addictive drug such as alcohol or cocaine but is in jeopardy of occasional slips, this cognitive labeling can facilitate consolidation of an abstinent adaptation.

As we shall see, the input of people close to the patient can help to reveal triggers to drug use that may not have been apparent to the patient. Such an approach is less valuable in the context of (a) a lack of motivation for abstinence, (b) fragile social supports, or (c) compulsive substance abuse unmanageable by the patient in the patient’s usual social settings. Hospitalization or replacement therapy (e.g., methadone or buprenorphine) may be necessary in such cases, because ambulatory stabilization through psychotherapeutic support is often not feasible, even with the support of family and close peers. On the other hand, for willing patients, or ones whom family and friends have convinced to cooperate, the network approach can be most valuable.

THE NETWORK THERAPY TECHNIQUE

This approach can be useful in addressing a broad range of addicted patients characterized by the following clinical hallmarks of addictive illness. When they initiate consumption of their addictive agent, be it alcohol, cocaine, opiates, or depressant drugs, they frequently cannot limit that consumption to a reasonable and predictable level; this phenomenon has been termed loss of control by clinicians who treat persons dependent on alcohol or drugs (2). Second, they have consistently demonstrated relapse to the agent of abuse, that is, they have attempted to stop using the drug for varying periods of time but have returned to it, despite a specific intent to avoid it.

This treatment approach is not necessary for those abusers who can learn to set limits on their use of alcohol or drugs; their abuse may be treated as a behavioral symptom in a more traditional psychotherapeutic fashion, nor is it directed at those patients for whom the addictive pattern is most unmanageable, such as addicted people with unusual destabilizing circumstances such as homelessness, severe character pathology, or psychosis. These patients may need special supportive care such as inpatient detoxification or long-term residential treatment.

Key Elements

Three key elements are introduced into the network therapy (NT) technique. The first is a cognitive–behavioral approach to relapse prevention, which has been considered valuable in addiction treatment (3,4). Emphasis in this approach is placed on triggers to relapse and behavioral techniques for avoiding them, in preference to exploring underlying psychodynamic issues.

Second, support of the patient’s natural social network is engaged in treatment. Peer support in Alcoholics Anonymous (AA) has long been shown to be an effective vehicle for promoting abstinence, and the idea of the therapist intervening with family and friends in starting treatment was employed in one of the early ambulatory techniques specific to addiction (5). The involvement of spouses (6) has since been shown to be effective in enhancing the outcome of professional therapy.

Third, the orchestration of resources to provide community reinforcement suggests a more robust treatment intervention by providing a support for drug-free rehabilitation (7). In this relation, Khantzian (8) pointed to the “primary care therapist” as one who functions in direct coordinating and monitoring roles in order to combine psychotherapeutic and self-help elements. It is this overall management role over circumstances outside as well as inside the office session that is presented to trainees, in order to maximize the effectiveness of the intervention.

COGNITIVE–BEHAVIORAL THERAPY AND SOCIAL SUPPORT

Cognitive–Behavioral Therapy

This format for treatment has been shown to be effective for a wide variety of substance use disorders, including alcohol (9), marijuana (10), and cocaine dependence (11). It is premised on the original findings by Wikler (12) on conditioning models of drug seeking in heroin-addicted subjects.

The cognitive–behavioral therapy (CBT) approach is goal oriented and focuses on current circumstances in the patient’s life. In network therapy, reference both in individual and conjoint sessions can be made to salient past experiences. CBT sessions are typically structured, so, for example, patients begin each network session with a recounting of recent events directly relevant to their addiction and recovery. This is followed by active participation and interaction of the therapist, patient, and network members in response to the patient’s report. CBT emphasizes psycho-education in the context of relapse prevention, so that circumstances, thoughts, and interpersonal situations that have historically precipitated substance use are identified, and the patients (and network members as well) are taught to anticipate where such triggers can precipitate substance use.

The process of guided recall, noted previously, is particularly important because it allows the therapist both individual sessions with the patient alone and network sessions––in conjunction with network members along with the patient––to guide the patient to recognize a sequence of conditioned stimuli (triggers) that play a role in drug seeking. Such triggers may not initially be apparent to the patient or network members but, with encouragement and prompting, can emerge over the course of an exploration of the circumstances that have led, either in the past or in a recent “slip,” to substance use.

Social Support

This issue has been studied in a variety of data sets in relation to the recovery from substance use disorders. For example, in the federal Project MATCH, three modalities, 12-step facilitation, motivational enhancement, and cognitive–behavioral approaches, were compared. In a secondary analysis of findings from this multisite study, it was found (13) that certain aspects of social support were most predictive of abstinence outcomes. Two social network characteristics that had a positive effect on outcome were the size of the supportive social network in the person’s life and the number of members who were abstainers (or recovering alcoholics). I have found that non–problem drinking participants are important to a long-term clinical outcome. In matter of fact, a large number of network members, when their participation is effectively maintained over time, can counter a variety of circumstances that may undermine a patient’s abstinence. Additionally, they can provide varied aspects of support relative to the patient’s experience in recovery. And indeed, they should be free of substance-related problems. Of interest in this context, it has been reported that men are more typically encouraged by their wives to seek help, whereas women are more often encouraged by mothers, siblings, and children (14).

Community Reinforcement

Family involvement in substance abuse treatment has long been shown to be effective in improving outcome, and there are numerous approaches that make use of social network involvement in treatment, including behavioral couple therapy (15), marital therapy (16), and the community reinforcement approach (17,18).

More specifically, a community reinforcement and family training (CRAFT) program includes many aspects of treatment that were employed in network therapy. The CRAFT approach was developed to encourage drinkers to enter therapy and reduce drinking, in part by eliciting support of concerned others as well as to enhance satisfaction with life among members of the patient’s social network who were concerned about his or her drinking. As in network therapy, the CRAFT program includes a functional analysis of the patient’s substance use, that is to say, understanding the substance use with respect to its antecedents and consequences. Like network therapy, it also serves to minimize reciprocal blaming and defensiveness among the concerned significant others and to promote a patient’s sobriety-oriented activities.

In one large trial in which concerned significant others were randomized to one of the three conditions, a comparison was made between Al-Anon facilitation therapy, an approach similar to the Johnson Institute interventions, and the CRAFT model (19). In that study, the CRAFT intervention was found to be more effective in engaging treatment-refusing, alcoholic subjects. Similar positive findings were obtained in studies on CRAFT with illicit drug users (20,21). On the other hand, in another study, concerned significant others were successfully trained to apply a modified Johnson Intervention technique in the absence of a therapist, and this approach was found to be successful in itself (22).

Initial Encounter: Starting a Social Network

So how does one go about developing NT? The patient should be asked to bring his or her spouse or a close friend to the first session. Alcoholic patients often dislike certain things they hear when they first come for treatment and may deny or rationalize, even if they have voluntarily sought help. Because of their denial of the problem, a significant other is essential to both history taking and to implementing a viable treatment plan. A close relative or spouse can often cut through the denial in a way that an unfamiliar therapist cannot and can therefore be invaluable in setting a standard of realism in dealing with the addiction.

Some patients make clear that they wish to come to the initial session on their own. This is often associated with their desire to preserve the option of continued substance abuse and is born out of the fear that an alliance will be established independent of them to prevent this. Although a delay may be tolerated for a session or two, it should be stated unambiguously at the outset that effective treatment can be undertaken only on the basis of a therapeutic alliance built around the addiction issue that includes the support of significant others and that it is expected that a network of close friends and/or relatives will be brought in within a session or two at the most.

The weight of clinical experience supports the view that abstinence is the most practical goal to propose to the addicted person for his or her rehabilitation (23,24). For abstinence to be expected, however, the therapist should assure the provision of necessary social supports for the patient. Let us consider how a long-term support network is initiated for this purpose, beginning with availability of the therapist, significant others, and a self-help group.

In the first place, the therapist should be available for consultation on the phone and should indicate to the patient that the therapist wants to be called if problems arise. This makes the therapist’s commitment clear and sets the tone for a “team effort.” It begins to undercut one reason for relapse, the patient’s sense of being on the patient’s own if unable to manage the situation. The astute therapist, however, will assure that he or she does not spend excessive time on the telephone or in emergency sessions. The patient will therefore develop a support network that can handle the majority of problems involved in day-to-day assistance. This generally will leave the therapist to respond only to occasional questions of interpreting the terms of the understanding among himself or herself, the patient, and support network members. If there is a question about the ability of the patient and network to manage the period between the initial sessions, the first few scheduled sessions may be arranged at intervals of only 1 to 3 days. In any case, frequent appointments should be scheduled at the outset if a pharmacologic detoxification with benzodiazepines is indicated, so that the patient need never manage more than a few days’ medication at a time.

What is most essential, however, is that the network be forged into a working group to provide necessary support for the patient between the initial sessions. Membership ranges from one to several persons close to the patient. Larger networks have been used by Speck (25) in treating schizophrenic patients. Contacts between network members at this stage typically include telephone calls (at the therapist’s or patient’s initiative), dinner arrangements, and social encounters and should be preplanned to a fair extent during the joint session. These encounters are most often undertaken at the time when alcohol or drug use is likely to occur. In planning together, however, it should be made clear to network members that relatively little unusual effort will be required for the long term, and that after the patient is stabilized, their participation will amount to little more than attendance at infrequent meetings with the patient and therapist. This is reassuring to those network members who are unable to make a major time commitment to the patient as well as to those patients who do not want to be placed in a dependent position.

Defining the Network’s Membership

Once the patient has come for an appointment, establishing a network is a task undertaken with active collaboration of patient and therapist. The two, aided by those parties who join the network initially, must search for the right balance of members. The therapist must carefully promote the choice of appropriate network members, however, just as the platoon leader selects those who will go into combat. The network will be crucial in determining the balance of the therapy. This process is not without problems, and the therapist must think in a strategic fashion of the interactions that may take place among network members. The following case illustrates the nature of their task:

A 25-year-old graduate student had been abusing cocaine since high school, in part drawing from funds from his affluent family, who lived in a remote city. At two points in the process of establishing his support network, the reactions of his live-in girlfriend, who worked with us from the outset, were particularly important. Both he and she agreed to bring in his 19-year-old sister, a freshman at a nearby college. He then mentioned a “friend” of his, apparently a woman whom he had apparently found attractive, even though there was no history of an overt romantic involvement. The expression on his girlfriend’s face suggested that she did not like this idea, although she offered no rationale for excluding this potential rival. However, the idea of having to rely for assistance solely on two women who might see each other as competitors was unappealing. The therapist therefore finessed the idea of the “friend,” and both she and the patient moved on to evaluating the patient’s uncle, whom he initially preferred to exclude, despite the fact that his girlfriend thought him appropriate. It later turned out (as expected) that the uncle was perceived as a potentially disapproving representative of the parental generation. The therapist encouraged the patient to accept the uncle as a network member nonetheless, so as to round out the range of relationships within the group, and did spell out my rationale for his inclusion. The uncle did turn out to be caring and supportive, particularly after he was helped to understand the nature of the addictive process.

Defining the Network’s Task

As conceived here, the therapist’s relationship to the network is like that of a task-oriented team leader, rather than that of a family therapist oriented toward insight. The network is established to implement a straightforward task, that of aiding the therapist in sustaining the patient’s abstinence. It must be directed with the same clarity of purpose that a task force is directed in any effective organization. Competing and alternative goals must be suppressed or at least prevented from interfering with the primary task.

Unlike family members involved in traditional family therapy, network members are not led to expect symptom relief for themselves or self-realization. This prevents the development of competing goals for the network’s meetings. It also assures the members protection from having their own motives scrutinized and thereby supports their continuing involvement without the threat of an assault on their psychological defenses. Because network members have—kindly—volunteered to participate, their motives must not be impugned. Their constructive behavior should be commended. It is useful to acknowledge appreciation for the contribution they are making to the therapy. There is always a counterproductive tendency on their part to minimize the value of their contribution. The network must, therefore, be structured as an effective working group with high morale. This is not always easy.

A 45-year-old single woman served as an executive in a large family-held business—except when her alcohol problem led her into protracted binges. Her father, brother, and sister were prepared to banish her from the business but decided first to seek consultation. Because they had initiated the contact, they were included in the initial network and indeed were very helpful in stabilizing the patient. Unfortunately, however, the father was a domineering figure who intruded in all aspects of the business, evoking angry outbursts from his children. The children typically reacted with petulance, provoking him in return. The situation came to a head when both of the patient’s siblings angrily petitioned me to exclude the father from the network, 2 months into the treatment. This presented a problem because the father’s control over the business made his involvement important to securing the patient’s compliance. The patient’s relapse was still a real possibility. This potentially coercive role, however, was an issue that the group could not easily deal with. The therapist decided to support the father’s membership in the group, pointing out the constructive role he had played in getting the therapy started. It seemed necessary to support the earnestness of his concern for his daughter, rather than the children’s dismay at their father’s (very real) obstinacy. It was clear to the therapist that the father could not deal with a situation in which he was not accorded sufficient respect and that there was no real place in this network for addressing the father’s character pathology directly. The hubbub did, in fact, quiet down with time. The children became less provocative themselves, as the group responded to my pleas for civil behavior.

The Use of Alcoholics Anonymous

Use of self-help modalities is desirable whenever possible. For the alcoholic, certainly, participation in AA is strongly encouraged. Groups such as Narcotics Anonymous, Pills Anonymous, and Cocaine Anonymous are modeled after AA and play a similarly useful role for drug abusers. One approach is to tell the patient that he or she is expected to attend at least two AA meetings a week for at least 1 month, so as to become familiar with the program. If after a month the patient is quite reluctant to continue and other aspects of the treatment are going well, the patient’s nonparticipation may have to be accepted.

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