Summary by Dmitry Ostrovsky, MD
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Based on “Principles of Addiction Medicine” Chapter by Marc Galanter, MD, and Helen Dermatis, PhD
THE NETWORK THERAPY TECHNIQUE
The network approach is useful for patients who experience loss of control and cannot limit consumption to a reasonable and predictable level. It is useful for patients who have consistently demonstrated relapse. Network therapy (NT) is not for abusers who can learn to set limits or for those with unusual destabilizing circumstances such as homelessness or psychosis.
Key Elements
The first key element is the cognitive–behavioral approach. Emphasis is placed on triggers to relapse and behavioral techniques for avoiding them, prior to exploring underlying psychodynamic issues. Secondly, support of the patient’s natural social network is integral. This includes peer support in Alcoholics Anonymous as well as involvement of spouses, which has been shown to be effective in enhancing the outcomes of professional therapy. Lastly, orchestration of resources to provide community reinforcement suggests a more robust treatment intervention.
COGNITIVE–BEHAVIORAL THERAPY AND SOCIAL SUPPORT
Cognitive–Behavioral Therapy
The cognitive–behavioral therapy (CBT) format is useful for many substance use disorders. CBT is goal directed and focused on current circumstances in a patient’s life. Patients begin each network session with a recounting of recent events directly relevant to their addiction and recovery, followed by active interaction between therapist, patient, and network members. CBT emphasizes psychoeducation in the context of relapse prevention so that patients and network members are taught to anticipate triggers that can precipitate substance use.
Social Support
It has been found that the size of the supportive social network in the person’s life and the number of members who were abstainers or recovering alcoholics had a positive effect on outcomes. It was also found that men are more often encouraged by their wives to seek help, whereas women are more often encouraged by mothers, siblings, and children.
Community Reinforcement
Social network involvement includes behavioral couple therapy, marital therapy, and the community reinforcement approach. Community reinforcement and family training program (CRAFT) includes many treatment aspects from network therapy. CRAFT was developed to encourage drinkers to enter therapy and reduce drinking by eliciting support of concerned significant others and to enhance satisfaction with life among members of the patient’s social network. CRAFT includes functional analysis of the patient’s substance use (identifying triggers and consequences) as well as minimizing the reciprocal blaming and defensiveness among the concerned significant others. Additionally, CRAFT promotes a patient’s sobriety-oriented activities.
Initial Encounter: Starting a Social Network
The patient should be asked to bring the spouse or a close friend to the first session. These partners can be essential to both history taking and to implement a viable treatment plan, largely due to the patient’s initial denial or rationalization of the addiction. Some patients insist on attending the first meeting alone, and this is often associated with the desire to continue substance use. The therapist should also assure the provision of necessary social supports to achieve that goal. First, the therapist should be available for phone consultation and should indicate that the patient should call if problems arise. This makes the therapist’s commitment clear and sets the tone for a “team effort.” The patient should also develop a support network that can handle the majority of day-to-day problems, which should leave the therapist to respond to occasional difficult questions. If problems in management arise in the period between initial sessions, the first few sessions may be scheduled at intervals as low as 1 to 3 days.
Defining the Network’s Membership
This process is undertaken with active collaboration of patient and therapist. The therapist must carefully promote the choice of appropriate network members by strategically considering the interactions that may take place among network members.
Defining the Network’s Task
The therapist’s relationship to the network is that of a task-oriented team leader as opposed to a family therapist oriented toward insight. The task is maintaining the patient’s abstinence. Competing and alternative goals should be suppressed or prevented from interfering with the primary goal.
The Use of AA
The therapist should mobilize the support network to pressure patient’s involvement with AA for a reasonable trial (at least two meetings a week for 1 month). Patients in AA sometimes experience a conversion, wherein they adopt the group ethos and express a deep commitment to abstinence. The commitment is often much stronger than one in patients undergoing psychotherapy alone. When conversion occurs, the therapist can take a more passive role in monitoring the patient’s abstinence and AA involvement, but should still monitor the patients’ commitment to AA.
Use of Pharmacotherapy in the Network Format
Pharmacotherapy can be valuable when integrated in the network format, especially when administration is observed. It is advised that alcoholic patients agree to abstain from alcohol the day prior to the first visit, so the therapist has the option of administering disulfiram.
Adapting Individual Therapy to the Network Treatment
The patient may feel deprived of attention unless individual therapy is framed as an opportunity for further growth following a period of network-assured abstinence. For individual therapy in network treatment, the primary objectives include addressing exposure to substance cues that might precipitate substance use and establishing a stable social context in an appropriate social environment that is conducive to abstinence with minimal disruption of life circumstances.
RESEARCH ON NETWORK THERAPY TREATMENT
Network therapy is included under the American Psychiatric Association Practice Guidelines for substance use disorders as an approach for facilitating treatment plan adherence.
Treatment by Psychiatry Residents
One psychiatric residency program developed and implemented a network therapy training sequence for cocaine-dependent patients treated by residents. Videotaped NT sessions were used to illustrate typical therapy situations. An NT rating scale was developed and evaluated for its reliability in distinguishing between network therapy and systemic family therapy for addiction. It was then used by clinical supervisors as a didactic aid to monitor therapist adherence to the study treatment manual.
Treatment by Addiction Counselors
Another study was conducted in a community-based addictions clinic using the same NT training sequence used for the psychiatry residents described above. There was increased abstinence and treatment retention in the NT group.
Network Therapy in Buprenorphine Maintenance
The impact of NT relative to medical management (MM) alone has been evaluated. The results of one study showed that 65% of the NT cohort produced opioid-free urines versus 45% in the MM group alone.
ADAPTATIONS OF NETWORK THERAPY TREATMENT
Some therapists have combined NT with other treatment modalities with positive results. One therapist combined elements of NT with social aspects of the community reinforcement approach and relapse prevention in patients with alcoholism. They referred to it as social behavior and network therapy (SBNT). The core element of SBNT is mobilizing the support network even if this involves network sessions conducted without the focal client.
PRINCIPLES OF NETWORK TREATMENT
Start a Network as Soon as Possible
1. It is important to see the patient as soon as possible because the window of opportunity for openness to treatment is generally brief.
2. If the person is married, engage the spouse early on (preferably during first phone call), explain that addiction is a family problem, and enlist spouse in assuring that the patient arrives to the first office visit with a day’s sobriety.
3. During the initial interview, build a strong case for the grave consequences of the patient’s addiction before patients can introduce their system of denial. This prevents the spouse from having to contradict the patient during the initial meeting.
4. Make clear that the patient needs to be abstinent starting now.
5. With alcoholic patients, consider starting disulfiram treatment as soon as possible and have the patient continue taking it under network member supervision (unless detoxification is required first).
6. Start arranging for a network at the first session.
7. Consider how to ensure sobriety until the next meeting and plan that with the network (e.g., daily AA attendance, planned activities).
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