Psychotherapy approach

A number of psychosocial treatments for alcohol and other substance use disorders exist and are widely used. In this chapter, we discuss six of these psychotherapies as they are applied to alcohol, cocaine, and opioid dependence brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, behavioral treatments (including contingency management and community reinforcement approaches), behavioral marital therapy, and 12-step facilitation. We also describe studies that examined the efficacy of a medication in combination with one or more of the six psychotherapies. In the second section of the chapter, we highlight research that directly studied the interaction between psychosocial and pharmacological treatments. 

Hypnosis maybe effective for severe NVP.11 Psychotherapy is another non-invasive treatment approach that is safe during pregnancy or in situations in which adverse treatment effects and drug interactions are a concern. One small study suggested that patients with hyperemesis gravidarum may benefit from the combination of psychotherapy and antiemetics. 

Psychotherapy focused on reducing the influence of the CNS on the gut has been studied. Cognitive behavioral therapy (CBT), dynamic psychotherapy, relaxation therapy, and hypnotherapy have been reported to be effective in some patients. However, CBT and relaxation therapy do not appear to be better than standard approaches.18 Biofeedback may provide relief in cases of severe constipation, but definitive evidence is lacking.16 Psychotherapy interventions provide relief from pain and diarrhea but not constipation.19... 

While pharmacologic agents may help prevent relapse, psychotherapy should be the core therapeutic intervention. Motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), 12-step facilitation (TSF), behavioral couples therapy (BCT), community reinforcement approaches, and contingency management are the best-studied forms of psychotherapy in this group of patients. 

Psychotherapy is an appropriate treatment approach for patients with psychogenic or mixed dysfunction. It should address immediate causes of dysfunction, and if possible the partner should attend sessions as well. Effectiveness is not well documented for organic dysfunction unless combined with other therapies. Advantages include non-invasiveness and partner participation, while disadvantages include increased cost and time commitment. 

This issue focuses on the themes of certainty and doubt, fragility and tenacious identity, in the psychotherapeutic process. Newman s paper explores some central tensions in the relation between consciousness and unconsciousness. Rowan offers a masterly account of what he plausibly claims are established salient features of the psychotherapeutic process, in terms of the analogy of alchemy. Balick s account of the 7th UKCP Professional Conference evokes the tensions activated by the interface between neuro-science and psychotherapy. And Tan and Zhong face us with the challenge of a communally and certainty based method, in relation to some antisocial sexual patterns, which appears to be more effective than more cautious established Western approaches... 

If the government s Pathfinder programme is a success, the problem of insufficient therapists may be solved. But what do we do in the meantime People who are depressed cannot wait until the year 2015 for help. Fortunately, there are some low-cost alternatives that are available right now. These are treatment approaches that are sometimes used in conjunction with psychotherapy, but can also be used as stand-alone treatments. Let us take a look at them. 

The core problem with the antipsychiatry approach is its practical limitations. How exactly does it assist the distressed individual who is suffering from the delusion that they have an atomic bomb inside their body It will be shown later that psychotherapy without drug treatment is largely ineffective (as Jung and Fried both concluded), whereas psychological therapy combined with active drug treatment is the most effective therapeutic approach. 

For years, psychiatric and drug abuse disorders were not even treated together. Now we know they commonly co-occur, which means for many years clients were getting only partial treatment. Even today we are still not sure how to treat these co-occurring conditions simultaneously in a consistently effective way with both psychotherapy and pharmacotherapy (see Chapter 5). The next century is likely to see many advances in both pharmacotherapy and psychotherapy to treat co-occurring conditions. There are effective methods to treat drug abuse and to treat other co-occurring psychiatric disorders. The next frontier in research is to learn how to combine these approaches in a way that can treat multiple disorders at once ... 

Combining pharmacotherapy and psychotherapy an evidence-based approach... 

The treatment of EOS requires a coordinated team approach and is based upon several components that have to be individually tailored to meet the needs of the patient and family. The treatment components comprise pharmacotherapy, individual psychotherapy, family oriented measures as well as specific measures of rehabilitation, described in several recent reviews (AACAP 2000 2001 Remschmidt et ah, 1996 2001 Lambert, 2001)... 

Comorbid personality disorders have long been associated with TRD and a poor response to antidepressant treatment. For example, Pfohl et al. (1984) observed only a 16% response rate in inpatients with comorbid depression and personality disorder compared with a 50% response rate in patients with pure depression. Similar results were reported from a study by D. W. Black et al. (1987), in which, with the use of ECT in addition to a TCA, the response rate among those with a comorbid Axis II disorder was lower, 42% compared with a 60% recovery in those without Axis II pathology. The best approach for these patients may be a combination of psychotherapy and medication. This approach was recently borne out by the Treatment of Depression Collaborative Research Project (Shea et al. 1990), which found that cognitive-behavioral therapy yielded a better response than either imipra-... 

Several treatment approaches, including maintenance medications, psychotherapies, a combination of medications and psychotherapies, and maintenance electroconvulsive therapy, for preventing recurrences of MDD have been considered by clinicians [American Psychiatric Association Task Force on Electroconvulsive Therapy 1990 Beck et al. 1979 Covi et al. 1974 Doogan and Caillard 1992 Elkin et al. 1989 Frank et al. 1993 N. S. Jacobson et al. 1991 Katon et al. 1992 Klerman et al. 1984 Kupfer 1991 Kupfer et al. 1992 S. A. Montgomery et al. 1988 Prien et al. 1984 Rehm 1979 Rush et al. 1977 Thase 1990). In this chapter, we focus on maintenance antidepressant medications. It is the only modality for which the database is reasonably extensive. 

An attempt has been made to discuss the position of drug therapy of various types of mental disorders within a wider perspective, and especially to clarify the relationship between drug therapy and non-drug treatments. It was necessary to deal separately with the various classes of psychopharmaceuticals and the disorders treated with them, and for our purposes it was also sensible to refer as far as possible to controlled, i.e. comparative, studies. The drawback of this evidence-based approach is obvious comparative studies of therapeutic procedures almost necessarily favor one of the compared treatments because they can never be carried out with completely identical preconditions for all treatments (Elkin et studies comparing psychotherapy with pharmacotherapy were scrutinized and discovered to include studies that were not entirely blind, random, controlled or of high quality, leading to inaccurate conclusions. Thus, meta-analyses based on flawed studies are clearly inadequate for the establishment of treatment guidelines (Klein, 2000). On the other hand, the value of an admittedly incomplete summary such as presented here is that results obtained in different places by different authors with different preconditions can be critically compared and related one to the other. 

All modalities, from electroconvulsive therapy (ECT) to psychotherapy, can be incorporated into our approach when empirical data support their utility. When sufficient data are lacking, we offer suggestions based on our cumulative clinical and research experience. 

Avoiding drugs that lower the threshold for panic symptoms, such as caffeine or over-the-counter stimulants, may also help. Some phobic symptoms are managed by in vivo exposure or cognitive therapy. In general, the best approach is a combination of pharmacotherapy and psychotherapy, in particular, cognitive behavioral techniques. 

Hamlin, M. (1988) An integrated cognitive behavioural approach to withdrawal from tranquillisers , in Dryden, W. and Trower, P. (eds) Developments in Cognitive Psychotherapy, London Sage Publications. 

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