Psychotherapy therapy Cognitive-behavioral

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. 

While pharmacologic agents may help prevent relapse, psychotherapy should be the core therapeutic intervention. Motivational enhancement therapy, cognitive-behavioral therapy, 12-step facilitation, and contingency management are the best-studied forms of psychotherapy in this group of patients. 

The type of psychotherapy that has been shown to help people with anxiety problems is called cognitive-behavioral therapy. Cognitive-behavioral therapy is the combination of two distinct kinds of psychotherapy—cognitive therapy and behavior therapy. 

In addition, a number of studies have compared the efficacy of specific forms of psychotherapy, particularly cognitive-behavioral therapy (CBT), and antidepressants in the treatment of patients with an acute episode of major depression (388, 389, 390, 391, 392, 393, 394 and 395). Most studies have reported these forms of psychotherapy and antidepressants to be equally effective. As a result of disparate findings, spirited debate has arisen with regard to this issue. Issues raised in this debate have included relative efficacy in patients with mild versus more severe episodes of major depression and the adequacy of antidepressant treatment in these studies. A summary of these issues is presented in the following paragraphs. 

Despite the diagnostic challenges that remain in trying to understand the nature of MDD in children and adolescents, advances in its treatment has progressed considerably since the last edition of this textbook. Over this interval, selective serotonin reuptake inhibitors (SSRIs) have superseded TCAs as the treatment of first choice based both on efficacy and safety considerations. As in adults, specific psychotherapies (cognitive therapy, cognitive-behavioral therapy, and interpersonal therapy) may be as effective as antidepressant medication, at least in mild to moderate depression in children and adolescents ( 111, 112). Also, evidence indicates that depression in children and adolescents may be more influenced than is depression in adults by psychosocial variables such as peers and family, as well as other environmental factors (113). 

Therapy and/or counseling is also very important. Different therapy approaches used in substance abuse treatment include individual psychotherapy, behavioral therapy, cognitive-behavioral therapy, group therapy, and family therapy. Often, more than one therapeutic approach is used during drug rehabilitation. 

Although medications are the primary treatment modality for bipolar disorder, it is important to consider the impact of medications in conjunction with other forms of treatment. For instance, milieu therapy, when inpatient care is necessary, will be most effective after initial medication response has reestablished some degree of cooperation and insight. Psychotherapy, especially cognitive, behavioral, and psycho-educational approaches, is effective with the medication-stabilized patient. Group therapy, which can include families, will often revolve around acceptance of the disease as well as of the need for long-term medication treatment, the side effects, and the implications of noncompliance. In instances of medication resistance or contraindications, ECT should be considered. 

Alcoholics Anonymous (AA) is a self-help organization for people whose common goal is recovery from alcoholism, and it is the most widely accessed resource for individuals with alcohol problems (McCrady and Miller 1993). The philosophy is based on the concept of alcoholism as a chronic disease that cannot be cured, but one that can be halted by means of complete abstinence. AA has described 12 principles or steps to guide those in recovery. Twelve-step facilitation, a manual-based psychotherapy to promote AA participation (Nowinski et al. 1992), was equally efficacious, compared with cognitive-behavioral and motivational enhancement therapies, in a large study of treatments for alcohol dependence (Project Match Research Group, 1997). 

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... 

Interpersonal therapy and cognitive behavioral therapy are types of psychotherapy that have well-documented efficacy for the treatment of MDD. Psychotherapy alone is an initial treatment option for mild to moderate cases of depression, and it may be useful when combined with pharmacotherapy in the treatment of more severe cases of depression. In fact, the combination of psychotherapy and pharmacotherapy can be more effective than either treatment modality alone in cases of severe or recurrent MDD. Psychotherapy can be especially helpful for patients with significant psychosocial stressors, interpersonal difficulties, or comorbid personality disorders.16... 

Psychotherapy (e.g., individual, group, and family), interpersonal therapy, and/or cognitive behavioral therapy / Stress reduction techniques, relaxation therapy, massage, yoga, etc. 

The main aim of this chapter is to review the current pharmacological treatments for children and adolescents with MDD. Although psychotherapy interventions, including cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) have also been found efficacious for the acute treatment of adolescents with MDD (e.g., Brent et ah, 1997 Mufson et ah, 1999), they will not be reviewed here. 

Agras, W., Rossiter, E.M., Arnow, and Schneider, J.A. (1992) Pharmacologic and cognitive-behavioral treatment for bulimia nervosa a controlled comparison. Am J Psychiatry 149 82-87. Agras, W., Walsh, B.T., Fairburn, C., Wilson, G.T., Kraemer, H. (1999) A multicenter comparison of cognitive-behavioral therapy an interpersonal psychotherapy for bulimia nervosa. 

Fairburn, C., Jones, R., Peveler, R., and Hope R. (1993) Psychotherapy and bulimia nervosa longer-term effects of interpersonal therapy, behavior therapy and cognitive behavioral therapy. Arch Gen Psychiatry 50 419 28. 

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-... 

During all phases of treatment, education, supportive therapy, and, at times, more specific types of psychotherapy are essential for a satisfactory outcome. For example, interpersonal therapy can complement adequate maintenance antidepressant treatment, possibly diminishing the frequency of episodes (see the section Role of Psychosocial Therapies in Chapter 7), and cognitive-behavioral techniques in combination with antiobsessive agents (e.g., clomipramine) can improve the quality of life for patients with obsessive-compulsive disorder, minimizing time spent on disabling rituals (see the section Obsessive-Compulsive Disorder in Chapter 13). 

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. 

Because this book focuses on psychopharmacotherapy, it is not intended to exhaustively review the role of psychotherapy. Nonetheless, some form of counseling is usually necessary during the treatment of major depressive disorder. Broadly defined, psychotherapy covers a wide range of modalities, from simple education and supportive counseling to cognitive-behavioral to insight-oriented psychodynamically based therapy. 

I. We want this book to be theory-neutral. Each model and every therapist makes unique contributions to the therapeutic process. You might be an expert in cognitive-behavioral therapy, family systems theory, interpersonal therapy, or another model your expertise is a critical component of healing. However, because we assume that you already have expertise in some type of psychotherapy, that is not the focus of this book. 

Although anxiety disorders, when untreated, can be the cause of substantial personal suffering, disability, and marital and family disruption, the progress made in the therapeutic area for conditions like panic disorder, OCD, and GAD, among other anxiety disorders, makes these conditions very gratifying to treat. Indeed, the skillful use of psychotherapies—cognitive-behavioral therapies appear to be most effective—and medications can produce dramatic and lasting improvement in many patients. 

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