Best Practices : Substance Abuse Treatment and Rehabilitation

c) Psychotherapeutic Approaches

The term "psychotherapy" has come to be used to refer to a wide variety of therapies that variously seek to give clients insight into their behaviours and to help them resolve conflicts originating in childhood experiences. Many of the other approaches currently applied to substance abuse treatment have their origins in psychotherapy (e.g., functional analysis was used by Otto Rank). The various psychotherapies are often complex and the course of therapy unpredictable, rendering them more difficult to evaluate using experimental methods.

Consistent with the scheme developed by Holder et al., four types of treatment will be considered under this heading: general counselling; confrontation; group psychotherapy; and individual insight-oriented psychotherapy.

General counselling refers to a supportive, directive, reality-based treatment, which is not specifically behavioural or confrontational. Holder et al. identified nine controlled studies of general counselling and concluded that, on aggregate, there was no evidence for the effectiveness of this approach. General counselling also received one of the highest negative scores on the Finney-Monahan index (-32).

Confrontational Interventions as defined by Holder et al. are concerned with breaking down defence mechanisms, especially denial. Confrontation often involves forceful feedback aimed at countering "resistance" to change. Holder et al. found four studies of confrontation and none supported its use. It has also been suggested that confrontation might have a negative effect by increasing resistance or lowering self-esteem (Eliany and Rush, 1992). Finney and Monahan ranked the effectiveness of confrontation near the bottom of all interventions considered (22 of 24).

Group psychotherapy is used extensively in addiction treatment, but the format and focus of groups vary widely. Some are confrontational while others are supportive and client-centred. However, as defined by Holder et al., behavioural and marital therapies fall outside the range of interventions considered under this heading. Holder et al. identified 13 studies of group therapy and found that only two had positive results. It should be noted that these reviews refer to studies of group psychotherapy, and not to the issue of the relative effectiveness of delivering treatment in an individual or group format.

Holder et al. concluded that overall there is no evidence that group psychotherapy works for alcoholics. Finney and Monahan's effectiveness score for group therapy was quite negative (-13), although it ranked somewhat higher on the Finney-Monahan scale than on the index used by Holder et al. (positions 16 vs. 23). This does not seem to seriously challenge Holder et al.'s conclusions about the lack of evidence for the effectiveness of group therapy.

Individual insight-oriented psychotherapy seeks to uncover unconscious conflicts and dynamics that are believed to cause excessive drinking. Major goals are to give clients insight into their problems and to help them work through unresolved conflicts originating in childhood experiences. Holder et al. identified eight studies of this type of therapy and concluded that there was no evidence of its effectiveness for people seeking treatment for alcohol problems. Finney and Monahan reclassified or excluded seven of these studies but noted that the one remaining study showed some benefit from psychotherapy.