RESUMEN
This article addresses how and why groups help people with addictive disorders feel better and change. It advances the position that problems in self-regulation and the psychological suffering that ensues are at the root of addictive disorders. Group work is especially effective in addressing these problems, providing a means of relief, and examining co-occurring characterological problems. The evolution of these ideas and the generation of a model for group therapy for substance abusers are traced over a 30-year period, and a list of principles about how and why group treatments work is presented. In addition, a number of advantages that group psychotherapy has over 12-step programs for some patients are provided. Group psychotherapy is presented as a unique corrective emotional experience.
Asunto(s)
Psicoterapia de Grupo , Trastornos Relacionados con Sustancias/rehabilitación , Humanos , Control Interno-Externo , Desarrollo de la Personalidad , Grupos de Autoayuda , Apoyo Social , Trastornos Relacionados con Sustancias/psicología , Resultado del TratamientoRESUMEN
BACKGROUND: Substance abuse is a common comorbid illness in patients with mood disorders. Little has been written about the pharmacologic treatment of patients with affective lability and co-occurring substance abuse, however. The following report will describe clinical experience using divalproex sodium in substance-abusing patients with mood disorder. METHOD: Twenty patients admitted to an intermediate-care inpatient substance abuse program were diagnosed with comorbid mood disorder (according to DSM-IV criteria) and treated with divalproex sodium in an open-label, naturalistic trial with no blind. All patients were followed clinically and were assessed using the Clinical Global Impressions scale (CGI) and laboratory studies. RESULTS: Seven patients referred while on divalproex treatment continued to exhibit improved mood. Eleven others had at least 1 week of follow-up, and 10 of these also showed improvement. In 13 cases, divalproex was used safely with other psychiatric medications. Two patients complained of slight tremor, 1 of whom was also taking fluoxetine. Fifteen of 17 patients in whom biochemistry and hematology laboratory studies were completed had unremarkable results; 2 other patients had pretreatment abnormalities, which worsened over the course of treatment. Mean plasma valproate level was 58.53 microg/mL. Mean length of follow-up was 38 days. Mean period of abstinence prior to starting medication was 48 days. Some patients reported decreased cravings, and, by self-report, all patients remained abstinent. CONCLUSION: This report suggests that divalproex sodium is efficacious and safe, both alone and in combination with other psychiatric medications, in treating substance-abusing patients with mood disorder.
Asunto(s)
Anticonvulsivantes/uso terapéutico , Trastornos del Humor/tratamiento farmacológico , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Ácido Valproico/uso terapéutico , Adulto , Conducta Adictiva/diagnóstico , Conducta Adictiva/psicología , Trastorno Bipolar/tratamiento farmacológico , Trastorno Bipolar/epidemiología , Trastorno Bipolar/psicología , Comorbilidad , Trastorno Depresivo/tratamiento farmacológico , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Quimioterapia Combinada , Estudios de Seguimiento , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Trastornos del Humor/epidemiología , Trastornos del Humor/psicología , Trastorno de Pánico/tratamiento farmacológico , Trastorno de Pánico/epidemiología , Trastorno de Pánico/psicología , Psicotrópicos/uso terapéutico , Centros de Tratamiento de Abuso de Sustancias , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicología , Resultado del TratamientoRESUMEN
The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.
Asunto(s)
Automedicación/efectos adversos , Trastornos Relacionados con Sustancias/etiología , HumanosAsunto(s)
Clozapina/uso terapéutico , Esquizofrenia Paranoide/tratamiento farmacológico , Trastornos Relacionados con Sustancias/prevención & control , Adulto , Enfermedad Crónica , Humanos , Masculino , Esquizofrenia Paranoide/complicaciones , Esquizofrenia Paranoide/psicología , Trastornos Relacionados con Sustancias/complicacionesRESUMEN
Alcoholism is associated with tremendous suffering, psychological denial, and physical and emotional debilitation. Much of the suffering that plagues alcoholics is rooted in core problems with self-regulation involving self-governance, feeling life (affects), and self-care. Alcoholics Anonymous is effective because it is a sophisticated group psychology that effectively accesses, corrects, or repairs these core psychological vulnerabilities. The traditions of storytelling, honesty, openness, and willingness to examine ("take inventory") character defects allow people to express themselves who otherwise do not feel or speak and help those who otherwise are deceitful (to self and others) and would deny vulnerability and limitation to openly admit to it.
Asunto(s)
Alcohólicos Anónimos , Alcoholismo/rehabilitación , Trastornos Relacionados con Opioides/rehabilitación , Grupo de Atención al Paciente , Adulto , Síntomas Afectivos/psicología , Alcoholismo/psicología , Femenino , Humanos , Relaciones Interpersonales , Masculino , Persona de Mediana Edad , Trastornos Relacionados con Opioides/psicología , Inhabilitación Médica , Autocuidado/psicologíaRESUMEN
A review of the substance abuse literature in the 1980s focuses on deficits in self-regulating capacities, in self-care functions, and in other vulnerabilities of the self, such as an inappropriate use of defenses and problems in intimacy. Various models which attempt to explain these behaviors are described, as well as techniques of dynamic psychotherapy for substance abuse, which emphasize the building of ego functions and the internalization of self-preservation functions. Commonalities and differences of substance abuse with other intensely driven compulsive behaviors (e.g., pathological gambling or certain sexual behaviors) are also considered.
Asunto(s)
Alcoholismo/rehabilitación , Terapia Psicoanalítica , Alcoholismo/psicología , Ego , Humanos , Control Interno-Externo , Apego a Objetos , Desarrollo de la Personalidad , Teoría PsicoanalíticaRESUMEN
The effectiveness of psychotherapy in the treatment of substance abuse continues to be debated among theorists and practitioners. This paper proposes that psychotherapy can play an important role in the treatment of the addictions. However, it is critical that this psychotherapy is geared toward the special needs of substance abusers. Using research on the process of change as a guide, a psychotherapeutic approach for substance abusers is described that responds to the needs of the individual as they shift during the different phases of recovery. Contemporary adaptations of psychodynamic psychotherapy are recommended, along with the appropriate cognitive-behavioral and self-help approaches. In addition, the different clinical considerations for alcohol versus cocaine abusers are examined as they evolve during the change process.
Asunto(s)
Alcoholismo/rehabilitación , Cocaína , Psicoterapia/métodos , Trastornos Relacionados con Sustancias/rehabilitación , Alcohólicos Anónimos , Alcoholismo/psicología , Terapia Conductista/métodos , Terapia Combinada , Humanos , Terapia Psicoanalítica/métodos , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
Addicts and alcoholics suffer vulnerabilities and deficits in self-regulation. A principal manifestation of their self-regulation disturbances is evident in the way they attempt to self-medicate painful affect states and related psychiatric problems. Individuals select a particular drug based on its ability to relieve or augment emotions unique to an individual which they cannot achieve or maintain on their own. Addicts and alcoholics usually experiment with all classes of drugs, but discover that a particular drug suits them best. Usually, painful affect states interact with other problems in self-regulation involving self-esteem, relationships, self-care, and related characterological defenses, making it more likely that addicts will experiment with and find the action of a particular drug appealing or compelling. Stimulants have their appeal because their energizing properties relieve distress associated with depression, hypomania, and hyperactivity; opiates are compelling because they mute and contain disorganizing affects of rage and aggression; and sedative hypnotics, including alcohol, permit the experience of affection, aggression, and closeness in individuals who are otherwise cut off from their feelings and relationships.
Asunto(s)
Adaptación Psicológica , Alcoholismo/psicología , Desarrollo de la Personalidad , Automedicación/psicología , Trastornos Relacionados con Sustancias/psicología , Humanos , Factores de RiesgoAsunto(s)
Trastornos Relacionados con Sustancias/terapia , Agotamiento Profesional/prevención & control , Terapia Combinada , Conducta Peligrosa , Objetivos , Humanos , Anamnesis , Motivación , Psicoterapia/métodos , Recurrencia , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
AA's success rests on its ability to establish and maintain abstinence. This basic and essential accomplishment has tended to detract from the fact that AA is successful in good part because it is a sophisticated psychosocial form of treatment that addresses human psychological vulnerabilities that alcoholics and others share related to problems of self-regulation. The "character defects" that AA addresses are related to attitudes about self and others that are embodied in character traits and styles that make interdependence, experience, and expression of feelings and self-care problematical and difficult. AA confronts these "defects" by effectively advocating surrender, acceptance of a Higher Power, and challenging human self-centeredness. In its insistence on openness, support, sharing of experiences, and mutual concerns, AA imaginatively employs group psychology to address vulnerabilities in self-governance and problems in regulating feelings and self-care.
Asunto(s)
Alcohólicos Anónimos , Alcoholismo/psicología , Teoría Psicoanalítica , Alcoholismo/rehabilitación , HumanosRESUMEN
The author advocates that a clinician play the role of a primary care therapist (PCT) for substance abusers to assure that appropriate treatment interventions are provided to meet patient needs. In treating substance abusers, the PCT must be concerned about patients' needs for control, containment, contact, and comfort, especially initially, but also in an ongoing way. The PCT functions in direct, coordinating, and monitoring roles in order to optimally provide and combine psychotherapeutic and self-help elements.
Asunto(s)
Atención Primaria de Salud , Trastornos Relacionados con Sustancias/terapia , Humanos , Grupo de Atención al Paciente , Relaciones Profesional-Paciente , Controles Informales de la Sociedad , Apoyo SocialRESUMEN
Psychotherapy with substance-dependent physicians presents special problems. Accurate assessment and effective response is rendered difficult due to underrepresentation or denial by the patient and countertransference impediments to recognition and limit setting by the therapist. Case examples illustrate problems, pitfalls, and therapeutic strategies.
Asunto(s)
Inhabilitación Médica , Psicoterapia/métodos , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Alcoholismo/rehabilitación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Trastornos Relacionados con Opioides/rehabilitación , Relaciones Médico-Paciente , Derivación y Consulta , Trastornos Relacionados con Sustancias/psicología , Transferencia PsicológicaRESUMEN
In this article we have brought to bear on the complex problem of substance dependency the psychodynamic perspective: a model that views the problem from the inner experience and psychological structure of the individual drug user. Chronic drug dependence has been associated with a range of personality styles and psychopathologic conditions but most frequently with character disorder and vulnerability to depression. Regardless of specific symptoms or personality styles, certain characterologic features are repeatedly observed to characterize substance-dependent individuals. These include problems in affect management, narcissism, object relations, judgment, and self-care. These developmentally and structurally determined problems generally predispose individuals to drug dependence because they are the basis of the distresses that are relieved by drug-taking; they specifically predispose to drug dependence because, in various ways, the taking of drugs and the experience of their effects are syntonic with existing modes of defense, adaptation, and self-concept. The actual vulnerability to substance dependency can vary considerably both between individuals and for the same individual at different times. For many, a necessary precipitating event involves a severe crisis in which usual adaptive capacities are diminished and narcissistic vulnerability is intense. Once drug taking is initiated in a susceptible state and the user has experienced adaptive benefit from the experience, a variety of other processes are set in motion that often lead to the state of dependency. These processes include both regressive effects that can exacerbate the original character problem and progressive effects that promote stable functioning. In both cases, however, this may interfere with further maturation of character, particularly when onset of use occurs in adolescence. Dependency involves the gradual incorporation of the drug effects and their experienced need into the defensive structure building activity of the ego itself. Undoing a dependency involves dealing with the unconscious and conscious components of this outcome. The user must be able to relinquish behaviors and drug effects that have come to be experienced as a valued (even if also hated) part of the self-capacity to function, cope, and be comforted in distress.
Asunto(s)
Trastornos Relacionados con Sustancias/psicología , Afecto , Humanos , Juicio , Narcisismo , Apego a Objetos , PersonalidadRESUMEN
In contrast to early psychodynamic formulations of addictions which stressed pleasure seeking or self-destruction, a modern psychodynamic perspective places greater emphasis on understanding addicts' disturbances in regulating their internal emotional life and adjustment to external reality. Effective treatment rests on providing interventions and responses that appropriately respond to addicts deficits in regulating affects and behavior. Treatment modalities must keep needs for comfort, control, and safety as the highest priorities, especially initially, in considering the choice of treatment or combination of treatments which are adopted or prescribed. The concept of a primary care therapist is advanced in which a single clinician takes responsibility for holding patients to other interventions and for monitoring which elements or combinations are most helpful. Benefits, pitfalls, limitations, and risks are considered for individual psychotherapy, self-help groups (i.e., AA and NA), and group psychotherapy. The role of psychopharmacologic approaches are considered as they pertain to psychotherapy.