Shifting cultural patterns challenge therapists who specialize in addiction

The Addiction Center reports that nearly 21 million Americans have at least one addiction; and drug overdose deaths have tripled since 1990. Furthermore, alcohol and drug addiction cost the economy more than $600 billion annually.

As addiction continues to take a physical, social and financial toll, mental health professionals strive to help those who struggle.

To determine a diagnosis and appropriate course of action, Sean J. McGlew, Psy.D, LP, traumatic stress and addiction psychologist at the Cambridge HealthAlliance outpatient center, created the Comprehensive Use Assessment, a tool that looks at a patient’s current and past relationship with substances, frequency of use and perception of a problem.

McGlew also uses the American Society of Addiction Medicine’s (ASAM) six dimensions to assess the necessary level of care. He works with medical doctors to initiate medication-assisted treatment (MAT), a “frontline therapy” that helps with early recovery, for clients with an addiction to alcohol.

He may also utilize the traditional 12-step model, as well as acceptance and commitment therapy (ACT). “Psychoeducation is also important,” he said.

Younger people today are introduced to substance use and marijuana earlier, which leads to dabbling in other substances and a “full blown addictive pattern,” McGlew said.

Recently, McGlew has noticed the presence of “more complex poly-substance abuse and addiction” rather than addiction to a single substance. “True alcoholism is much less common in the emerging population. There’s a big rise in the type of drugs being used, including club drugs, which are LSD-based. They produce a similar feel to alcohol, but much faster,” he said. “This is a cultural shift.”

Before he begins an intervention, McGlew focuses on the “stage of change” and evaluates how the abuse is impacting the client’s ability to function. He also asks the client his perception of risk and how problematic the behavior is. “These are big questions that drive the direction of the therapy,” he said.

Dual diagnosis is common in patients, according to McGlew. Females may present with an eating disorder that stems from the use of methamphetamine or some other stimulant.

Post-traumatic stress disorder (PTSD) and addiction is common in patients who have experienced trauma. “Opiates dull the pain and shut down the central nervous system,” McGlew said.

Tara Bogs, Ph.D, CPRP, owner, Elevate Psychological Services, LLC in East Greenwich, Rhode Island, agrees that multiple substance use problems have become common. She treated 2,000 clients last year and half of them had two addictions.

She has seen combination problems involving alcohol and benzodiazepines, cannabis and/or opiates as well as opiates with cannabis, which she calls a “carry along friend.” With the legalization of marijuana in some states, stigma has been reduced, leading to an upswing in usage, according to Bogs.

Treatment for both alcohol and opioid addiction might require inpatient detox protocols with motivational interviewing, components of dialectical behavior therapy, and mindfulness, although interventions are individually based and continuity of care is important, Bogs said.

Certain factors influence the treatment plan, according to Bogs. The substance and modality, the stage of use and strategies that have worked in the past and what has not should be considered. “The therapist has to create a treatment plan that fits with the client’s financial and environmental circumstances.”

Addiction can affect both males and females and, while the treatment is typically the same, it’s wise to separate clients into gender-specific groups, Bogs noted. In a female group, clients learn how substance use can affect the body at any stage from pre- to post-pregnancy and stages in between. “It’s critical to have conversations related to self and others,” she said.

Separate groups also provide a safe space for clients to explore any past traumas.

Throughout the therapeutic process, it’s critical to frequently review the client’s progress, said Bogs. “It’s long term therapy. There is no end. You have to move away from that thought. Behavior change is long term. The client is living and embracing recovery.”

Although treating patients with addiction can be rewarding, the therapist must face the reality of relapse. Bogs said, “Relapse is part of most, but not all, stories. But we still have energy and hope.”

While face-to-face therapy is still the standard, telehealth has been making some inroads in the therapeutic arena. Recently, Michael V. Pantalon, Ph.D, private practitioner and cofounder, Center for Progressive Recovery in New Haven, Connecticut, has focused his efforts on online assistance for those with addictions.

“I’m not a tech expert by any means, but wanted to provide evidence-based support in a digital health platform for those who might otherwise have no one to guide them. This was born out of necessary because only 12 percent of people with an addiction get any help,” he said.

This digital support system, RecoveryPad, is based, in part, on the findings of Project ASSERT (Alcohol & Substance abuse Services, Education and Referral to Treatment), a study out of Yale School of Medicine.

Pantalon supervised the ASSERT project, which assists patients in the emergency department who demonstrate risky alcohol and drug use behavior to access treatment and care. He is also a faculty member in the Department of Emergency Medicine at Yale.

Pantalon views this platform as “help for all,” a way to provide comprehensive, accessible and low-cost assistance to those in need. It is also HIPAA compliant, he noted. 

In 2014, Pantalon developed the online recovery coach program whereby he trains those in recovery and/or those who already provide coaching services to offer round-the-clock professional and compassionate support to clients via text on any device across time zones.

He emphasized that the coaches offer support, education, and motivation, but don’t diagnose and treat. “They are a useful conduit to getting the patient to a provider and keeping them there,” he said. The Center for Progressive Recovery has trained 86 coaches to date.

Pantalon admitted there are challenges with online support, but they are the same a therapist would encounter in a face-to-face meeting with a patient. “Ambivalence – it’s part of the disease in sometimes not wanting to change behavior. The coach does not push but they meet clients where they are,” he said.

“At the root, we’re saving a life. We’re glad when a client ‘gets it’ and is ready to embrace recovery,” said Bogs. ” When you save one person, you typically save a whole family dynamic.”

Phyllis Hanlon has been a regular contributor to New England Psychologist since 1999. As an independent journalist, she has also written for a variety of traditional and alternative health magazines and business consumer and trade publications.  She also serves as writer/editor for custom publications.