Faculty Bibliography

OBJECTIVE: Cocaine abuse, particularly in crack form, is highly prevalent among patients with severe socioeconomic disadvantages who are treated in municipal general hospitals. The authors describe and evaluate a day treatment program for 30 such patients that combines peer-led self-help and professional care provided by a general hospital psychiatric service. METHODS: Treatment outcomes at one year for 92 patients referred to the day program from the hospital's psychiatric services and 58 perinatal patients referred from the obstetric services were examined using chi square and regression analyses to determine whether certain variables, especially referral source, were related to outcome. An acceptable treatment outcome was defined as three successive negative urinalyses before termination or at the end of one year of treatment. RESULTS: Almost all the patients were unemployed members of ethnic minorities, and most abused at least one substance in addition to cocaine. The 150 patients attended the program an average of 44 times during the year, and 39 percent had an acceptable treatment outcome. Patients referred from psychiatric services had a better outcome than perinatal patients. CONCLUSIONS: Peer-led milieu treatment and professional services can be combined in the general hospital to provide intensive ambulatory care for socioeconomically disadvantaged substance abusers. Techniques and services for engaging perinatal patients in treatment should be developed

Describes an effective treatment for addicted patients in office practice. In network therapy, the therapist draws on family and peer support in the office setting to secure abstinence and aid in relapse prevention. This approach complements individual therapy and can draw on self-help groups and other modalities as well. Assessment of a series of 60 patients treated for alcohol and drug dependence demonstrates the mode of operation and the outcome of this approach. 46 experienced major or full improvement, and those using disulfiram under observation of a network member showed the best outcome.

Describes the mechanics of introducing cognitive-behavioral training into a self-help drug treatment program. Issues that emerged in developing such a paradigm in an outpatient clinic treatment program for cocaine users included incorporating coping techniques into a therapeutic community (TC) milieu, professional leadership vs self-help, and theoretical incompatibilities between 12-step programs and psychological models emphasizing self-control. Although cognitive-behavioral training shares the TC emphasis on self-help, a systematic approach was needed for it to achieve acceptance within the intense cohesiveness of the TC. Examples of applicable behavioral skills training included overcoming social anxieties, dealing with nonverbal experience, and anger management.

Individual therapists in office practice are often considered to have limited effectiveness in treating alcohol and drug dependence. In this article the author describes network therapy, an approach developed to assure greater success in such treatment. It uses psychodynamic and behavioral therapy while engaging the patient in a support network composed of family members and peers. A cognitive-behavioral model of addiction, based on the role of conditioned withdrawal in relapse, is described. Related techniques for securing abstinence are then reviewed; they augment individual psychotherapy to help patients avoid relapse caused by the affective and environmental cues that precipitate drug seeking. The role of social cohesiveness as a vehicle for engaging patients in treatment is outlined next, along with a related technique for enhancing an addicted patient's commitment to the therapy. This is done by using the patient's family and peers as a therapeutic network to join the patient at intervals in therapy sessions. The network is managed by the therapist to provide cohesiveness and support, undermine denial, and promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing members' involvement. Applications of network therapy to ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting are reviewed

Rational Recovery (RR) is a new self-help movement for substance abusers, with a cognitive orientation. It has been suggested as an alternative to Alcoholics Anonymous. This study was designed to examine the nature of RR and its impact on those who join. A national sample of 433 substance-abusing people attending 63 established RR groups was evaluated, using codable self-report questionnaires completed at RR meetings. Members were mostly men with college experience who had previously attended AA. Among recruits who attended their first RR meeting in the last month, 38% were abstinent in the last month. Among members who had joined 3 or more months before, 73% were abstinent in the last month; they had attended an average of 4.1 RR meetings in that month, and carried out exercises at home based on Rational Emotive Therapy. Among those who joined 6 or more months before, 58% reported at least 6 months of abstinence. Among members with a history of heavy cocaine use, the portion reporting abstinence in the last month was not significantly different from those who had never used cocaine. The minority of members who were engaged for 3 months were still drinking, though, and did so on an average of 9.9 days in the last month. RR succeeded in engaging substance abusers and promoting abstinence among many of them while presenting a cognitive orientation that is different from the spiritual one of AA. Its utility in substance abuse treatment warrants further assessment

Assessed the status of fellowship programs in addiction psychiatry. Surveys were sent to all fellowship programs that reported to the Center for Medical Fellowships in Alcoholism and Drug Abuse at New York University from 1987 to 1991, to residency training program directors in psychiatry, and to medical education personnel in addiction institutions in the US and Canada. The survey revealed a considerable increase in the number of established addiction fellowship programs, from 27 in 1987 to 48 in 1990-2991. Data for analysis were available for all but 1 of these programs. Clinical, or patient care work, was by far the most commonly reported activity. Data on residency program affiliation, the prior training of applicants, and salary range are also presented. Findings are compatible with the considerable growth of medical training in addictions in recent years, particularly in departments of psychiatry (M. Galanter et al; see PA, Vol 76:20366).