By Arnold M. Washton, PhD

Abstract

Although substance use disorders (SUDs) are among the most frequently occurring health problems in the U.S. today, few psychologists have adequate clinical training and skills in this area and few address alcohol/drug problems routinely in their clinical practices. Most treatment for SUDs is provided not by practicing psychologists but by specialized addiction treatment programs and clinics. Although there are many reasons why psychologists traditionally have avoided dealing with alcohol/drug problems, this article offers compelling reasons why all practicing psychologists should acquire the necessary skills to address SUDs competently. Well-trained psychologists already possess the most essential therapeutic skills for delivering good treatment to substance-using patients. The challenge is for practitioners to adapt, modify, and refine these skills to enhance their effectiveness with these patients. Acquiring basic proficiency in addressing SUDs must become an integral part of the education and training of all psychologists. The goal is not for every psychologist to become a substance abuse expert or specialist, but to insure that all practitioners acquire at least the core competence to recognize, evaluate, and address SUDs competently and reliably in their patients.

Why Psychologists Traditionally Have Avoided Treating SUDs

The most obvious reason why psychologists have avoided treating SUDs is their lack of specific training in this area. Like other health care professionals, few psychologists have acquired the core knowledge base about SUDs or received clinical training/supervision in addictive disorders as part of their graduate or postgraduate education. Not surprisingly, psychologist’s lack of familiarity with SUDs and relevant clinical skills leaves them without the professional confidence to adequately address these problems and discourages them from getting involved with substance-abusing patients they encounter in the course of mental health practice. Not surprisingly, psychologists frequently overlook or give short shrift to alcohol/drug problems in their psychotherapy patients failing to identify, assess, and address SUDs in those receiving treatment for other mental health problems.

A second reason why psychologists avoid treating SUDs is an entrenched belief that these disorders are best treated in specialized addiction treatment programs because the type of targeted treatment these patients require is presumed to lie outside the scope of what an office practitioner can competently provide (Miller and Brown, 1997). Accordingly, most practitioners exclude substance-abusing patients from their caseloads and often as a matter of course refer them out to addiction treatment programs. This happens even when the patient and therapist have established a good working relationship with one another and the patient does not want to be sent off to an addiction treatment program or clinic.

A third reason for avoiding SUDs is the long-held belief by many practitioners that people with alcohol/drug problems are simply not good therapy candidates (Imhof, 1995). Substance abusers are often presumed to be character disordered, impulsive, untrustworthy, highly resistant to treatment, unmotivated to change, unresponsive to psychotherapeutic interventions, and just too much trouble to deal with in office practice. This stereotype creates an unfortunate self-fulfilling prophecy. Clinicians not knowing how to deal effectively with SUDs are not likely to do well with these patients and become frustrated when they are unable to engage or treat them successfully. These experiences serve only to confirm the negative stereotype and reinforce a negative attitude and stance on the part of the therapist toward substance-abusing patients. Many therapists have not had the opportunity to see that the negative behaviors and personality distortions associated with chronic substance use often disappear shortly after the alcohol/drug use stops. Antisocial, narcissistic, and/or other serious personality disorders certainly do exist among substance abusers, but people with these treatment resistant disorders represent only a minority of the addicted population.

A fourth reason why psychologists avoid treating SUDs stems from long-standing ideological conflicts and incompatibilities between mental health professionals on the one hand and the mainstream addiction treatment system on the other (Margolis & Zweben, 1998). Many if not most psychologists reject the idea that addiction is an incurable disease. And many are uncomfortable with what they perceive as the rigid dogmatic approach of AA and 12-step oriented programs that continue to dominate the addiction treatment field. Psychodynamic therapists are more inclined to view addiction not as an incurable disease but as a symptom or byproduct of underlying psychological conflicts. At the other end of the spectrum are behavioral psychologists who similarly reject the disease model, but view substance use as a multi-determined learned behavior maintained by biological, psychological, and social reinforcers. Although a unitary disease model continues to dominate the larger addiction treatment field, psychotherapeutic concepts, approaches, and techniques are being brought into mainstream addiction treatment. For example, there is growing appreciation for the role of the therapeutic alliance and the therapist’s style of relating to patients as key factors in determining patient engagement, retention, and clinical outcomes in addiction treatment (Miller & Rollnick, 1991).

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Why Psychologists Should Know How To Deal with SUDs

Not least among the reasons why psychologists should know how to address SUDs is the widespread prevalence and negative consequences of SUDs in the general population. Alcohol and drug problems are the most frequently occurring health and mental health problems in the U.S. today and their negative impact is enormous (Reiger et al., 1990). SUDs are associated, for example, with extraordinarily high rates of morbidity and mortality including: substance-related death and serious injury resulting from overdose, drowning, suicide, homicide, and domestic violence; problems of sexual abuse, high-risk sexual behaviors, exposure to HIV and other STDs; drug-induced psychiatric disorders; adverse interactions with medications prescribed for other medical conditions; and, a wide range of serious medical problems directly caused or exacerbated by substance abuse (Institute of Medicine Report, 1990).

Of special importance is the fact that SUDs are highly prevalent among people seeking help for all types of mental health problems even when substance abuse itself is not a presenting complaint (Ross, Glaser, & Germanson, 1988; Reiger et al., 1990). It is equally true that mental health (MH) problems are highly prevalent among people with SUDs. The clinical importance of these observations is that attempting to treat one type of problem without treating the other may be ineffective or even futile. Undiagnosed and untreated SUDs can diminish or completely nullify the effectiveness of treatment for other MH problems. Similarly, undiagnosed and untreated MH problems can adversely affect the outcome of treatment for SUDs. The interaction between SUDs and other MH problems is complex, multifaceted, and not adequately understood. Chronic use of psychoactive substances can induce behavioral changes and psychiatric symptoms that mimic almost any type of mental health disorder ranging from anxiety and depressive disorders to personality disorders and psychoses. It is equally true that mental health problems can promote the use and abuse of psychoactive substances. Many people with MH problems use alcohol/drugs as “self-medication” seeking relief and/or distraction from anxiety, depression, phobias, delusions, and other sources of emotional distress.

In view of the high rates of comorbidity between MH and substance abuse problems, professionals who treat SUDs must have the skills to identify, differentially diagnose, and address a wide range of mental health problems including depressive disorders, anxiety disorders, personality disorders, sexual disorders, posttraumatic stress disorders, psychoses, etc., all of which are over-represented among people with alcohol/drug problems. Many of these problems continue unabated or intensify during periods of abstinence. Clearly it is advantageous for SUDs to be treated by professionals who have both specialized expertise to offer targeted treatment for SUDs and broader clinical expertise to address a wide range of other MH problems. These requirements cannot be met by the traditional one-size-fits-all approach that characterizes the addiction treatment system or by addiction counselors who the lack clinical flexibility, advanced mental health training, and sophisticated diagnostic/treatment skills needed to deal with co-occurring SUDs and MH problems effectively.

Another reason why psychologists should know how to treat SUDs is the recognition that these disorders are fundamentally behavioral and psychological in nature (Miller & Brown, 1997). This recognition stands in direct contrast to the prevailing view of SUDs as primarily biological problems with a genetic basis requiring medical interventions such as pharmacotherapy and hospitalization. Although certain medications can be helpful adjuncts in treating SUDs, experts generally agree that pharmacotherapy is best regarded not as stand-alone treatment, but as a supplement to psychosocial interventions. It is also worth noting that SUDs respond to many of the same psychotherapeutic principles and interventions that apply to other mental health problems. The efficacy of addiction treatment approaches based on behavioral and other psychotherapeutic techniques is well documented. Included among these are: motivation-enhancement strategies based on Rogerian principles of client-centered therapy (Miller & Rollnick, 1991); relapse prevention strategies based on principles of cognitive-behavioral therapy (Marlatt & Gordon, 1985; Washton, 1989); solution-oriented and other brief therapy techniques (Berg & Miller, 1992; Hester & Bien, 1995); and, harm reduction approaches (Denning, 2000).

Additional reasons for psychologists to acquire core competence in treating SUDs stem from concerns about economic and professional survival in a healthcare marketplace increasingly controlled by managed care. Given the extraordinarily high prevalence and complex interaction between SUDs and other mental health problems, managed care companies and other third-party payers look increasingly for mental health providers who are able to recognize and address SUDs competently in all patients, regardless of the patient’s presenting complaints (Washton & Rawson, 1999). Psychologists lacking this ability may ultimately find themselves with fewer managed care referrals or excluded from provider panels entirely. It is also worth noting that psychologists who can deal competently with SUDs are in a good position to seize opportunities created by the dramatic shift away from inpatient and residential programs toward outpatient treatment of SUDs. There is a burgeoning demand for community-based practitioners who can focus not only the patient’s substance use, but also skillfully address the complex matrix of psychological and social problems in which SUDs are often embedded.

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What Psychologists Can Uniquely Offer

Miller & Brown (1997) assert boldly that practicing psychologists are particularly well qualified by their training and expertise to treat SUDs. This assertion flies in the face of common notions that treatment for alcohol/drug problems is best delivered in specialized programs by counselors who are themselves recovering addicts and that treating addiction requires an entirely separate knowledge base and set of therapeutic skills that most professionally-trained therapists simply do not possess. To the contrary, there are many reasons to suggest that the core training and skills of competent psychotherapists are highly applicable and of great value in treating SUDs (with appropriate modification) and that a clinician’s history of personal addiction is largely irrelevant in determining his/her effectiveness in treating others with the problem (Miller and Rollnick, 1991).

Well-trained psychologists already possess the most essential therapeutic skills for delivering good treatment to substance-using patients. The challenge is for practitioners to adapt, modify, and refine these skills to enhance their effectiveness with these patients (Washton, 1995; Washton, in preparation). In stark contrast to confrontational tactics used routinely in mainstream treatment programs, psychologists place high value on forming a friendly therapeutic alliance with their patients as a central feature of the treatment process. Psychologists are trained to be good listeners, to convey nonjudgmental acceptance and positive regard for their patients, to work therapeutically with the patient’s resistance not against it, and to remain vigilantly aware of their own countertransference reactions as potential obstacles to the therapeutic work. Studies show consistently that the therapist’s attitude and clinical stance matter a great deal in treating SUDs (Miller et al., 1993). In particular, Rogerian qualities of therapist warmth, friendliness, nonjudgmental acceptance, and empathy are more important predictors of retention and favorable treatment outcomes than the therapist’s theoretical orientation or treatment philosophy.

Psychologists are trained to be sensitive and responsive to individual differences. The wide-ranging heterogeneity of clinical problems associated with SUDs and the diversity of the patient population in terms of demographics and other personal characteristics requires clinical flexibility and sophistication to accommodate individual differences. Psychologists are generally well prepared to make important diagnostic distinctions and to individualize treatment according to differing patient needs- essential ingredients for delivering effective treatment.

Psychologists with expertise in treating addiction can lower barriers that prevent many people with alcohol/drug problems from seeking professional help (Washton, in preparation). Many people are unwilling to even consider the option of going into an addiction treatment program or of attending an Alcoholics Anonymous (AA) meeting as a first step toward addressing their problems. Fears of public exposure and being labeled as an “addict” or “alcoholic” are often insurmountable concerns. Dismissing these concerns as “denial” and “resistance” offers no solution. It stands to reason that people who are not at all sure that their substance use is really a problem are not likely to go to an addiction treatment facility looking for help. The real hope lies not in labeling and confronting patients aggressively, but in making treatment less threatening and more appealing to people in need. Psychologists are in an ideal position to offer low-threshold, low-intensity interventions that make it easier for reluctant, ambivalent patients to enter treatment. Unlike addiction treatment programs, office-based therapy attracts people in earlier stages of developing more serious problems as well as those still struggling with acknowledging and accepting that a problem already exists.

The important point here is that office practitioners have an important role to play in identifying early warning signs of emerging SUDs and intervening effectively to arrest the problem before it causes severe and possibly irreversible harm (Washton, 1995). Typically, by the time people arrive at an addiction treatment program their alcohol/drug problems have already progressed to the point of severe addiction and they have already suffered serious consequences that could have been avoided by earlier intervention. Many people with alcohol/drug problems seek professional consultation and advice from psychotherapists as a first step in trying to decide whether or not their substance use is really a problem and what type of treatment, if any, may be indicated. Accordingly, it is all the more critical for office practitioners to provide attractive low-threshold entry points for these patients.

Another advantage of treating SUDs in office practice is that it adds flexibility and choice to the menu of existing treatment options. Increased treatment options means an increased ability to match the treatment more precisely to the specific needs of each individual patient. Moreover, office practitioners are not constrained by agency policies, procedures, or other external controls over treatment philosophy and approach. There are no rules dictating which patients are admitted into treatment and how treatment should be done. To the contrary, office practitioners have the freedom and flexibility to decide what patients to treat and by what methods to treat them.

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Implications for the Training of Psychologists

Acquiring the clinical competence to address SUDs skillfully and consistently must become an integral part of psychologists’ education and training. The goal is not for every psychologist to become a substance abuse expert or specialist, but to insure that all practitioners acquire at least the core competence to recognize, evaluate, and address SUDs reliably in their patients. Miller and Brown (1997) state that effective treatment of SUDs is not a mysterious art- noting that scientific evidence points to the efficacy of therapeutic styles and treatment approaches that are well within the repertoire of many if not most psychologists.

So how can we make basic proficiency in addressing SUDs a standard part of psychologists’ clinical training and expertise? With regard to graduate training, specific steps for accomplishing this goal might include such things as: (a) offering elective courses and practica on substance abuse and its treatment; (b) integrating material about SUDs into existing courses in psychopathology, assessment, developmental psychology, personality, social psychology, and psychotherapeutic theory and approaches; (c) insuring that clinical supervisors make concerted efforts to teach interns and other trainees how to screen for, assess, and treat SUDs; (d) incorporating APA’s knowledge-based objectives for SUDs into graduate coursework and clinical training of psychology students; (e) incorporating techniques for assessing and treating SUDs into standard practicum training of all clinical, counseling, and educational psychologists; and, (f) creating specialty substance abuse tracks within practicum and internship placements including opportunities for mentoring and dissertation research in the etiology, treatment, and prevention of SUDs.

With regard to postgraduate and continuing education, many more clinical workshops and seminars focusing on the most current and effective methods for conceptualizing and treating SUDs should be held throughout the year at national and local conferences. In states with mandatory continuing education (CE) for psychology licensure renewal, a certain number of credit hours dedicated to SUDs should be made part of the CE requirement similar to existing requirements in many states on child abuse reporting and domestic violence (e.g., California instituted this requirement several years ago).

The American Psychological Association’s (APA’s) selection of substance abuse as the first area of clinical practice for proficiency certification is a highly noteworthy development and the most definitive action taken by APA thus far to both encourage psychologists’ greater involvement in this area and to identify those who already possess the requisite knowledge and skills. According to the APA College of Professional Psychology, proficiency certification in SUDs is designed to “provide a uniform national credential to licensed psychologists who meet eligibility requirements” and to identify those psychologists who have acquired the requisite knowledge and clinical experience associated with competent practice in the assessment, treatment, and prevention of psychoactive substance use disorders.” (For information about the proficiency certificate, contact: APA College of Professional Psychology, 750 First Street, NE, Washington, DC 20002-4242. Tel: 202-336-6100 Fax: 202-336-5797. Online at: http://www.apa.org/college.)

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An Urgent Call

There are many compelling, overarching reasons why all psychologists should have the competence to recognize, assess, diagnose, and treat SUDs in their clinical practices. Alcohol and drug problems are so prevalent, so destructive, and so intricately intertwined with other mental health problems and medical conditions that failure to address SUDs is likely to result in poor clinical outcomes and other adverse consequences. It can be argued that as integral members of the healthcare provider community, psychologists have a professional and ethical responsibility, perhaps even a mandate, to acquire the necessary knowledge and expertise in this area. Evidence strongly supports a view of SUDs as fundamentally behavioral and psychological problems that can be treated effectively by psychotherapeutic methods. Therapeutic skills commonly acquired by psychologists are associated with successful outcomes in substance-abusing patients. Given the increasing demand in the healthcare system for cost-effective community-based treatment of SUDs, psychologists with the requisite skills are in an excellent position to incorporate substance abuse treatment into the array of treatment services they already offer in clinical practice. Psychology training programs must insure that psychologists of the future are prepared to deal effectively with these highly prevalent disorders that often coexist with other mental health problems and contribute greatly to preventable human suffering.

References

Berg, I.K., & Miller, S.D. (1992). Working with the problem drinker: A solution-focused approach. New York: W.W. Norton.

Denning, P.(2000). Practicing harm reduction psychotherapy: An alternative approach to addictions. New York: Guilford Press.

Hester, R.K., & Bien T.H. (1995). Brief treatment. In A.M. Washton (Ed.). Psychotherapy and substance abuse: A practitioner’s handbook. New York: Guilford.

Imhof, J.E. (1995). Overcoming countertransference and other attitudinal barriers in the treatment of substance abuse. In A.M. Washton (Ed.). Psychotherapy and substance abuse: A practitioner’s handbook. New York: Guilford Press.

Institute of Medicine, National Academy of Sciences (1990). Treating drug problems. Washington, DC: National Academy Press.

Margolis, R.D., & Zweben, J. E. (1998). Treating patients with alcohol and other drug problems: An integrated approach. Washington, DC: American Psychological Association.

Marlatt, G.A., & Gordon, J.R. (1985). Relapse prevention. New York: Guilford Press.

Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.

Miller, W.R., & Brown, S.A. (1997). Why psychologists should treat alcohol and drug problems. American Psychologist, 52, 1267-1279.

Miller, W.R. & Rollnick S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Reiger, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264, 2511-2518.

Ross, H.E., Glaser, F.B., & Germanson, T. (1988). The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry, 45, 1023-1031.

Washton, A.M. (1989). Cocaine addiction: Treatment, recovery, and relapse prevention. New York: Guilford Press.

Washton, A.M. (Ed.) (1995). Psychotherapy and substance abuse: A practitioner’s handbook. New York: Guilford.

Washton, A.M. (in preparation). Substance abuse treatment in office practice: A psychotherapist’s guide to doing what works. New York: Guilford Press.

Washton , A.M., & Rawson, R.A. (1999). Substance abuse treatment under managed care: a provider perspective. In M. Galanter & H.D. Kleber (Eds.), Textbook of substance abuse treatment (pp. 545-552). Washington, DC: The American Psychiatric Press.

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This article appeared originally in the New Jersey Psychologist, Spring 2001.

Arnold M. Washton, Ph.D. is an addiction psychologist in private practice in New York City and Princeton, NJ. He has specialized in treating substance use disorders for over 25 years and is the author of numerous books on addiction and its treatment.

Address: 36 West 44^th Street, Suite 816, NY, NY 10036. (212) 944-8444

Email: Arnold Washton, Ph.D.

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