“When doing therapy with a drug-addicted patient, must I know what neurobiological changes have occurred in the brain as a result of addiction? Can therapy undo permanent brain damage, that would otherwise forever cripple the patient when it comes to the urge for alcohol?” Thanks to Rikke for these interesting questions.
Ordinarily, we don’t do exploratory therapy with any drug-addicted person until he has been in recovery for at least a few months. Why? For many drug addicts, drugs are a defense against experiencing feelings and anxiety. If you explore feelings and anxiety beyond the patient’s capacity to bear them, his defenses against feeling will fail and he will resort to drugs to numb out his feelings because his defenses no longer do the job.
Thus, for many drug-addicts it’s best to begin with supportive therapy using motivational interviewing techniques and the research of the process of change group. Your supportive therapy with an active user will help him begin to see that his drug use is a problem and motivate him over time to reduce his usage of alcohol or drugs. Goals here are complicated.
In the U.S. abstinence is considered the only real practical goal for alcoholics. However, in the U.K a considerable amount of research into harm reduction has found that many alcoholics can be helped to reduce their use of alcohol to levels that are no longer harmful. Given these various positions in the field, I suspect that some patients may benefit from a harm reduction strategy, and that others may need to be abstinent in order to maintain their recovery.
Once the patient is in rehabilitation, a more exploratory therapy can be very helpful for many drug-addicted patients. In my DVDs of the fragile patient and the patient who uses projection, you see how to work with the regressive defenses that often come up with drug-addicted patients.
However, having said that, don’t forget that drug-addicted patients can be anywhere on the spectrum of psychoneurosis. Some are psychotic, some have a borderline level of character pathology, and some have neurotic conflicts. Thus, you need to assess each patient on an individual basis so that you know how to regulate the patient’s anxiety, and which defenses you will need to restructure. I always begin with the graded format with drug-addicted patients because I want to assess the patient’s anxiety and affect tolerance and self-observing capacities first. Then I work to gradually increase the patient’s capacities. If you get too high a rise of feeling, anxiety, or regressive defense, the patient will be at risk of relapse. Thus, ask about feelings, build the capacity for anxiety regulation, and help the patient see and let go of regressive defenses. Go slow.
In the average clinic, we do not have access to good instruments to assess the degree and type of brain damage patients have from drug use. Many patients begin to function better over time as their bodies detox during a period of abstinence. However, we can assess where the patient’s anxiety is discharged. We can also assess the patient’s ability to see his defenses and their price. At this stage of assessment, we may find that the patient’s ability to regulate anxiety is so poor, that his cognition is impaired. On the other hand, we may find a patient whose anxiety is well regulated and his cognition is impaired. In that case, we have probably some brain damage. In that case, proceed very slowly and make sure the patient always understands what you say.
Certainly, with good anxiety regulation, and building of other capacities, we see improvements of neuroplasticity of the brain. With patients who suffer brain damage, their progress will be slower and may be quite limited. However, I have found that some brain-damaged patients benefit from an additional treatment to psychotherapy known as Low Energy Neurofeedback System, or LENS. Many patients who receive this neurofeedback treatment or others report a great drop in anxiety physically which results in a drop in the need for substances to regulate their bodily discomfort and, as a result, they become far less impulsive. The research on this method is fairly limited, however, I have found it very useful for anyone suffering from brain damage to consider this option as an adjunct to psychotherapy.
Take home point: do supportive therapy with active drug users. Once the patient is abstinent, you can use the graded format to gradually build the patient’s affect tolerance, anxiety regulation, and restructure regressive defenses. Always avoid excessive rises of feeling, anxiety, and regressive defenses to avoid precipitating a relapse in the patient.