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Critical Appraisal of Studies and Reviews
A study of behavioral addictions conducted by Grant, Schreiber, and Odlaug (2013) provides insights into the process of the development of addictions. CBT and opioid antagonists are suggested as effective treatments for some addictions. These findings can be interpreted in the following ways: both pharmacotherapy and behavioral interventions are effective, but the underlining processes that connect different addictions (substance use and other dependencies) are not yet fully researched.
Lanza, Garcia, Lamelas, and González‐Menéndez (2014) compare the effectiveness of CBT and ACT (acceptance and commitment therapy). According to them, CBT was more effective when conducted posttreatment, while the ACT was effective at follow-up (Lanza et al., 2014). The following conclusions can be drawn from these results: depending on the phase of treatment, different strategies change in effectiveness; ACT might be more effective than CBT about long-term effects.
Carroll et al. (2014) examine the effect of computer-based training for cognitive-behavioral therapy (CBT4CBT) on cocaine-dependent individuals who are maintained on methadone. The authors argue that CBT4CBT can be an effective adjunction to the treatment of individuals addicted to cocaine, as participants who were assigned to this type of therapy were more likely to attain three weeks of abstinence from cocaine (Carroll et al., 2014). These results indicate that CBT4CBT is an effective intervention for individuals addicted to cocaine who are maintained on methadone, but they also show that the use of CBT4CBT needs to be supported by pharmacological intervention.
Filges and Jorgensen (2016) conducted a systematic review of randomized trials that compared CBT to other interventions to evaluate its effectiveness. The results show that CBT performs neither better nor worse than other interventions (e.g., Motivational Enhancement Treatment, Functional Family Therapy (FFT), etc.). Thus, other interventions can be used as effective substitutions of CBT. At the same time, CBT is more common in interventions that target individuals who suffer from substance abuse, and to make such interventions more effective, other types of treatment can be used together with CBT.
Carroll and Smethells (2016) study sex differences that influence drug seeking and drug abuse. According to them, hormonal conditions can increase or decrease (estrogen and progesterone respectively) cocaine and nicotine-seeking behavior (Carroll & Smethells, 2016). Using these results, one can conclude that hormonal conditions need to be taken into consideration when treating drug abuse. At the same time, as these treatments also target specific behaviors such as impulsivity, anxiety, depression, etc., it is possible to assume that interventions should focus on these behaviors to reduce the chance of recurrent drug abuse in patients.
Mohr et al. (2012) research the influence of telephone-administered vs. face-to-face CBT on patients of primary care. The study aimed to determine which type of CBT was more effective. According to the authors, both of these interventions were effective, but T-CBT was more effective in adherence, while face-to-face CBT provided better maintenance. Thus, it can be seen that in patients with poor adherence, T-CBT can be an option, but the recurrence of the condition or illness (depression, in this case) will also be more likely, which is unsuitable for Emilia and her goals.
McHugh, Hearon, and Otto (2010) examined the use of CBT and other supporting interventions in people with substance use disorders (SUDs). The authors found out that CBT and other interventions (such as pharmacotherapy) can provide better results than CBT alone (McHugh et al., 2010). Although these findings support the use of CBT, it can also be concluded from them that not all services are capable of providing combined interventions. Furthermore, not all interventions are tested thoroughly to support their effectiveness. Nevertheless, CBT is actively researched and tested currently, which makes its use more reliable.
DeVito et al. (2012) conducted a study about the neural influences of behavioral therapy among patients with substance abuse. The study indicated that improved task performance and cognitive control were present; the subthalamic nucleus (STN) was seen as a part that plays an important role in cognitive control. Thus, further research might find that medical interventions directed at STN will be effective in treating substance abuse in individuals. At the same time, as behavioral therapy is a basis for this research, its influence on changes in behavior is also high.
Witkiewitz, Bowen, Douglas, and Hsu (2013) suggest that mindfulness-based relapse prevention (MBRP) can be used for the treatment of drug craving among substance abusers. According to the authors, MBRP is effective because it focuses on creating awareness of the experiences and acceptance of them (Witkiewitz et al., 2013). Thus, the results of this study show that a different approach to drug abuse experiences can emerge in patients, helping them to cope with drug craving. At the same time, it is unlikely that MBRP will be effective in eliminating drug addiction in individuals with SUDs (i.e., Emilia), and thus other interventions that treat biological and affective symptoms are necessary.
Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) review a set of meta-analyses that focus on measuring and evaluating the effectiveness of CBT about different disorders (e.g., SUDs, anxiety disorders, personality disorders, etc.). The study identified that CBT was effective in individuals with nicotine and cannabis addiction, but less effective in those who were treated due to alcohol or opioid dependence. On the one hand, these results can be interpreted as supporting the use of CBT in individuals with different types of addiction, as CBT was not proven to be completely ineffective in alcohol/opioid dependence. On the other hand, if the addiction is accompanied by other comorbid conditions such as depression, anxiety, panic attacks, etc., CBT will be highly effective as it is used for the treatment of these conditions as well.
Selecting and Implementing the Intervention
The CBT was chosen as the primary intervention for the following reasons:
- It aligns with Emilia’s goals and desires about her drug addiction, i.e., she wants to start treatment, avoid using drugs, and overcome her addiction but cannot do it due to the reinforcing nature of drug use and resulting adherence to cocaine.
- The CBT will be accompanied by family therapy (home-based multidimensional family therapy) to support Emilia’s wish to improve and reconstruct her relationships with and ties to her family. Due to her decision to terminate a previous pregnancy, relationships with her family deteriorated significantly. MDFT will be effective in building cooperation between Emily and her family, improving relationships between relatives via behavioral changes (Filges, Andersen, & Jorgensen, 2015).
- Job education to ensure that Emilia can acquire skills (both practical and social) to find a suitable position and support abstinence from drugs.
Quantitative researches conducted by Carroll et al. (2014), Mohr et al. (2012), and DeVito et al. (2012) indicate moderate-to-high effectiveness of CBT in patients with SUDs. It should be noted that CBT that used a face-to-face approach or was conducted through different means (the Internet, telephone) was proven to be effective either way. The research conducted by DeVito et al. (2012) is especially significant as it indicates how the behavioral therapies influence patients’ behaviors by affecting parts of the brain (the subthalamic nucleus (STN) and midbrain and surrounding regions), thus indicating that these interventions are effective not only at psychological but also at physiological levels. The results of the study provided by Carroll et al. (2014) are significant because they show how CBT can serve as an adjunct to methadone maintenance therapy, thus emphasizing a pharmacotherapy + behavioral therapy approach. Mohr et al. (2012) notice that the medical professional’s decision to choose a type of CBT therapy (face-to-face or telephone-administered) will influence both the adherence and effect of the therapy, thus providing different opportunities that depend on patient’s and physician’s/nurse’s goals in treatment.
Qualitative research supports my decision to use CBT as a basis for treatment. Grant et al. (2013) indicate that the use of CBT is justified because it targets the underlying processes standard for many types of addictions, and its ability to change patient’s behavior aligns with Emilia’s goals to stop using drugs. The comparison of CBT and ACT by Lanza et al. (2014) is useful because it provides a critical view of CBT, at the same time pointing out why it might be effective in this case. The authors agree that CBT is effective at posttreatment, but argue that ACT is more effective at follow-up (Lanza et al., 2014). The effectiveness of CBT in this study supports the author’s decision to use it, but, at the same time, ACT can be considered as an option too if the use of CBT will be less effective than expected. Carroll and Smethells (2016) provide a thorough and detailed study about sex differences and their impact on behavioral dysfunctions, indicating that early exposure to alcohol or drugs can predict the development of drug abuse, which is relevant to Emilia’s case, as she was diagnosed with a SUD at an early age (<25 years old). Carroll and Smethells (2016) prove that behavioral dyscontrol is a factor common for different addictions (including substance and drug a), which supports my decision to choose CBT and other supporting implementations for Emilia’s treatment.
Interventions that I found unsuitable include pharmacotherapy only or behavioral therapy only approaches, as several studies indicate that if these ways of treatment are used separately, they are unlikely to be effective (Carroll & Smethells, 2016; Grant et al., 2013; Mohr et al., 2012). Brief interventions (<25 days) were also excluded as possible variations of treatment as both the 12-step program and CBT chose for the intervention require more time to provide the full effect.
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Measurable Treatment Goals
The identified treatment goals for Emilia concerned her abstinence from drug use, improvements in her relationships with the family, and socialization through education and acquisition of skills necessary for a job. They were chosen based on her objectives and goals. Perse, these concepts are unmeasurable; that is why I have created specific treatment goals that are easier to calculate, evaluate, and measure:
- Abstinence from drugs. At least three-week abstinence from drug use is expected during the first phase of the intervention (one month after the beginning of the treatment). A long-term goal, related to this one, is drug abstinence for one to two years after the full completion of the intervention cycle (12 months). As Emilia has a son, the disruptions in her abstinence from drugs will have negative consequences for her and her family. A calculated goal will be easier to follow and check.
- Rebuilt ties to the family. As the chosen CBT and family therapies rely on the participation of Emilia and her loved ones, the number of therapies attended (e.g., twenty out of twenty or three out of twenty) will be measured to see whether the goal was achieved. As the current number of therapies necessary for Emilia is yet unknown, it is estimated that if 60 to 75% of sessions are attended, the objective is completed. Is less than 60% of sessions are attended by Emilia and/or her relatives, the goal will not be achieved.
- Job education. Job education targets Emilia’s desire to gain social skills and find a job to support herself and her son. This goal relies on Emilia’s ability to attend educational training or workshops related to the occupation she is interested in. If Emilia chooses one or several training courses and attends them appropriately (e.g., visits 65-80% of the provided training sessions), the goal will be achieved. If less than 65-80% of the sessions/lessons are attended, the goal will be considered unachieved.
As can be seen, these treatment goals align with Emilia’s desires and are constructed in a way to ensure that both Emilia and I can measure them accurately.
To provide services effectively, a social worker needs to collaborate with different professionals who might be occupied in the area of public health, legal communities, faith-based institutions, education, etc. In the case of Emilia, a social worker will address her different needs by working with her family (relatives and the son), her supervisors in the public health (e.g., physicians and nursing professionals) who will monitor her detox program, and psychologists/psychotherapists who will provide CBT sessions to Emilia. It is also possible that a social worker will need to maintain contact with Emilia’s supervisors or manager in the job education area as her outcomes in this training will directly relate to her educational successes. The involvement of a faith-based institution is also likely.
A social worker will collaborate with public health, represented by a public health professional. In this case, both the social worker and the public health professional will be working on ensuring that Emilia’s detox program is completed effectively and on time. The public health professional might discuss specifics of the detox program and medication used with the social worker to outline their effects on Emilia.
A social worker might collaborate with a religious representative. If Emilia seeks spiritual counseling during her rehabilitation, a religious representative will be involved together with the social worker to monitor Emilia’s progress. The social worker can discuss Emilia’s goals with the religious representative to understand how faith-based institutions can influence them.
A social worker is likely to collaborate with Emilia’s supervisor or manager in job education. The educator will help the social worker track Emilia’s progress and point out areas of concern if any are detected. The social worker can also provide counseling to Emilia about her potential successes and failures at job education, discussing steps for active learning.
Practice Informed Research
The collected information can be used in research in several ways. First, it is important to conduct research that will compare the use of CBT in individuals with different forms of drug addiction (e.g., heroin, cocaine, methamphetamine, etc.). The results of such a study will indicate the possible effectiveness of CBT on different drug users. Second, the information collected in this research can be used in further research to understand how the treatment that consists of several (three, in this case) interventions affects the drug user’s abstinence from drugs. Further research can focus on the number of interventions preferred for treatment and rehabilitation of former drug abusers and use the results of this research as a starting point. Third, the patient’s desire to overcome the problem and reintegrate into society can also be useful for future research when evaluating the influence of motivation on therapy and medication adherence.
Practice can be informed by the research if the implications of this research are considered in other treatments involving CBT as well. For example, if professionals will apply CBT and family therapy with other patients who have a similar medical history, their practice will be informed by this research. The use of face-to-face and/or telephone-administered CBT can also be considered by other professionals when using CBT in their practice, as these methods provide different adherence and maintenance of the therapy. If other researchers and medical professionals are unsure whether they should implement CBT and family therapy simultaneously when treating individuals with drug addiction, they can rely on the information from this research to determine the effectiveness of such a combined technique.
As research on the use of CBT indicates that it might be ineffective in centers where the personnel is unqualified for providing such services, policymakers need to create a policy that will regulate the diffusion of CBT and rehabilitation-based services in metropolitan and rural areas. Another aspect of the research essential for policymaking is the collaboration between different professionals and their influence on treatment. Future policies can regulate the cooperation among social workers, educators, medical professionals, legal advisors, etc. that targets individuals with drug addiction and treatment provided to them. A research-informed policy will emphasize the necessity of such collaborations and their effectiveness compared to interventions led by one professional instead of a group. Emilia’s desire to reintegrate is a factor that needs to be taken into consideration by policymakers. In this case, her motivation can be used as proof that people with drug addiction need to be protected from stigmatization legally, via specific policies that regulate opportunities (occupational, educational, etc.) available for such people who want to stop using drugs.
Social service delivery can use the collected information to understand what measures can be used to prevent drug use in communities. First, interventions based on the methods proposed in this research can be used by social workers to reduce the recurrence of drug use in their communities. Second, social workers can evaluate the use of other techniques depending on an individual case, using comparisons of CBT to other therapies presented in this paper. Third, social service delivery can use this information to improve communication with current drug users, pointing out opportunities that can help them overcome their addiction.
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