Adapting Standard CT for Depression

As one would expect, the application of CT for depression with comorbid substance abuse/dependence entails certain considerations that go beyond the treatment methods for depression alone. Some of these considerations have to do with a patient's (1) aversion to admitting, discussing, or otherwise ameliorating the substance abuse problem; (2) markedly reduced ability to utilize the psychological skills learned in session when he/she is chemically impaired outside of the session; (3) maladaptive belief that alcohol and other drugs are effective and necessary palliatives for his/her depression; and (4) misuse of 12-step principles to counteract some of the tenets of CT. These four considerations, which do not represent an exhaustive list, are expounded upon below.

Patient Aversion to Discussing the Substance Abuse Problem

Many patients who are willing to discuss their clinical depression openly with their therapists are far less eager to address their use of alcohol and other substances. For example, I once treated a patient who proclaimed vehemently that she would leave therapy if I "got on a high horse" and brought up her use of alcohol. Rather than insist on talking about her alcohol abuse on the spot, or (conversely) capitulate to a countertherapeutic demand to remain indefinitely silent about an important clinical issue, I tried to find an entry point into a productive therapeutic dialogue. Thus, I commented on the patient's assumption that I would "get on a high horse," noting how acting in such a manner would be at odds with the collaborative spirit of CT to which I was committed, and explaining that I was prepared to discuss all the patient's agenda items respectfully, with the intent of improving her overall functioning and quality of life.

Some patients are unmoved by such comments, and may in fact abandon therapy rather than face an issue they would prefer to avoid. This puts the therapist in a bind, because it is not a good idea to collude with a potentially dangerously incomplete therapeutic agenda, nor is it favorable to lose the chance to establish a productive working relationship with the patient, and have him/her leave therapy and receive no treatment whatsoever. At such times, it is useful to refer to the "stages of change" model in the field of addictions treatment (Prochaska, DiClemente, & Norcross, 1992), which spells out the methods of working with patients in a "precontemplative" stage (before patients even consider changing their behavior) or a "contemplative" stage (when patients start to think about changing but are not yet taking active steps). The goal involves "meeting the patients where they are," such that a therapeutic relationship can be established and strengthened. In doing so, therapists increase the likelihood that the work of CT will move toward successively later stages of change (e.g., preparation, action, maintenance), enabling both parties to deal actively with the problems related to patients' chemical dependence.

This is an imperfect solution, because there is no guarantee that patients will advance in their level of readiness to discuss their substance abuse, and the damage caused by their addiction may be worsening in the meantime. Nevertheless, for patients who are steadfast in their wish to talk only about their depression, and not about alcohol and other drug use, the stages of change approach may offer the best hope of breaking through, so that all topics may eventually be put on the table. In the early stages, the therapist can tread lightly, while recommending that the patient keep a log of his/her drinking or use of other drugs, "just to take some data," with no explicit demand for reductions. The automatic thoughts elicited by this self-monitoring exercise (or by its being assigned) can further serve as useful points of intervention, even if the overtly stated goal does not specifically target changing the patient's addictive behaviors.

Patient Impairment Interferes with Utilization of CT

As psychoactive chemicals alter executive cognitive functioning, patient's ability to use the psychological skills they learned in CT is likely hindered when they are actively drinking and using. For example, the patient who is able to complete a Dysfunctional Thought Record (DTR; see J. S.Beck, 1995) in session may be helpless to generate alternative responses to depressogenic thoughts while sitting at home in an inebriated state. Similarly, the patient who is able to use problem-solving skills in session to weigh the pros and cons of an important decision may impulsively act unwisely when high on drugs during the weekend. Most dangerously, the suicidal patient who—while sober in session—agrees to a set oftherapeutic strategies to keep him/her safe may be rendered incapable ofstaying with this critical program when drunk, or when coming down off a cocaine or amphetamine high. As one therapist told his patient, "I trust your sober mind, but if you're drinking or drugging, I have much less confidence in your brain functioning, and in your ability to stick to our agreements for safety."

One of the ways to increase the likelihood that a chemically impaired patient will be able to use his or her CT skills in the midst of a depressive crisis is to prepare self-help materials in advance of such a situation. For example, patients can make audiotapes in which they give themselves well-reasoned instructions on what to think about to resist doing any number of tempting but harmful things. This tape can also include words of encouragement to stay the course of treatment, even under adverse circumstances and when experiencing cognitive impairment and emotional dyscontrol while under the influence. This method is based on the principle that pas sive recognition of the proper course of action requires less concentration and focus than the free recall of such complex information. Patients should have their audiotapes, written reminders, important phone numbers (for emergency contacts), and other such therapeutic "props" out in the open, so that they are easily spotted. Adding to the self-help materials on a regular basis makes them an ever-expanding "rainy day journal."

Patients' Use of Substances to Self-Medicate Their Depression

Some patients express the belief that alcohol and other drugs are "the only things that work to help me cope with my depression." They resist the idea that the substances are part of the problem, and defend their need to drink and use to "take the edge off" their sadness and forget about their problems, even if just for a little while. Therapists can empathize with patients' desire to use whatever palliative they can find to alleviate their emotional suffering, but they also offer psychoeducation about the vicious cycle of mood disorders and chemical dependence. A patient might argue that if the therapist's point of view about chemical substances has merit, then ADM should also be seen as problematic in dealing with depression. The therapist can quickly point out that ADM does not impair the patient's judgment and behaviors, but does improve the patient's mood in a steady, gradual, nonaddictive way, and is designed to improve the patient's health, satisfaction, and ability to interact effectively with family and society at large.

Of course, therapists cannot simply suggest that patients give up their preferred method of coping without working with them toward new, healthier means of dealing with the depression. Therapists can acknowledge that the noticeable effects of these new methods may not be as immediate as (for example) taking a shot of whiskey, but that they are more enduring, less problematic, and more able to engender an increase in self-efficacy, which has been found to be associated with positive outcome in treatment (Ramsey, Brown, Stuart, Burgess, & Miller, 2002).

Patients' Misuse of 12-Step Principles to Counter the Spirit of CT

Patients with comorbid depression and chemical dependence sometimes attend a 12-step facilitation group (12SF) in conjunction with their CT. By and large, this can be a very positive thing, because 12SF (e.g., Alcoholics Anonymous [AA], 1976) offers valuable social support to people who often feel alone or believe they have burned their bridges with others. Unfortunately, there are times when patients engage in all-or-none thinking about the tenets of AA and similar groups, to the detriment of their participation in CT.

For example, Step 1 involves admitting powerlessness in the face of the addiction. The purpose ofthis step is to break through denial and to humble oneself in the presence of a problem whose scope must be acknowledged in order to be overcome. Unfortunately, some people take this "powerlessness" concept to its extreme, to the point of dismissing the idea of learning coping skills and building self-efficacy as a sort of self-delusion that is at odds with an honest admission of having an addiction. Cognitive therapists help their patients to think more creatively and flexibly about how the concepts of "powerlessness" and "self-efficacy" actually can be complementary. The pow-erlessness has to do with the old methods of supposed coping that have failed again and again, such that the objective evidence cries out for broad, sweeping change. The self-efficacy skills are about having the courage to change, and to learn new ways of coping. There is nothing inherently contradictory about respecting the overwhelming power of an addiction, while also striving to grow, to learn, and to gain well-founded confidence in living effectively.

Another way that patients spuriously pit 12SF against CT is by implicitly rejecting the importance and relevance of concepts such as "harm reduction" (Marlatt, 1998) and "the abstinence violation effect" (Marlatt & Gordon, 1985). Such patients fear that their cognitive therapists are missing the point when they try to help them decatastrophize their lapses into substance use. These patients believe that any slip into drinking and drugging is in fact a straight path to catastrophe, and these patients bristle at the notion that they can learn from the slip, contain the scope of the lapse, and stay committed to abstinence as the ultimate goal. In such cases, the cognitive therapist can confirm that they too believe that abstinence is the preferred outcome of treatment. However, there is little evidence that engaging in catastrophic, all-or-none thinking is beneficial to treatment of clinical depression, and to one's sense of hope in continuing to "fight the good fight" toward sobriety. In fact, some patients who adhere to the all-or-none model actually pervert the spirit of the 12 Steps by giving themselves permission to go on a binge or a bender in response to a minor slip, reasoning maladaptively that they have blown their sobriety, period, and that degree is immaterial. Thus, we have a self-fulfilling prophecy of "one drink equals a drunk."

By contrast, the cognitive model posits that patients who experience a slip do not have to fall prey to the abstinence violation effect (Marlatt & Gordon, 1985), in which their distress over breaking their abstinence leads to further self-medication, thus worsening the slip and leading to a downward spiral. Instead, patients can view each incremental use of the drink or other drug as a new decision, which may at any time be "no more using" (Beck et al., 1993). Thus, the vicious cycle of using, hopelessness, self-reproach, self-medication, and further hopelessness can be broken before too much damage is done. When this occurs, the similarity and congruity between 12SF and CT in response to a lapse are readily apparent: Both models now view the patient as being in a "high-risk situation," in which a renewed commitment to getting help for the addiction is the highest priority.

Supplementation of Standard CT for Depression

Additional intervention modalities (beyond CT) for the depressed patient with a substance use disorder include pharmacotherapy, detoxification (either outpatient or inpatient), family interventions, and group therapy, including 12SF. All of these modalities are compatible with outpatient CT, provided that the various clinicians involved do not denigrate each other's treatment approach to the patients, even subtly.

Pharmacotherapy for Depression

Some patients who are in CT for their depression are concurrently on ADM. Patients receiving psychopharmacotherapy are typically told that it is best that they not consume alcohol (or, at the very least, that they restrict their drinking to a minimum) while taking ADM. Unfortunately, patients with depression comorbid with alcohol and other substance abuse are prone to disregard such medical advice. The likely result is that the medication(s) will be rendered less effective, and/or that there will be potentially harmful pharmacological interactions (Evans & Sullivan, 2001). Either way, patients may grow disenchanted with their ADM and assume that it is not working, or that it is causing even more physiological distress.

All too commonly, therapists are taken by surprise upon learning that a patient has discontinued his/her ADM, often well after the fact. To safeguard against this, a therapist can routinely inquire about the patient's use of the ADM and ask sympathetically about any difficulties, while also assessing whether the patient is actually adhering to the prescribed regimen.

Some patients harbor maladaptive beliefs about their ADM. Thus, cognitive therapists should inquire about patients' views about their phar-macotherapy, and highlight any problematic assumptions patients may be making that may interfere with treatment. For example, when "Len" flatly stated that his ADM was "useless," his therapist noted that it would be possible to give the ADM a fair assessment only after Len discontinued use of all other psychoactive chemicals (in his case, alcohol and marijuana), then observe his response to the ADM over a period of weeks and months. Len did not immediately get the point—that what he viewed as recreational substances were actually central nervous system depressants, and that he was not giving his ADM a fair chance to play a positive, therapeutic role. Len's therapist said, "I am deeply concerned that you are willing to give up taking the chemicals that are potentially therapeutic, while you are determined to continue taking the chemicals that are worsening your psychological and physiological condition."

Although a review of the specific psychotropic medications that are appropriate for depressed patients with substance use disorders is beyond the scope of this chapter, a few general comments are pertinent. For example, Evans and Sullivan (2001) emphasize that these patients are not good candidates for sedating medications, whether they be benzodiazepines or ADMs with soporific qualities. Among the medications that do not pose the risk of abuse, SSRIs are often a popular choice, because they are very safe in case of overdose and are easy to use. Presenting an alternative view, Rounsaville (2004) reviewed the extant randomized controlled trials on ADM for comorbid depression and cocaine use, and found more favorable results for medications such as desipramine and bupropion than for SSRIs.

Pharmacotherapy for the Substance Use Problem Per Se

For alcohol use disorders, disulfiram (Antabuse) can be an important part of the treatment regimen (Carroll, Nich, Ball, McCance, & Rounsaville, 1998). Disulfiram treatment generally requires direct supervision by either a clinician or a close family member of the patient. In the early years of disulfiram use some fatalities occurred, such as when a patient would engage in binge drinking while taking high doses of the medication. Today, the standard doses have been lowered considerably, thus reducing the risk to negligible levels. When the treatment is working properly, the patient is deterred from drinking alcohol because of the expected, noxious physiological effects produced by its interaction with disulfiram.

Opiate antagonists, such as naltrexone, can also be helpful adjuncts for the dually diagnosed, depressed individual who is seriously committed to sobriety and wishes to reduce the cravings (for alcohol, opiates, and other drugs) that produce high risk for relapse (Anton et al., 1999; Petrakis et al., 2005). As with disulfiram, naltrexone has the best chance of success if its use is supervised. A further pharmacological option for the patient who is dependent on opiates is methadone maintenance therapy. Although data are lacking as to the efficacy of this treatment with dually diagnosed patients, there are no well-established contraindications (Mueser et al., 2003).

Pharmacological detoxification is an additional option for those patients who seem unlikely to stop their use of alcohol and other drugs, even when motivated to change and given adequate social support. This can be performed on an outpatient basis or, alternatively, in an inpatient setting, especially when detoxification entails medical risks. When benzodiazepines are used, doses need to be kept moderate.

Support Groups, 12SF, and Family Interventions

People with substance abuse or dependence often find that there is subtle (and not-so-subtle) social pressure to continue drinking and drugging. Even when persons who use alcohol and other drugs receive disapproval at home, they often find acceptance in a peer group that collectively "gives permission" for such behavior (Alverson, Alverson, & Drake, 2001). Patients sometimes complain that if they relinquish their substance use, then they will no longer have friends (Beck et al., 1993). Thus, it can be very useful for patients to take part in support groups (e.g., 12SF; National Alliance for the Mentally Ill; Rational Recovery, Trimpey, 1996) or more formal therapy groups designed to provide social support and psychological tools for achieving and maintaining sobriety (see Mueser et al., 2003). Groups that are not developed in an inpatient setting often have flexible schedules, so that people can attend sessions even if they work full time, and provide a rational answer to those patients who state that they "don't have time" to take part.

Although the 12SF has not been subject to empirical evaluation for the depressive aspect of the dual diagnosis, there has been some support for its effectiveness in reducing the addictive behaviors, thus making it a viable supplemental treatment to CT (Morgenstern, Labouvie, McCrady, Kahler, & Frey, 1997; Ouimette, Finney, & Moos, 1997).

Families play an important role in the lives of persons with dual disorders, for better or worse. For example, the family can serve as vital sources of support for a patient who is feeling ashamed and hopeless. There is ample evidence that the adverse effects of family stress and conflict (centering on a person's mental illness and/or chemical dependence) are bidirectional, with both the patient and the family exhibiting deterioration in functioning and quality of life (e.g., Dixon, McNary, & Lehman, 1995; Fichter, Glynn, Weyer, Liberman, & Frick, 1997). Thus, there is much at stake in trying to help coordinate care between patients and their families in an optimal way.

Descriptions of family-based treatment approaches along with supporting empirical evidence, can be found in Mueser and Glynn (1999).

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