Treatment Issues

The more complicated the clinical picture, the more important the therapeutic relationship and a well-formulated case conceptualization in maximizing the utility of the structure and techniques that comprise CT. This point is quite salient with depressed patients who also have problems with alcohol and other drugs, many of whom may be put off by the therapist's focusing on their drinking and/or drugging, thinking it is accusatory, irrelevant, stigmatizing, and a sign that the therapist "doesn't understand." The therapist often has to engage in a delicate balancing act, on the one hand being tactful, caring, and cautious in bringing up "hot topics" such as chemical dependence, and on the other hand being flexible enough to respect the patient's alternative agenda to preserve the ongoing working relationship. Because premature dropping out of treatment is a significant problem in a substance-abusing population (Siqueland et al., 2002), the therapist has to develop a repertoire of assessment questions and interventions that are empathic, clear, and collaborative, and that give the message that the patient's problems are understood well, without personal judgment.

The specific techniques of CT for depression (e.g., Moore & Garland, 2003) and for substance-related disorders (Beck et al., 1993), are well-articulated in a comprehensive fashion elsewhere and are beyond the scope of this chapter. However, it is important to note some of the particular adaptations to CT for depression that clinicians must consider to deal effectively with dually diagnosed individuals, as summarized below.

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