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Interestingly, the research found that all people are not affected similarly by alcohol or drug abuse.  For some the cognitive centers of the brain are more affected, for others the emotional centers are more affected.  And for some both centers are affected.  This has profound implications for treatment.  One treatment does not fit all abusers.  There is no magic bullet.  In order to determine the best fit for any given individual, a complete psychological history and history of abuse and treatment must be taken.  This places the individual into a context in order to decide what approach or approaches may be most beneficial.

Most treatment approaches agree that that the focus of treatment must be on the cessation of substance abuse.  Even those experts who believe that it is possible for the alcoholic to learn to drink in moderation suggest that cessation for a period of time in the beginning of treatment is necessary in order for the patient and clinician to develop a clear picture of the role alcohol plays in the individual’s life.  Most approaches, however, have abstinence as their goal, especially for those individuals who have a family and personal history of chronic abuse.

The following are some of the current treatment approaches for substance abuse:

·    Individual skill-based treatments: these approaches help clients interact more effectively with others without using alcohol or drugs.  These approaches focus on coping and skills training to help clients quit or decrease abusing alcohol and drugs by teaching them strategies to address interpersonal, environmental and individual “skill deficits” that may provoke substance abuse.

·    Motivational Enhancement Treatments: this approach is based on a model that encourages patients to explore the consequences of drinking in a supportive, nonthreatening environment.  One technique, called motivational interviewing, asks patients what about their alcohol or drug use causes them difficulties, enabling clients to examine their habits objectively.  Once clients see how substance abuse or dependence affects their lives, they are motivated to change.

·    Cognitive Behavioral Treatment:  CBT states that human behavior is learned through personal experience and cognitive thought patterns.  Changing behavior requires learning how to think differently about situations and how to change dysfunctional behaviors that cause problems.  Alcohol dependent people have learned to drink in response to specific situations.  The treatment task is to identify the “alcohol triggers” and then apply techniques to develop new ways of thinking and new behavioral skills for coping with these triggers.

·    Environmental and relationship-based treatment: in this approach family members and significant others are taught coping skills and strategies to help influence their loved one’s drinking and motivation to change.

·    Behavioral marital and family treatment: this approach works with both the individual and the spouse or family to decrease or eliminate abusive drinking-related consequence.

·    Twelve-step programs: these inpatient or outpatient programs are based on the 12-step model of Alcoholics Anonymous except that professionals lead them.  Some professionals in private practice also use such a model, while other practitioners use AA to supplement and support the work being done by the patient in individual treatment.

·    Medications:  Two medications disulfiram and naltrexone have been approved by the FDA for alcoholism with a third showing promise, acamprosate, which is pending approval. Naltrexone appears to be most effective with fewer side effects.

As mentioned previously, no one treatment is effective for all substance abusers.  Several variables must be taken into account in order to find the treatment that is most effective for any given person.  Such factors as duration of addiction, family history, degree of substance abuse, extent of disruption in the patient’s life, health, degree of motivation, to mention the most obvious, must be evaluated.

The first step in the treatment of substance abuse, after collecting a complete psychological, health, and substance abuse history, is to focus on harm reduction.  If an individual is placing him or herself, or his or her family, in immediate danger, action must be taken to reduce the impending danger.  Sometimes this may require inpatient treatment and sometimes it may involve the entire family.  It requires developing a plan of action that can be implemented quickly.  The focus during the early sessions is on changing the addictive behavior.  In order for treatment to be effective, the individual must be sober.  That is the first goal.  Staying sober is the bulk of the work.  Once sobriety has been achieved, treatment can focus on helping the patient restructure his or her thinking, behavior, lifestyle, and focus.  Maintaining sobriety becomes a top priority especially in the early stages of treatment.

Frequently substance abusers have personality difficulties in addition to their addiction.  Such concurrent psychological problems as depression, anxiety, social phobia, low self-esteem and other such personality issues, need to be addressed as well as the addiction.  Alcoholics and drug abusers often use various substances as a form of self-medication to help them cope with these issues.  In treatment, however, we first focus on the substance abuse and then work with the personality issues that may coexist. Sobriety or harm reduction is the immediate goal.


Our typical image of an addict is someone in a back alley shooting up or a drunk tottering on the street.  This depiction is grossly misleading.  Addicts are often professionals in high-powered positions.  They are surgeons, judges, lawyers, dentists, CEOs, business owners.  They are making decisions that affect the lives of thousands of individuals and costs millions of dollars in lost productivity and through faulty decisions.  Too often, these people are in denial about their abuse and do not recognize the extent to which they are cognitively impaired.

There is no one cause for substance abuse and no one treatment. Substance abuse is a biosocialpsychological problem.  Genetic predisposition may be more of a factor in one individual than another.  The role of brain chemistry and genetics is different from person to person.  Social and psychological influences likewise vary.  Hence, treatment must be tailored to each person.

The first priority in treatment should be harm reduction with eventual sobriety.  When the individual is “clean and sober,” s/he can collaborate in his or her treatment with full mental acuity.  A treatment plan can then be devised and a determination can be made as to what factors are influencing the abuse. Then a decision can be made as to whether moderate drinking, in the case of the problem drinker, is possible. Some approaches, however, such as AA, believe that abstinence must be a lifetime commitment. Other approaches suggest that moderate drinking is possible for some alcoholics.  In either case, a thorough evaluation is necessary and sober brain is required to make that decision.

[Please add your thoughts and experiences on this topic in the comment section of this blog.  This blog is intended as a forum for folks to raise issues, share experiences, and promote dialogue on important issues of contemporary life.   Please sign up as a Facebook Fan at www.docdreyfus.com/fanpage. For additional information about me and my practice, please visit my website at www.DocDreyfus.com.]