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EDITORIAL

Guidelines for psychosocial interventions in addictive disorders in India

An introduction and overview

Murthy, Pratima

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doi: 10.4103/psychiatry.IndianJPsychiatry_35_18
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Abstract

INTRODUCTION

There is a Dickensian irony in the current situation assessment in the area of addiction. The remarkable progress in elucidating the processes and mechanisms underlying addiction has been stymied by the growing problem of substance use disorders, behavioural addictions, newer psychoactive substances, newer addictions and newer populations developing addiction.1 Contemporary conceptualization of addiction views it as an interaction between the individual's biology and the environment.2 In addition to vulnerability, a good understanding of the effects of substances and addictive behaviours on the body and mind, a good understanding of available interventions, the importance of family support and follow-up support are all important in restitution and recovery in addiction, which can be best conceptualized as a complex hydra-headed problem.3

The broad principles of effective treatment for addictive disorders suggest viewing it as a complex but treatable disorder; ensuring that treatments are available; individualising treatments; having effective treatments that address the multiple needs of the affected individual; retaining the affected individual in treatment for an adequate period of time; making available therapies which motivate a person to change, providing incentives for abstinence, building skills to resist the use of drugs or problem behaviours, replacing drug use or problem behaviours with constructive and rewarding activities, improving problem-solving skills and facilitating better interpersonal skills; combining medications and a comprehensive behavioural treatment programme; continually assessing and modifying the treatment according to the individual's changing needs and treating co-morbid physical and mental disorders.4

Many of the programmes and guidelines for psychosocial intervention in India are not readily available in the public domain, or have not been adequately tested for efficacy in the clinical or community settings.

The impetus for developing psychosocial interventions

The therapeutic nihilism that tended to colour professional attitudes in treating persons with addictive disorders in the past has given way to a more optimistic belief in the ability of persons with addiction to change when provided timely and continued support; positive and non-judgmental attitudes to persons with addictive disorders and a better understanding of the chronic and relapsing nature of such disorders. Most importantly, the need to look at the treatment of addiction in a human rights framework and treat the affected individuals with dignity5 has also influenced the development of interventions for persons with addictive disorders. The huge treatment gap of about 86% for alcohol use disorders6 and the huge shortage of mental health human resources7 have fueled the need to explore community interventions for these disorders.89 The challenge for substance use is to have both population- based interventions and clinical interventions which prevent progression from misuse to dependence and reduce risk for non-communicable as well as communicable disorders.101112 In addition, it is also important to develop person-centred comprehensive interventions. As with other chronic, relapsing conditions, after-care support and relapse prevention become critical components of such comprehensive interventions.

Early psychosocial intervention guidelines

The early intervention guidelines for the treatment of addiction were largely guided by clinical expertise, experience and adaptation of the available evidence. The most popular evidence base for psychosocial interventions for addictive disorders have involved cognitive-behavioural approaches, motivation enhancement approaches and relapse prevention approaches13 and guidelines in India have also incorporated these approaches.

In the 1990s, the UNODC developed a set of pamphlets for use by non-specialist health professionals covering the following areas: assessing a person with drug dependence; building a new future in recovery; individual counselling; the role of the family in addiction enabling; the role of the family in providing support in addiction recovery and the treating professional in support of such families; aftercare as an important component of addiction management (and not as an ‘afterthought’); crisis intervention; relapse management and community intervention.14

Alongside these activities, seminal work has been done in the area of psychosocial interventions. The camp approach, popularized by TTK,15 has been effectively used in a variety of settings in India.161718 The need for community-based aftercare, based on the expertise of organizations working in this area led to an emphasis on community-based intervention and follow-up. Follow-up care has been shown to improve retention in both tobacco cessation19 as well as in alcohol dependence.20

Guidelines for the management of substance abuse disorders (including addressing the psychosocial issues) for medical officers were developed by NIMHANS,21 NDDTC, New Delhi22 and other institutions, and have included a manual of practice for brief interventions.23 Manuals have been available for the training of counselors, particularly in family and group interventions.24

About a decade back, as part of a WHO-Government of India collaboration, the De-Addiction Centre (now the Centre for Addiction Medicine) at the National Institute of Mental Health and Neuro Sciences developed a dedicated manual on psychosocial interventions for persons with substance use, outlining both the theory underlying these interventions and their practice in clinical and community settings.25 This manual was primarily intended for physicians, who can often, in their busy clinical practice, are tempted to prescribe a plethora of pills rather than combine them with either a brief but effective psychosocial interventions, or network with other professionals for a more intensive intervention. The topics covered in this manual were diverse, and reviewed the planning of psychosocial interventions; models of brief intervention; motivation enhancement; relapse prevention; follow-up and aftercare; group interventions; family interventions; providing extra-treatment support; community level interventions and the opportunities and challenges in providing psychosocial interventions.

Guidelines for psychosocial interventions based on needs

Intervention guidelines have also been developed for women with substance use disorders, including women injecting drug users based on their assessed needs2627 Similarly, intervention guidelines for children with drug use have also been evolved based on a needs assessment.28

Tobacco cessation initiatives in the south-east Asia region have gradually intensified following the Framework Convention on Tobacco Control, of which tobacco cessation support forms an important component. Counselling manuals for doctors and dentists29 as well as for community health workers30 to psychosocially assist their cessation attempts have been developed for the South-East Asia region. National tobacco cessation guidelines include a major component of psychosocial interventions.31

Psychosocial interventions have a role not only for addiction, but harmful patterns of substance use, particularly that of tobacco and alcohol as risk factors for non-communicable diseases (NCD). The WHO country office has supported the formulation of psychosocial interventions to reduce the preventive risk factors for NCDs, which include, apart from tobacco and alcohol cessation, to interventions for unhealthy diet, physical inactivity, indoor air pollution and stress. These intervention guides are available for medical officers, counsellors and community health workers.

Recent manuals and psychosocial intervention guidelines

During the last decade, several attempts have been made to develop and test manuals for their effectiveness in the field. Some examples of these include a manualized intervention developed at NIMHANS for couples has been shown to be associated with better clinical outcomes as compared to treatment as ususal.3233 A manual has been developed and tested at NIMHANS, with support from the Indian Council for Medical Research (ICMR), to provide psychosocial interventions for women partners of men with alcohol used disorders.34 Further areas of focus are to develop interventions for specific issues like anger management, which can be effective in reducing risk to relapse.35

In more recent times, work from Sangath has demonstrated the effectiveness of psychosocial interventions by lay counselors for persons with alcohol use disorders,9 with a manual developed for this intervention.36

Workplace based interventions for preventing and addressing substance use disorders have a significant psychosocial component and have shown to be successful in a variety of settings.20 The drawback has been the lack of empirical data in this area, although there is a large workplace prevention programme in Karnataka37 which showed substantial benefits for the affected individuals and organisations. A large newspaper publisher subsequently supported the documentation of guidelines to workplace well-being, with a primary focus on substance use prevention and management.38

In addition to manuals and treatment guidelines, studies in India have discussed the still very low levels of identification of substance use disorders in health care,39 barriers to care for substance use disorders in diverse populations like injecting drug users and women.4041

An introduction to Clinical Practice Guidelines for psychosocial intervention in addictive disorders

The Indian Psychiatric Society has recently brought out clinical practice guidelines for the assessment and management of substance use disorders as well as the management of newer and emerging addictive disorders in India.4243. There are also detailed speciality-led descriptions of comprehensive psychosocial intervention in substance use disorders.44

This supplement has been conceptualized in different sections to provide the readership recommendations on the assessment in addictive disorders (Section I); describe various approaches to therapies in addictive disorders (Section II); discuss innovative approaches and some special populations that need specific focus (Section III); highlight community-based approaches to addictive disorders (Section IV) and finally discuss the ethical issues and need for research development in the area of addictive disorders (Section V). Case vignettes are introduced in many of the articles to illustrate steps in assessment and management.

Assessment in addictive disorders

The introductory article begins with the changes in the perception of addictive disorders and the harmful myths and misconceptions that lead to resistance to treatment seeking. It emphasises the need for a bio-psycho-social approach, and attempts to dispel the myth that all such interventions are time consuming and require highly specialized training. It describes the range of psychosocial interventions from initiation of the intervention to rehabilitation. The broad principles of addiction management are discussed, as are the challenges in the delivery of psychosocial interventions.

Tools for psychosocial assessment that capture socio-demographic characteristics, neuropsychological function, psychiatric co-morbidity, psychological vulnerabilities, current social functioning of the person with a substance use disorder are described, along with a discussion on which tool may be relevant for use in specific groups of individuals. In a busy clinical practice, or in settings where there is a dearth of trained human resources, it is necessary to have a brief screening for cognitive dysfunction, as this may interfere with a patient's ability to engage in psychosocial interventions.

High rates of co-morbidity have been described in patients with substance use disorders.4546 The article on co-morbidity discusses the importance in assessing co-morbidity, how it can be assessed with a good clinical history, a thorough mental state examination as well as an instrument-based assessment. Clinical case vignettes highlight the importance of a good case history to establish the chronology of the addiction and co-morbidity. An algorithm of the management of clinical co-morbidities is provided.

Psychosocial interventions

The second section describes different types of psychosocial interventions in addictive disorders. Brief interventions, most commonly represented by the acronym FRAMES and the basic principles of motivational interviewing which form the basis of brief interventions are discussed. The article on relapse prevention discusses the assessment of intrapersonal and interpersonal determinants of relapse, differences between lapse and relapse, and the specific intervention strategies for relapse prevention. The next article brings into focus cognitive behavioural therapy (CBT) interventions, which target the maintaining factors of addictive behaviours and preventing of relapse. Apart from the conventional CBT therapies, third wave behaviour therapies focus on awareness building, skills to tolerate stress and mindfulness practices. The article on psychoanalytic psychotherapy highlights how effective it can be in carefully chosen patients, whose needs go beyond the immediate control of substance use. Psychoanalytical psychotherapies can help individuals achieve a deeper awareness of themselves, their unconscious desires, motivations and conflicts, which the individual may use to bring about more adaptive changes.

Cognitive rehabilitation is a therapy programme which can help persons with addictive disorder deal with their cognitive, behavioural and emotional deficits using systematic approaches such as cognitive retraining and EEG neurofeedback.

A detailed assessment of co-morbidities highlighted earlier is an essential pre-requisite to psychosocial management of co-morbidities or dual diagnosis. An important thing to recognize is that a lack of improvement in one of the disorders leads to relapse in both. The authors of the article on dual diagnosis recommend that the same team of professionals manage both the disorders in the same setting. They also discuss the challenges of implementing interventions in persons with dual diagnosis.

Since substance use adversely impacts not just the individual, but also the family, the need to involve the family is discussed at length. The principles and conduct of some of the specialized marital and family therapies are described.

Various kinds of sexual dysfunctions occur in patients with substance use disorder and persisting sexual dysfunction is often associated with treatment non-adherence, relapse and marital disharmony. A detailed assessment and personalised approach is required for such conditions. Clinicians rarely encounter sexual addictions, although the problem does exist in the community and is associated with adverse consequences, shame, guilt and distress. Despite the lack of robust data in this area, it is well recognised that there is a high co-morbidity with other addictive behaviours, including substance use disorders. Such problems can be helped with intensive programmes that focus on core triggers and beliefs about sexual addiction and to develop healthier choices and coping skills to minimize urges.

Group therapy for addictive disorders has a long history and has been popularized by self-help groups like the Alcoholics Anonymous, Al-Anon, Alateen, Smokers Anonymous, Narcotics Anonymous, Gamblers anonymous, Sexual Addicts Anonymous etc., While the self-help groups are not the focus of discussion, group therapy is an essential part of professional group interventions and shares the universal principles of group work. It can be an effective intervention in outpatient, inpatient and community settings.

Innovative approaches and special populations

The section on innovative approaches first discusses transdiagnostic issues which are focused on identifying core vulnerabilities and applying universal principles to therapeutic treatment. Third wave therapies and their clinical applications and specific techniques are discussed. The article on video-based relapse prevention highlights a specially developed cue-based video to reduce relapse in persons with alcohol dependence and discusses its potential use in relapse prevention in a variety of addictions.

Another area of growing interest is the use of the ever-expanding digital technology applications in mental health to addiction interventions, including the scope and challenges surrounding e-consultations, virtual visits and focus on self-management. The therapeutic uses of social media and tele-ECHO concepts to build primary care provider proficiency in health care are also discussed.

While the applications of modern technology are numerous, another growing problem is technology addiction. Many of these addictions are explained on the same theoretical paradigms as clinical addictions and cognitive behaviour and motivational enhancement interventions. Specific techniques such as practicing the opposite, goal setting, abstinence from certain applications, joining support groups and family interventions are suggested as approaches in this challenging area.

The next part of this section discusses psychosocial interventions in children and adolescents with substance use disorders, and highlights the importance of child-focused, multidisciplinary, multi-systemic approaches with family participation and community involvement. This is followed by special populations, as addiction-treatments have essentially been male-focused, and though women form a substantial proportion of the population, they still construe special populations as far as addiction treatment is concerned. It is well recognised that minority populations have high rates of risky sexual behaviours and addiction47 and psychosocial interventions need to be tailored to suit their needs. With a growing older population in India, with worrying levels of tobacco and alcohol use,48 psychosocial interventions in this group are extremely important and need to occur in a supportive, non-judgmental and non-confrontational style. Recommended interventions in older adults involve three main approaches, namely cognitive-behavioural, supportive and brief intervention approaches.

Section IV covers community based psychosocial interventions. The first article in this section discusses the importance of community mobilization in creating awareness about substance use and also encouraging individuals to seek treatment. It discusses the TTK rural camp approach, the Manjakkudi model, which is well known for several decades. Steps in developing a workplace programme is also discussed.

Important approaches to making services available and accessible to people is to develop services for substance use disorders within the communities and closer to people's homes. Task sharing by involving non-specialist health workers can be an important step to address the large treatment gap and the approaches to such interventions are discussed. This article provides empirical evidence that alcohol use disorder outcome can be improved interventions that are focused on building motivation and a focus to change alcohol-related cognitions and problem behaviours and enhancing social networks. It suggests a strategic shift to collaborative community and home-based delivery of psychosocial interventions.

Ethical issues and research in psychosocial interventions for addictive disorders

It needs to be recognised that persons with addictive disorders face several ethical issues related to their treatment and therapists need to be constantly aware of these issues and deliver ethical care both in clinical settings as well as in other circumstances, as evident from the article on ethics. The fundamental principles of medical ethics of non-maleficence, beneficence, autonomy and justice are very relevant in the management of persons with addictive disorders. The principles of dignity and honesty need to guide treatment approaches. Ethical challenges may involve the intervention, the affected individual, the therapist or the setting in which the intervention is provided.

The concluding article focuses on research issues in psychosocial interventions. It discusses the importance of having a sound theoretical understanding of addiction, asking the right questions and designing the studies appropriately. A clear definition of the intervention is important. Mediators, moderators and confounders of treatment need to be accurately identified while determining the actual effects of psychosocial interventions. Although the research in psychosocial interventions in India is quite scanty,49 the time is right to strengthen psychosocial intervention guidelines by robust research in the area.

Strengths and limitations

The biggest strength of this series of articles is that the authors have a substantial experience working in addiction and related fields. The available empirical evidence has also been examined to suggest these psychosocial treatment guidelines. The use of case vignettes allows a pragmatic understanding of not just the ‘what to do’, but the ‘how to do it’. The use of algorithms also helps to enhance the understanding of the approaches to intervention.

There are several deficiencies in this supplement. It has not focused in detail on some of the practical issues of follow-up and aftercare in persons with addictive disorders. It has also not addressed many of the extra-treatment support needs of persons with addictive disorders. It is well recognised that persons with addictive disorders have significant employment problems (VATSUD).50 In addition, they have several other needs, including housing, education, legal aid, financial and social support. The utility of self-help groups, including empirical evidence of their effectiveness have not been examined. The problems of substance use in custodial settings such as prison are high51 and guidelines for preventing drug use and HIV among incarcerated substance users have been developed,52 but these need to be tested for their effectiveness. Psychosocial intervention also mandates a good understanding of the basic bio-medical underpinnings of addiction and the pharmacological approaches to detoxification and relapse prevention. These are important issues that form an essential part of comprehensive management, but are outside the purview of this supplement.

IN CONCLUSION

While there is a tendency to divide both the theoretical understanding and treatment approaches to addictive disorders as either biomedical or psychosocial, the individual with addiction does not perceive this dichotomy, nor should the treating health care professional. All the health care needs of the individual with addiction must be comprehensively assessed and handled, preferably in a 'single-window’ approach, or through efficient networking with the community resources. It is high time that the recommended interventions go beyond physical health and psychological interventions to address the broader needs of the individual in the community, including employment, housing, social security and other needs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Psychosocial interventions; addictive disorders; India; overview; approaches; personalised; holistic

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