Using the Internet for clinical training: a course on network therapy for substance abuse.
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Alcoholism↗
Biomedical subjects
M Galanter
Publications and source records attributed to M Galanter.
Dual diagnosis patients in the modified therapeutic community: does a criminal history hinder adjustment to treatment?
The efficacy of the drug-free therapeutic community (TC) in treating patients with chemical dependence and in rehabilitating persons with criminal histories has been extensively studied and is well established since the late 1960's. More recently, this format has been modified in order to treat individuals suffering from both addictive disorders and chronic, severe mental illness. In an indigent inner-city population, this latter group includes many patients who also have significant histories of criminal behavior. To date, there have been no systematic attempts to assess the impact of a history of criminality on the course of treatment of these patients, as they might be thought less adaptable to the milieu of a TC. In the current study, data from a sample of homeless male MICA patients were analyzed to determine if those patients with a history of criminal convictions were as likely as non-criminal patients to adjust effectively to the social milieu of a modified drug-free therapeutic community. Of 183 sequential admissions studied, 76 had never been convicted of a crime, 46 had 1 conviction, and 61 had 2 or more. No differences were observed between the groups with respect to length of stay, social adjustment on admission, and change in social adjustment during the first two months of treatment. These findings suggest that a history of criminal conduct does not compromise a dually diagnosed patient's likelihood of engaging in the social contract necessary for successful treatment in a TC.
Adult↗
Validation of a scale for network therapy: a technique for systematic use of peer and family support in addition treatment.
Substance abuse treatments are increasingly employing standardized formats. This is especially the case for approaches that utilize an individual psychotherapy format but less so for family-based approaches. Network therapy, an approach that involves family members and peers in the patient's relapse prevention efforts, is theoretically and clinically differentiated in this paper from family systems therapy for addiction. Based on these conceptual differences, a Network Therapy Rating Scale (NTRS) was developed to measure the integrity and differentiability of network therapy from other family-based approaches to addiction treatment. Seven addictions faculty and 10 third- and fourth-year psychiatry residents recently trained in the network approach used the NTRS to rate excerpts of network and family systems therapy sessions. Data revealed the NTRS had high internal consistency reliability when utilized by both groups of raters. In addition, network and nonnetwork subscales within the NTRS rated congruent therapy excerpts significantly higher than noncongruent therapy excerpts, indicating that the NTRS subscales measure what they are designed to measure. Implications for research and training are discussed.
Adult↗
Network Therapy for addiction: assessment of the clinical outcome of training.
Mental health practitioners in the office setting are often seen as deficient in addiction treatment skills. Relevant training in often quite limited, and trainees are generally not introduced in an effective office-based modality. We studied the feasibility of teaching beginning therapists how to apply Network Therapy, a cognitive-behavioral approach to achieving abstinence and preventing relapse that augments individual therapy with support from family and friends. The therapists were 19 psychiatric residents without experience in substance abuse treatment or outpatient therapy, and the patients were 24 cocaine-dependent patients who received a 24-week course of Network treatment. The patients remained in treatment for an average of 15.4 weeks. Seventy-nine percent of their observed weekly urine toxicologies were negative for cocaine, and 42% of patients produced clean urines in the 3 weeks immediately before termination. The overall outcome compares favorably with that reported in studies on cocaine treatment where experienced therapists were employed. Our results suggest that naive mental health trainees can be taught to apply Network Therapy for effective substance abuse management. This is particularly relevant to technology transfer for general mental health trainees, who are often thought to be perceived to be refractory to learning about the outpatient management of addiction.
Adult↗
Perceived social support and treatment retention on an inpatient addiction treatment unit.
The authors measured perceived social support among patients and their families as a predictor of retention in an inpatient addiction rehabilitation program. After detoxification from all substances of abuse, 66 sequentially admitted inpatients gave demographic and diagnostic information and completed scales of perceived social support from the program and their own families. Scales were completed at 7, 14, and 21 days. A total of 46 subjects completed the 21-day program, and 20 did not. Homeless status, initial weak perceived social support from family, and a relatively shorter history of crack-cocaine use were correlated with completion of the program. Patients with stronger connections to shelter and family were less likely to complete an inpatient addiction rehabilitation program. Patients who reported more years of crack-cocaine use were also less likely to complete the program. The authors discuss implications for treatment.
Adult↗
Differences between men and women in dual-diagnosis treatment.
The authors reviewed the charts of all women and a randomly selected sample of men over a 6-month period on two addiction treatment units at Bellevue Hospital Center in New York. The men were more likely to be admitted with schizophrenia and to have used substances of abuse other than alcohol, and the women were more likely to be admitted with affective disorders. Also, the women on the dual-diagnosis ward were more likely to be domiciled (i.e., not homeless), and the women on both units were significantly more likely to report having been crime victims. These findings suggest that dually diagnosed women need a substantially different treatment paradigm from men.
Adult↗
The MICA therapeutic community: challenges for residents and staff.
Therapeutic communities (TCs) are residential self-help programs for recovering addicts. Traditional TCs are staffed by recovered addicts. Recently the TC model has been modified for the treatment of chemical abusers with severe mental illness. These programs are to varying degrees staffed by mental health professionals. Furthermore, they are often housed in institutions whose model for care is based on service to patients rather than self-help. There are inherent conflicts in the modified TC which is a hybrid of these two treatment approaches. This paper explores issues related to the roles of patients, mental health professionals, and the parent institution in the TC modified for the treatment of the mentally ill chemical abuser.
Attitude of Health Personnel↗
Spirituality and the treatment of the dually diagnosed: an investigation of patient and staff attitudes.
Spirituality is a neglected area of study and research in the treatment of addictions. The role of spirituality in the treatment of the dually diagnosed has received particularly scant attention. One hundred and one patients on an in-patient dual-diagnosis unit, as well as the 31 members of the nursing staff who treat them were surveyed. Patients and staff were questioned about their spiritual beliefs and what was the role of spirituality in the patients' recovery from addiction. Staff were questioned about their own spirituality and what they think the patients' level of spirituality is. In addition the staff were asked what they think the patients' view of spiritually is. Results indicate that the patients and staff are equally spiritually oriented. The patients view spirituality as essential to their recovery and value spiritual programming in their treatment more than some concrete items. The nursing staff underestimated both the patients' level of spirituality and this importance placed on spiritual issues. The authors suggest that more attention should be given by staff to spirituality in the treatment of this population.
Adult↗
Treatment of perinatal cocaine addiction: use of the modified therapeutic community.
Treatment outcome was evaluated for perinatal cocaine addicts admitted to a hospital-based day treatment clinic, organized as a modified therapeutic community (TC) modality. The perinatal program consisted of a specialized track for women embedded within this larger coed day treatment clinic. A total of 87 perinatal women (28 pregnant at intake, the remaining 59 postpartum) were compared with cohorts of nonperinatal women (N = 63) and men (N = 158) admitted during the period of evaluation (September 1989 through December 1993). In logistic regression analysis, successful discharge urine status (last three urines prior to discharge drug-free) was associated with current child custody involvement (odds ratio = 2.80, 95% C.I. = 1.16-6.72), entering treatment when not postpartum (odds ratio = 0.15, 95% C.I. = 0.05-0.42), and taking psychiatric medication (odds ratio = 2.04, 95% C.I. = 1.11-3.72). Both pregnant and postpartum perinatal women showed a similar pattern of shorter treatment as compared with nonperinatal women and male clients, averaging 2 months of treatment as compared with 4 months for nonperinatal clients. Factoring out pregnancy and postpartum status, the women in treatment fared as well as men with respect to both retention and discharge urine standings. This finding indicates that programmatic modifications need to address specific perinatal issues and not gender issues per se. Also, a differential pattern in discharge urine status of women who enter treatment while pregnant vs. those who enter when postpartum suggests that outreach and recruitment be targeted, but not limited, to pregnant women.
Adult↗
Can cocaine addicts with severe mental illness be treated along with singly diagnosed addicts?
Large numbers of indigent cocaine abusers now present in center-city hospitals. Since many are also diagnosed for severe mental illness, options for their effective treatment are needed. The authors investigated the feasibility of treating these dually diagnosed patients along with the majority of abusers who were not severely impaired in a program that combines peerled treatment with psychiatric management and pharmacotherapy. Although group confrontation techniques were used, schizophrenics (N = 71) and patients with major depressive disorder (N = 50) experienced an outcome as good or better than the less impaired (N = 177) on retention, visit rates, and urinalysis results.
Adult↗
Medical student and patient attitudes toward religion and spirituality in the recovery process.
This study compares the views on spirituality of dually diagnosed patients (diagnosed with both substance abuse and general psychiatric disorders) and medical students in order to investigate their respective orientations toward spirituality and their views of the importance of spirituality in the treatment of addiction. We administered a modified version of Feagin's "Orientation to Life and God Scale" to assess religious and spiritual orientation in both the patients and students. A second series of items was developed and administered in order to compare the patients' and students' perceptions of the relative importance of a religious and spiritual orientation in substance abuse treatment. A third series of items was also given to compare the nature of religious and health-related services on the inpatient unit that patients and students most wanted to see improved. We found that the medical students responsible for treating substance abuse are significantly less religiously and spirituality oriented than the patients they treat, and that the students do not indicate that spirituality is an important component in the care of these patients. It may be clinically relevant to train medical students in the potential importance of spirituality in addiction treatment so that they can incorporate spirituality into the treatment of addictions.
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Community based heroin addicts who turn to experimental treatment rather than conventional care.
In this paper we report on a community based sample of heroin addicts not in addiction treatment who responded to the offer of experimental treatment (buprenorphine) for heroin addition. Comparison to a sample of methadone maintenance clients from the same geographic area reveals that on average the community sample began heroin use later, attained a higher level of education, and were most likely to have had a significant cohabitation relationship. The methadone maintenance sample, on the other hand, reported significantly greater regular use of drugs of abuse other than heroin. Each group may represent a different subgroup drawn from the heterogeneous heroin-addicted population. Implications for improved recruitment into treatment and enhanced treatment design are drawn from these findings.
Adult↗
The impact on behavior of notifying methadone patients of their HIV serostatus.
Questions have arisen about the implications of notifying drug abusers of their HIV serostatus. One major concern is that awareness of HIV infection would have a negative impact on abstinence from drug abuse. In order to ascertain the effects of serostatus notification, the authors reviewed the clinical records of 73 methadone patients who learned of their serostatus within 20 weeks after enrolling in the clinic and thereafter remained in treatment for at least 1 year. They found that, at serostatus notification, seropositive patients were more likely to be socially disadvantaged and were younger than the seronegatives at first opiate use. After serostatus notification, seropositives had more "fair hearings" for noncompliance with program norms and used more cocaine. Although the patients notified of HIV infection may have more behavioral problems, further research is needed to determine whether or not this reflects antecedent behavior patterns and drug use.
Adult↗
A treatment system for combined psychiatric and addictive illness.
Patients with combined general psychiatric and addictive disorders are a major public health problem in the US, and are being increasingly recognized as such world-wide. The authors describe a model treatment system for such patients in one municipal hospital in New York. It is composed of three complementary units: a locked ward, a halfway house and a day program. Treatment is based on a peer leadership approach coupled with professional treatment, and provides multiple levels of care to address the needs of respective patients. Of 464 admissions evaluated and treated, most were from disadvantaged minorities, homeless and abusers of cocaine. All were admitted with acute psychiatric or perinatal presentations, and carried Axis I diagnoses in addition to their substance abuse. Clinical experience over 6 years is reviewed, suggesting the feasibility of reorganizing general hospital psychiatric services to address the needs of the dually diagnosed.
Adult↗
HIV-1 among inner city dually diagnosed inpatients.
The objectives of this study were to investigate HIV-1 seroprevalence and risk factors, disease progression, and awareness of HIV-1 serostatus in a population of inner city, substance using, psychiatric inpatients. To pursue these goals, we tested 118 (103 M, 15 F) dually diagnosed, acute care inpatients for HIV-1 antibodies and administered structured interviews. Twenty-seven (23%, including 24 M and 3 F) of the subjects were HIV-1 seropositive. Seropositivity was twice as great among intravenous drug users and men who had sex with other men as among patients not belonging to either of these two groups. Logistic regression analysis among male subjects revealed a significantly elevated HIV-1 risk associated with a primary diagnosis of depression (odds ratio adjusted for age, race, and presence of an AIDS risk behavior = 4.2, 95% confidence interval = 1.1, 16.5; p = 0.04). Less than half of the seropositives knew their HIV-1 status prior to this study, one had AIDS and four had two or more constitutional symptoms of AIDS. The high rate of seropositivity in this indigent, dually diagnosed population presents challenges to the health-care community. That few individuals had HIV-1 related symptoms may have implications for other treatment settings.
Adult↗
Network therapy for addiction: a model for office practice.
Individual therapists in office practice are often considered to have limited effectiveness in treating alcohol and drug dependence. In this article the author describes network therapy, an approach developed to assure greater success in such treatment. It uses psychodynamic and behavioral therapy while engaging the patient in a support network composed of family members and peers. A cognitive-behavioral model of addiction, based on the role of conditioned withdrawal in relapse, is described. Related techniques for securing abstinence are then reviewed; they augment individual psychotherapy to help patients avoid relapse caused by the affective and environmental cues that precipitate drug seeking. The role of social cohesiveness as a vehicle for engaging patients in treatment is outlined next, along with a related technique for enhancing an addicted patient's commitment to the therapy. This is done by using the patient's family and peers as a therapeutic network to join the patient at intervals in therapy sessions. The network is managed by the therapist to provide cohesiveness and support, undermine denial, and promote compliance with treatment. The author presents applications of the network technique designed to sustain abstinence and describes means of stabilizing members' involvement. Applications of network therapy to ambulatory detoxification, disulfiram and naltrexone administration, relapse prevention, and contingency contracting are reviewed.
Adult↗
A general hospital day program combining peer-led and professional treatment of cocaine abusers.
OBJECTIVE: Cocaine abuse, particularly in crack form, is highly prevalent among patients with severe socioeconomic disadvantages who are treated in municipal general hospitals. The authors describe and evaluate a day treatment program for 30 such patients that combines peer-led self-help and professional care provided by a general hospital psychiatric service. METHODS: Treatment outcomes at one year for 92 patients referred to the day program from the hospital's psychiatric services and 58 perinatal patients referred from the obstetric services were examined using chi square and regression analyses to determine whether certain variables, especially referral source, were related to outcome. An acceptable treatment outcome was defined as three successive negative urinalyses before termination or at the end of one year of treatment. RESULTS: Almost all the patients were unemployed members of ethnic minorities, and most abused at least one substance in addition to cocaine. The 150 patients attended the program an average of 44 times during the year, and 39 percent had an acceptable treatment outcome. Patients referred from psychiatric services had a better outcome than perinatal patients. CONCLUSIONS: Peer-led milieu treatment and professional services can be combined in the general hospital to provide intensive ambulatory care for socioeconomically disadvantaged substance abusers. Techniques and services for engaging perinatal patients in treatment should be developed.
Adult↗
Age at onset of alcoholism as a predictor of homelessness and drinking severity.
The relationships between drinking history, housing history, several clinical variables and treatment retention after detoxification were evaluated in 109 inner-city alcoholics. Compared to men with a fixed abode, homeless subjects (N = 50) reported a history of alcoholism of early onset and increased severity. No differences in aftercare retention were found between homeless and non-homeless subjects.
Adult↗