Thomas J. Morgan, Psy.D.

Tom Morgan on Identifying & Treating

Unreported Alcohol & Drug Problems

On June 1, Dr. Thomas Morgan addressed NJ-ACT on treating alcohol and drug abuse.  Tom explained that the traditional treatment package includes detox, 28-day inpatient rehab, and AA for every abusing patient.  But he recommended offering patients a range of treatment options, one of which was gradually working toward abstinence.  When patients choose the goal of treatment, treatment is more likely to succeed.

Assessment

            In New Jersey, 41% of patients seeking mental health treatment have both psychological and substance abuse disorders.  Therapists may identify abuse by embedding the issue in an assessment of patients’ health habits – exercise, diet, sleep, and tobacco use.  If patients report use of psychoactive substances, always get details.  What exactly do patients mean by “social” drinking?”  How big is one beer?  How often is occasionally?  Therapists should also be alert to clues of abuse such as a family history of addictions or ADHD, trauma, physical or sexual abuse, legal problems, or being a perpetrator or victim of domestic violence.     

            Non-verbal clues from the treatment process include: the smell of alcohol or marijuana; constricted or dilated pupils; psychomotor agitation or retardation, especially when these shift from one session to the next; impulsive acts such as arguments, violence, or sexual acting out; and mood swings, suspiciousness, hostility, or any emotional overreaction.     Tom also described several normed screening tools that are readily incorporated into the therapy process:  CAGE (Ewing, 1984) has 4 items; AUDIT (Saunders, et al., 1993) has 10 items; TWEAK (Chan, et al., 1993) has 5 items; and the Trauma Scale (Skinner, 1984) has 5 items. 

Psychotherapy

            Cognitive-behavioral therapists can treat substance abuse with behavioral coping skills training which includes: refusal skills, assessing high risk situations, skills for coping with urges and cravings, managing thoughts about alcohol and drugs, and relapse prevention. This approach is described in Treating Alcohol Dependence: A Coping Skills Training Guide by Monti, et al., Guilford Press, 2002.

            Tom pointed out that taking a confrontational approach with substance abusers is likely to generate denial and result in patient termination.  Instead, he recommended an accepting, Rogerian therapeutic style geared to patients’ readiness to change.  Instead of arguing with patients, listen.  Explore the advantages of getting high.  Work on patients’ embarrassment about acknowledging their abuse.        

            When therapists feel frustrated or find themselves doing all the talking, they are probably in the action stage of treatment while the patient is still in contemplation or pre-contemplation.

 Adjunctive Treatment

            Ambivalent patients often do well in SMART Recovery, a cognitive behavioral self-help group.  Based on REBT, SMART emphasizes self-efficacy and patient responsibility for changing self-defeating behaviors and thoughts.  It offers scientifically-based information in a tolerant, friendly, and empathic atmosphere that encourages abstinence as an eventual goal (http://www.smartrecovery.org).   

In Community Reinforcement Training (CRT) the abuser is not present, but family members learn to modify their behavior toward the abuser first by observing and later by modifying triggers and consequences of abuse.  They also learn to communicate more effectively with the abuser, introducing meaningful rewards into their relationship, and suggesting treatment at an appropriate time.                              

                                                                                                Lynn Mollick

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