Over the recent years, the number of people involved in drug and substance abuse has drastically increased. In fact, as of 2015, it was estimated that at least 20.8 million people aged as young as 12 and older were diagnosed with substance use disorder (Adams, 2016). A substance use disorder is a medical sickness marked by clinically significant impairments in social function, health and voluntary control over substance use (Adams, 2016). The substance use disorders vary in duration, complexity, and severity from mild to severe (Adams, 2016). Consequently, although many behavioral treatments such as contingency management, cognitive behavioral therapy, mindfulness-based relapse prevention and technology-based treatments have been suggested to treat substance disorders, a single therapy is not sufficient. A combination of the various behavioral treatments is more effective for substance use disorder because two or more therapies will eliminate the weaknesses of a single therapy and enhance the attainment of the patient goals during an intervention.
Combining therapies in the treatment of substance disorders among individuals is effective as it eliminates the weaknesses of a single method leading to more effective patient outcomes. For example, contingency management (CM) and cognitive behavioral therapy (CBT) are two therapies that have been proven through research to be most effective in treating substance disorders. In CM, patients receive rewards or incentives for attaining specific behavioral goals (Davis et al., 2016). However, despite its high efficacy, it has been argued that there are high rates of return to baseline substance use once the incentives or rewards are withdrawn (Padwa & Kaplan, 2017). This means that in a situation where the patient needs long durations of treatment, CM becomes ineffective because incentives may be costly to sustain for a longer period (Padwa & Kaplan, 2017).
On the other hand, researchers insist that CBT is highly efficacious for treating substance use disorders through correcting cognitive thought processes (Carroll et al., 2014). The effectiveness of CBT is mostly attributed to its ability to offer long duration interventions to the victim as its effects are maintained and even strengthened after treatment termination (Carroll et al., 2014). Important to note about CBT is the fact that the victim is equipped with coping skills which he or she will develop and use even after the therapy sessions with a psychologist (Carroll et al., 2014). But CBT has been criticized for low motivation and engagement strategies for the patients (Carroll et al., 2014). From this discussion, it can be seen that CM and CBT are both effective, but each has a weakness that can be corrected by the other. CM has a shortfall regarding durability, that is, its reliance on rewards makes it a short-term therapy because it cannot be sustained once the incentives are withdrawn. If CM is combined with CBT, this weakness is eliminated because CBT is a long-term intervention strategy that helps clients develop coping skills to use after therapy. Similarly, CBT has a weakness of low motivation and engagement of the client during therapy. If it is combined with CM, incentives are introduced which enhances motivation and engagement of the clients. Thus, combining two therapies mitigate the weaknesses of a stand-alone treatment and increase patient outcomes.
Also, combining therapies is more effective as it enhances cognitive functioning which in turn increases skill acquirement and help the patient to avoid substance abuse. A psychologist may opt to use CBT to treat a substance abuse patient, for instance. CBT is a cognitively demanding therapy (Hofmann & Asmundson, 2017). However, substance abuse patients entering CBT may be having cognitive deficits as it has been shown that chronic drug abuse leads to deficits in cognitive functioning (Hofmann & Asmundson, 2017). Such deficits include response inhibition, decision-making, working memory, planning and attention, all which are executive areas crucial for acquirement and implementation of coping skills taught in CBT when preparing the patient to deal with substance disorder. This means that for CBT to be effective, interventions that enhance such areas of cognitive functioning are required to increase acquirement of coping skills and improve the capacity of the patient to avoid substance abuse or even encourage abstinence. By combining CBT with other enhancing interventions such as pharmacologic agents and computerized cognitive remediation, the effectiveness of CBT is improved (Hofmann & Asmundson, 2017). This is because pharmacologic treatments, as well as the cognitive remediation, improve neurocognitive processes in the substance abuse patients which enhance their skill acquirement and the capacity to abstain from drug abuse. Therefore, combining CBT with other intervention strategies that improve cognitive function enhance its effectiveness through higher coping skill acquirement for treatment of substance disorders among the patients.
Moreover, a combination of treatments is more efficient as it increases access to evidence-based therapies. For example, combining empirical treatments such as CM, CBT and community reinforcement approaches (CRA) with technology-based treatments has been shown to reduce substance use rates (Marsch et al., 2014). This is because besides the CBT sessions, for example, the patient can still access evidence-based treatments from the internet through a mobile phone, a tablet or a computer. Thus, when technology-based interventions, as well as therapies such as CBT, are combined, the patient gets more access to evidence-based therapies through their internet devices even from home and during off-sessions.
Nonetheless, there are instances when combining therapies may become less effective than using a single treatment for substance use disorder patients. As discussed earlier, CM, for instance, becomes an expensive therapy when the patient needs a longer period of intervention. Although combining CM and CBT results in a highly effective treatment for substance use disorder among the patients, the resulting costs may thus be exorbitant for the victim. Effective intervention strategies are those that are affordable to the patient (West et al., 2015). Going by this premise, using CBT, as a single treatment, becomes effective because it is not as expensive as the combination with CM would be.
Combination of therapies in the treatment of substance use disorder in patients is more effective as the use of two or more treatments at ago fixes the weaknesses of one therapy, enhance the other intervention and increase access of evidence-based therapies for the patients. Each of the psychological therapies for treating substance use disorder presents weaknesses which are eliminated when a combination of two or more therapies are used simultaneously. Also, use of interventions such as those that improve cognitive functioning enhance the effectiveness of the main therapies like CBT. Further, a combination of therapies enhances the chances of increased access to evidence-based interventions by the patients apart from main counseling sessions. However, when combining therapies for substance use disorder patients, it is important that costs are considered as one may end up with expensive therapy sessions that are less effective for the patient. Thus, therapy combinations should optimize the benefit for the patient but at the same time should not be exploitative when costs are evaluated.
Adams, J. M. (2016). Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health. Washington, DC: HHS.
Carroll, K. M., Kiluk, B. D., Nich, C., DeVito, E. E., Decker, S., LaPaglia, D. & Ball, S. A. (2014). Toward empirical identification of a clinically meaningful indicator of treatment outcome: features of candidate indicators and evaluation of sensitivity to treatment effects and relationship to one year follow up cocaine use outcomes. Drug & Alcohol Dependence, 137, 3-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878068/
Davis, D. R., Kurti, A. N., Skelly, J. M., Redner, R., White, T. J., & Higgins, S. T. (2016). A review of the literature on contingency management in the treatment of substance use disorders, 20092014. Preventive medicine, 92, 36-46. https://www.sciencedirect.com/science/article/pii/S0091743516302146
Hofmann, S. G., & Asmundson, G. J. (Eds.). (2017). The science of cognitive behavioral therapy. Academic Press.
Marsch, L. A., Guarino, H., Acosta, M., Aponte-Melendez, Y., Cleland, C., Grabinski, M., ... & Edwards, J. (2014). Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment. Journal of Substance Abuse Treatment, 46(1), 43-51. http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(13)00200-6/
Padwa, H., & Kaplan, C. D. (2017). Translating Science to Practice: Lessons Learned Implementing Evidence-Based Treatments in US Substance Use Disorder Treatment Programs. European Journal on Criminal Policy and Research, 1-12. https://link.springer.com/article/10.1007/s10610-017-9360-3
West, R., Raw, M., McNeill, A., Stead, L., Aveyard, P., Bitton, J. & Borland, R. (2015). Healthcare interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction, 110(9), 1388-1403. http://onlinelibrary.wiley.com/doi/10.1111/add.12998/full
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