Drug and Alcohol Dependence, 4 (1979) 439 - 447 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
Review
Paper
EFFECTIVENESS OF PSYCHOTHERAPEUTIC METHADONE MAINTENANCE DAVID
439
COUNSELING
IN
P. DESMOND
Department 7703 Floyd (Received
of Psychiatry, University Curl Drive, San Antonio,
of Texas Health Science Texas 78284 (U.S.A.)
Center
at San Antonio,
July 31, 1978)
Summary Therapeutic counseling has been widely advocated with methadone maintenance, but its effectiveness has not been demonstrated. A review of the literature revealed a dearth of scientific investigations comparing treatment outcomes with and without counseling services. The few studies which have been reported seem to suggest that counseling does not significantly change treatment outcomes as measured by the usual indicators of illicit drug use, arrests, employment, and retention in the program. These studies suffered from a number of methodological flaws, however, including failure to adhere to research design, small sample size, poorly matched control groups, inadequate outcome criteria, and absence of post-treatment follow-up. Previous investigators have been nearly unanimous in calling for further studies of this issue. Since the cost of counseling services represents a major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies.
Of what value are counseling services in methadone maintenance programs? Counseling, often modeled after techniques falling under the broad category of psychotherapy, is an aspect of methadone maintenance treatment that has received relatively little critical attention. The consistency and vehemence with which counseling services are advocated is remarkable. For example, Kleber [l] asserts that “Methadone is a drug, not a treatment. Rehabilitation involves effective psychotherapy and vocational/educational help along with the methadone”. Likewise, Weiner and Schut [2] state, “despite the real and symbolic importance of methadone to the drug addict, the counseling relationship is still central to the rehabilitative process”. And Senay [3], writing in the American Handbook of Psychiatry, comments, “Although the provision of counseling and auxiliary social services in metha-
440
done maintenance has not yet been conclusively proven to influence treatment outcome, few serous observers doubt that such services play a vital role”. Reports of early investigations by Dole and associates of the use of methadone as an agent for blocking narcotic craving often emphasized a metabolic defect hypothesis of addiction, and de-emphasized the role of psychotherapeutic intervention in methadone maintenance. Probably the best example of this is a report published in 1967 in which Dole and Nyswander [4] stated, “The lack of formal psychotherapy in the treatment reflected the experience of the professional staff that routine program . . . psychotherapy was not needed for rehabilitation of the patients”. Dole’s awareness of the personal and social problems of the compulsive heroin user was largely ignored. However, in reporting their initial findings in 1965, Dole and Nyswander [ 51 pointed out that “the question at issue was whether a narcotic medicine, prescribed by physicians as part of a treatment program, could help in the return of addict patients to normal society” (emphasis added). In 1968, when Dole et cd. [6] published the results of the treatment of 750 New York City addicts with methadone, improvements in social functioning of the patients were not attributed to the medication alone, but to the overall efforts of the program staff, including nurses, counselors, and social workers. Several years later Dole [ 71 again warned that without these supportive services, “the program would merely be a dispensary”. Brecher [8] reported that Dole and associates saw a need to compare the effectiveness of methadone maintenance with and without supportive services, and set up a minimal services dispensary for this purpose. He predicted that, “When the results from this unit are later compared with results in full service units serving comparable groups of addicts, more light will be thrown on the value of and need for auxiliary services”. The results of the study, if completed, have not been published. Lowin [9] was one of the first observers to point out the lack of adequate research in this area. He commented, “ . . . . there is virtually nothing written at all about the supportive therapies that are supposed to accompany the administration of methadone. The role of supportive services may be acknowledged when programs are designed, but it is not reflected in the research literature which is emerging from methadone programs”. Five years later, Powers and Powers [lo] found the situation still unchanged, asserting, “Despite the recognized need for research, relatively few studies have been published on counseling with methadone clients”. Lowin speculated that the role of supportive services such as counseling and psychotherapy had not been subjected to close scrutiny for several reasons. These services fall under the umbrella of “multimodal therapy”. In a multimodal program, there is room for every school of therapy. He suggested that offering a broad range of services was a political solution that gave each competing profession a slice of the pie, and helped neutralize criticism aimed at a purely pharmacological therapy.
441
The studies The first clinical study of the relationship between counseling and other supportive services and the outcome of methadone maintenance treatment was reported by Ramer et al. [ll] in 1971. Ramer attempted to evaluate treatment of a small group of San Francisco addicts, half of whom were to receive methadone and no other formal treatment. The rest were to receive methadone plus a variety of services, including group and individual psychotherapy, crisis intervention, and vocational guidance. The design was not adhered to, however, because “many addicts in the group receiving only methadone exhibited a patent need for other help in addition to chemical maintenance”. They were allowed to have access to other services. The service modality most widely used was crisis intervention (used by 79 percent of the patients), followed by vocational guidance (used by 48 percent). Curiously, the patients who most frequently received psychotherapy had a notably higher rate of attrition from the program. Ramer concluded that two-thirds of the patients required little more than occasional ancilliary services and suggested that the group of patients exhibiting severe adjustment difficulties could be more appropriately treated in a program which included intensive therapy in an inpatient facility, such as a therapeutic community. In 1972, Senay et al. [12] reported results of a study of 157 voluntary Chicago patients randomly assigned to either a full-service methadone unit or a dispensary with no auxiliary services. About half of the full-service group received methadyl acetate instead of methadone in a double-blind experiment. Difficulties in adhering to the study design were again given as the most significant finding: the dispensary staff refused to withhold psychological support and counseling from the patients. The investigators were forced to proceed with minimal services on the “no service” unit. There were no significant differences in drug use, employment, or selfreported illegal activity among the patient groups during the 4%week course of the study. Retention was reported to be better among methadone fullservice patients than the minimal-service patients but the difference was not statistically significant, The full-service groups required significantly more changes in methadone dosage than the dispensary group. Senay noted that, because random assignment had resulted in substantial dissimilarities between the study groups, “more research is needed to assure that any differences exist”. In 1973 Willett [ 131 reported results of an exploratory study designed to determine whether group therapy as an adjunct to methadone was more effective in producing “therapeutic change” than methadone treatment alone. Thirty patients were divided into three groups of ten, with one group designated as analytically orientated psychotherapy, one a “T-group”, and the third a control group receiving medication (methadone) only. The Tgroup sessions consisted of sensitivity training and role playing, with emphasis on the here and now. Drop-outs reduced the size of each group of patients to six. The control group patients were somewhat younger and had
442
fewer criminal convictions than therapy group patients. Changes in behavior were measured by a 128-item Interpersonal Check List (ICL). The only other measure of treatment outcome used was urinalysis results. Therapy sessions lasted eight weeks. The methadone-only patients recorded no significant changes in ICL scores at the end of eight weeks. The two therapy groups showed modest changes in scores. The analytical therapy group had the only statistically significant change on an individual sector of the ICL, an increase in the Rebellious-Distrustful sector. The group therapy patients had a mean of 0.48 positive urines per week against a mean of 0.35 for controls. The significance of the difference, if any, was not reported. Willett concluded that the results “generally supported” the contention that group therapy, together with methadone treatment, can effect changes in interpersonal behavior as measured by the ICL. No claim was made regarding the impact of therapy on the traditional indicators of program retention, illicit drug use, criminal behavior, and financial dependency. Willett warned that the short-term nature of the study, as well as the small sample size and equivocal nature of the results, precluded definitive conclusions. In 1976 Janke [ 141 reported a study of the effectiveness of maintenance with and without counseling services in a Portland, Oregon, program. He compared treatment outcomes for 887 patients during a 45-month period in which the program operated on a “purely medical” model, with outcomes for 878 patients during a subsequent 36-month period in which the program operated on a “heavily psychotherapeutic ” model. Pre-treatment characteristics of both groups were approximately the same. A successful outcome was defined as completing treatment by voluntary detoxification from methadone. Any other type of termination, such as incarceration, death, or dropping out, was considered a failure. Patients treated under the psychotherapeutic model were found to complete treatment successfully with nearly twice the frequency of patients treated without psychotherapeutic counseling (48% us. 25%). However, on other measures the two treatment groups did not differ significantly. No difference was found in the rate at which either group returned for treatment after termination. Retention rates were also similar: 26% of the patients in each group remained in treatment without interruption throughout each evaluation period. Except for tabulating the frequency of return to the treatment program, Janke obtained no follow-up data to indicate which group of patients did better after leaving the program.
Discussion There are important differences in design and implementation among the four studies cited. Ramer et al. attempted an experimental study using a small treatment group and a small control group of patients, but abandoned
443
the design. Senay et al. tried a similar experiment with larger numbers of subjects, but also failed to adhere to the design. Janke did a retrospective study of clinical records of two large groups of patients, but since this was a naturally occurring experiment, some variables were unknown or uncontrolled. His selection of a single criterion of treatment success (interrupted vs. completed treatment) makes it difficult to draw comparisons with other studies, as does Willett’s choice of ICL scores only. Willett’s study also suffers from small sample size and an ill-matching control group. Probably the most notable characteristic which these four studies had in common was a disclaimer that the results reported were not definitive, combined with a call for further investigation. A thorough search of the subsequent treatment literature revealed that no attempt to replicate the work of any of these investigators has been reported. There have been a few studies published which indirectly address the issue of counseling effectiveness. Rosenberg et al. [ 151 compared a group of Boston patients who received counseling during the waiting period for methadone treatment with a group who were merely put on a waiting list. The two groups of applicants (n = 100 each) were remarkably similar in background demographic characteristics and histories of drug use. The intervention of the intake counselor was related to a non-significant increase in percentage of patients who saw a physician and were admitted (50% US.41% of waiting-list controls). One month after admission, 31% of the counseled patients remained in treatment compared to 25% of controls. This difference was also non-significant. At the end of 20 weeks, the percentage of counseled patients still in treatment was significantly higher than controls who had not received counseling, 25% vs. 15%. Rosenberg found that retention in treatment was associated with duration of patients’ drug habits as well as pretreatment counseling. He concluded that the tendency to remain in treatment beyond twenty weeks “is related mainly to the length and severity of the drug abuse”, but that involvement in treatment (counseling) from the outset tends to hold more in the program. Note that Rosenberg et al. reported only differences between pre-treatment counseling and no counseling, not the difference between intreatment counseling and no counseling. Ball et al. [16] studied attitudes of both patients and staff toward treatment in a large Philadelphia methadone-maintenance program. Questionnaires were administered to 224 patients and 42 staff members. Approximately two-thirds of the patients were black males aged under 30. Findings suggested that the relationship between counseling activities and treatment outcome may be obscure in part because of disparities in staff-patient beliefs regarding the nature of addiction. For example, 95% of the staff thought that addicts were “mentally ill”, while 80% of the patients thought addicts were not mentally ill. Sixty percent of the patients reported a preference for non-professional staff (the ex-addict counselors), those least likely to take a psychotherapeutic approach to treatment. A minority of patients, 42%, agreed that professional staff are helpful in treatment.
444
Ball et al. described the lack of consensus concerning etiology of addiction as their outstanding finding, and suggested that a “therapeutic impasse” existed between staff and patients. Brown and Thompson [17] compared a group of patients assigned to ex-addict counselors with a similar group assigned to non-addict counselors in a Washington D.C. program (not all patients were on methadone maintenance, but the proportion of maintenance patients in each group was the same). Ex-addict counselors were “not expected to have either academic or employment experience in the counseling field”, whereas the non-addict counselors were expected to be “therapists”. Over a twelve-month period no differences were found between the two groups of patients in terms of program retention, use of illicit drugs, employment, or rates of arrest. Brown and Thompson concluded that ex-addict and non-addict counselors did not differ significantly in terms of treatment effectiveness. They offered two hypotheses to explain their finding: (1) Counselors of both kinds who have the opportunity to interact within the treatment setting may come to resemble one another in the ways they perceive and perform in their role; and (2) the ex-addict’s background and experiences act in some way to offset the non-addict counselor’s superior academic and counseling experience. A third and simpler hypothesis apparently did not occur to them: Counseling may not be a critical factor in the outcome of methadone maintenance treatment. There is some clinical opinion in the literature to support such an alternative hypothesis. For example, Bourne [18] is openly skeptical of the impact of psychotherapeutic counseling. In a review of the literature on methadone maintenance treatment, he concluded “ . . . there is little evidence that methadone maintenance programs as presently operated are an effective means of achieving significant psychological change per se. Those changes that do occur appear to be the result of being rescued from the constant stress of life on the street, rather than being due to classical psychotherapy ’ ‘. Karkus [19] asserts that “Formal psychotherapy has little place in a methadone program, even with serious problem patients, provided that patients receive help in solving day-to-day problems and are allowed to develop self confidence and respect”. O’Malley et al. [20] described heroin to psychiatric intervention”. addicts seen in outpatient clinics as “refractory Recently, Brill [21] has also suggested that traditional psychotherapeutic After tracing the evolution of drug techniques are “minimally effective”. abuse treatment philosophies since 1930, he concluded, “ . . . most addicts were not capable of . . . personality changes, of probing into the unconscious, or of developing insight”. Nevertheless, many clinicians believe that a majority of chronic opioid drug addicts exhibit serious psychopathology, and require intensive therapeutic intervention in order to correct underlying personality problems [ 1, 22 - 241. Methadone is seen by advocates of the psychotherapeutic approach as a tool or lever with which to hold the patient in treatment. “Methadone
445
may provide the same clinical opportunity in opiate addiction as Thorazine has in some schizophrenics”, says Perkins [ 251. “In both, the heavy burden of symptoms is so lightened by the medication that other interventional techniques from counseling to therapy may be employed as needed”. Kaufman and Blaine [26] also believe that, once stabilized on methadone, addicts’ chances for personality change increase. They suggest that this may be due to the psychotropic properties of methadone, which of aggressive “dampen primitive affects”, and thus facilitate the exploration and sexual feelings which is essential to ego-reconstructive psychotherapy. Khantzian [ 27, 281 has suggested that methadone may play a direct role in promoting improved psychological and behavioral functioning in patients maintained on methadone independent of concurrent psychotherapy : “By its stabilizing action [methadone] counteracts the disorganizing influences of aggression on the ego and thereby reverses painful regressed states and makes healthier adaptations possible”. Other clinicians [23, 291 have also suggested that methadone may be a bona fide psychotropic agent in itself, at least for some patients. Results of experimental studies [30 - 321 of the mood-altering properties of chronically administered methadone have been equivocal, but generally do not support this hypothesis. Most suggest that tolerance to the euphorigenic effects of methadone develops along with tolerance to other effects. Resume Divergent clinical opinions have been expressed regarding the value of counseling services in methadone maintenance programs. Review of the treatment literature has revealed a dearth of systematic studies of this question, and the few which have been done suffer from methodological weakness. Methodological problems encountered include failure to adhere to research design, small sample size, poorly matched control groups, loss of subjects during study, inadequate outcome criteria, and absence of posttreatment follow-up. Nevertheless, the studies seem to indicate that differences in outcome of methadone maintenance treatment with and without psychotherapeutic counseling may be small as measured by the usual, quantifiable, indicators of success. Since the cost of counseling services represents the major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies. Failure to conduct and publish such studies is a serious problem which should concern not only the treatment and research components of the mental health care services system, but the public and private entities which provide funds for these services as well. The push for counseling in conjunction with the dispensing of methadone will probably continue despite the lack of empirical evidence documenting its efficacy. Study of the individual, professional, and societal value judgements behind these attitudes, all of which help to shape policies on the treatment of drug dependence, is also needed.
446
Acknowledgements This study was supported in part by the National Institute on Drug Abuse, Grant DA0083. The author wishes to thank James F. Maddux, MD, for helpful review and comment.
References 1 H. D. Kleber, Methadone maintenance treatment - a reply. Amer. J. Drug Ale. Abuse, 4 (1977) 267 - 272. 2 H. Weiner and J. &hut, The interaction between counseling and methadone in the treatment of narcotic addicts. Int. J. Clin. Pharmacol., 11 (1975) 292 - 298. 3 E. C. Senay, The treatment of drug abusers, in S. Arieti (ed.), American Handbook of Psychiatry, Vol. 5, Basic Books, New York, 1975, p. 839. 4 V. P. Dole and M. E. Nyswander, Heroin addiction - a metabolic disease. Arch. Intern. Med., 120 (1967) 19 24. 5 V. P. Dole and M. E. Nyswander, A medical treatment for diacetylmorphine (heroin) addiction. J. Amer. Med. Assoc., 193 (1965) 646 - 650. 6 V. P. Dole, M. E. Nyswander and A. Warner, Successful treatment of 750 addicts. J. Amer. Med. Assoc., 206 (1968) 2703 - 2714. 7 V. P. Dole, Rehabilitation of patients on methadone programs. Proceedings of the Fifth National Conference on Methadone Treatment. National Association for the Prevention of Addiction to Narcotics (NAPAN), New York, 1973, pp. 1 - 7. 8 E. M. Brecher (ed.), Licit and Illicit drugs. Consumers Union, Mount Vernon, 1972, p. 165. 9 A. Lowin, Development and evaluation of social services to the drug addict. Proceedings of the Fourth National Conference on Methadone Treatment. NAPAN, New York, 1972, pp. 311 - 313. 10 R. J. Powers and H. B. Powers, Counseling with methadone clients: a review of recent research. Drug Forum, 6 (1978) 249 - 259. 11 B. S. Ramer, M. 0. Zaslove and J. Langan, Is methadone enough? The use of ancillary treatment during methadone maintenance. Amer. J. Psychiat., 127 (1971) 1040 1044. methadyl 12 E. C. Senay, J. H. Jaffe, S. diMenza et al., A 48 week study of methadone, acetate, and minimal services. Psychopharmacol. Bull, 9 (1973) 37 (abstr.). 13 E. A. Willett, Group therapy in a methadone treatment program: an evaluation of changes in interpersonal behavior. Int. J. Addict., 8 (1973) 33 - 39. 14 P. Janke, Differential effects on completion of treatment in a medical us., psychotherapeutic model for methadone maintenance. Paper presented to the Third National Drug Abuse Conference, New York, March 25 29, 1976. 15 C. M. Rosenberg, N. McCain and V. Patch, Engaging the narcotic addict in treatment. Drug Forum, 1 (1972) 145 - 152. 16 J. C. Ball, H. Graff and J. J. Sheehan, The heroin addicts’ view of methadone maintenance. Brit. J. Addict., 69 (1974) 89 95. 17 B. S. Brown and R. F. Thompson, The effectiveness of formerly addicted and nonaddicted counselors on client functioning. Drug Forum, 5 (1976) 123 129. 18 P. G. Bourne, Methadone: Benefits and Shortcomings. Drug Abuse Council Inc. Washington D.C., 1975, Publication MS-12, pp. 11 12. 19 H. D. Karkus, Methadone us. psychotherapy in the treatment of addiction. Int. J. Addict., 8 (1973) 427 434. 20 J. E. O’Malley, W. H. Anderson and A. Lazare, Failure of outpatient treatment of drug abuse: I. Heroin. Amer. J. Psychiat., 128 (1972) 865 868.
447 21 22 23
24
25
26 27
28 29
30 31 32
L. Brill, The treatment of drug abuse: evolution of a perspective. Amer. J. Psychiat., 134 (1977) 157 - 160. R. A. Savitt, Psychoanalytic studies on addiction: ego structure in narcotic addiction. Psychoanal. Quart., 32 (1963) 43 57. L. Wurmser, Methadone and the craving for narcotics: observations of patients on methadone maintenance in psychotherapy. Proceedings of the Fourth National Conference on Methadone Treatment. NAPAN, New York, 1972, pp. 525 - 528. V. Davidson, Transference phenomena in the treatment of addictive illness: love and hate in methadone maintenance. In J. D. Blaine and D. A. Julius (eds.), Psychodynamics of Drug Dependence, U. S. Department of Health, Education and Welfare, Washington D.C., 1977, pp. 118 - 125. M. E. Perkins, Psychiatric management and the future system of care in drug abuse, in W. Keup (ed.), Drug Abuse: Current Concepts and Research. C. C. Thomas, Springfield, 1972, p. 456. E. Kaufman and G. B. Blaine, Full services in methadone treatment. Amer. J. Drug. Ale. Abuse, 1 (1974) 213 - 231. E. J. Khantzian, A preliminary dynamic formulation of the psychopharmacologic action of methadone. Proceedings of the Fourth National Conference on Methadone Treatment. NAPAN, New York, 1972, pp. 371 - 374. E. J. Khantzian, Opiate addiction: a critique of theory and some implications for treatment. Amer. J. Psychother., 28 (1974) 59 - 70. G. J. McKenna, A. Fisch and M. E. Levine et al., The use of methadone as a psychotropic agent. Proceedings of the Fifth National Conference on Methadone Treatment. NAPAN, New York, 1973, pp. 1317 - 1324. W. R. Martin, D. R. Jasinski, C. A. Haertzen, et al., Methadone -a reevaluation. Arch. Gen. Psychiat., 28 (1973) 286 - 295. E. R. Gritz, S. M. Shiffman, M. R. Jarvik, et al., Physiological and psychological effects of methadone in man. Arch. Gen. Psychiat., 32 (1975) 237 - 242. D. A. Blake and C. Distasio, A comparison of level of anxiety, depression and hostility with methadone plasma concentration in opioid-dependent patients receiving methadone on a maintenance dosage schedule. Proceedings of the Fifth National Conference on Methadone Treatment. NAPAN, New York, 1973, pp. 1308 - 1316.
Review
Paper
EFFECTIVENESS OF PSYCHOTHERAPEUTIC METHADONE MAINTENANCE DAVID
439
COUNSELING
IN
P. DESMOND
Department 7703 Floyd (Received
of Psychiatry, University Curl Drive, San Antonio,
of Texas Health Science Texas 78284 (U.S.A.)
Center
at San Antonio,
July 31, 1978)
Summary Therapeutic counseling has been widely advocated with methadone maintenance, but its effectiveness has not been demonstrated. A review of the literature revealed a dearth of scientific investigations comparing treatment outcomes with and without counseling services. The few studies which have been reported seem to suggest that counseling does not significantly change treatment outcomes as measured by the usual indicators of illicit drug use, arrests, employment, and retention in the program. These studies suffered from a number of methodological flaws, however, including failure to adhere to research design, small sample size, poorly matched control groups, inadequate outcome criteria, and absence of post-treatment follow-up. Previous investigators have been nearly unanimous in calling for further studies of this issue. Since the cost of counseling services represents a major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies.
Of what value are counseling services in methadone maintenance programs? Counseling, often modeled after techniques falling under the broad category of psychotherapy, is an aspect of methadone maintenance treatment that has received relatively little critical attention. The consistency and vehemence with which counseling services are advocated is remarkable. For example, Kleber [l] asserts that “Methadone is a drug, not a treatment. Rehabilitation involves effective psychotherapy and vocational/educational help along with the methadone”. Likewise, Weiner and Schut [2] state, “despite the real and symbolic importance of methadone to the drug addict, the counseling relationship is still central to the rehabilitative process”. And Senay [3], writing in the American Handbook of Psychiatry, comments, “Although the provision of counseling and auxiliary social services in metha-
440
done maintenance has not yet been conclusively proven to influence treatment outcome, few serous observers doubt that such services play a vital role”. Reports of early investigations by Dole and associates of the use of methadone as an agent for blocking narcotic craving often emphasized a metabolic defect hypothesis of addiction, and de-emphasized the role of psychotherapeutic intervention in methadone maintenance. Probably the best example of this is a report published in 1967 in which Dole and Nyswander [4] stated, “The lack of formal psychotherapy in the treatment reflected the experience of the professional staff that routine program . . . psychotherapy was not needed for rehabilitation of the patients”. Dole’s awareness of the personal and social problems of the compulsive heroin user was largely ignored. However, in reporting their initial findings in 1965, Dole and Nyswander [ 51 pointed out that “the question at issue was whether a narcotic medicine, prescribed by physicians as part of a treatment program, could help in the return of addict patients to normal society” (emphasis added). In 1968, when Dole et cd. [6] published the results of the treatment of 750 New York City addicts with methadone, improvements in social functioning of the patients were not attributed to the medication alone, but to the overall efforts of the program staff, including nurses, counselors, and social workers. Several years later Dole [ 71 again warned that without these supportive services, “the program would merely be a dispensary”. Brecher [8] reported that Dole and associates saw a need to compare the effectiveness of methadone maintenance with and without supportive services, and set up a minimal services dispensary for this purpose. He predicted that, “When the results from this unit are later compared with results in full service units serving comparable groups of addicts, more light will be thrown on the value of and need for auxiliary services”. The results of the study, if completed, have not been published. Lowin [9] was one of the first observers to point out the lack of adequate research in this area. He commented, “ . . . . there is virtually nothing written at all about the supportive therapies that are supposed to accompany the administration of methadone. The role of supportive services may be acknowledged when programs are designed, but it is not reflected in the research literature which is emerging from methadone programs”. Five years later, Powers and Powers [lo] found the situation still unchanged, asserting, “Despite the recognized need for research, relatively few studies have been published on counseling with methadone clients”. Lowin speculated that the role of supportive services such as counseling and psychotherapy had not been subjected to close scrutiny for several reasons. These services fall under the umbrella of “multimodal therapy”. In a multimodal program, there is room for every school of therapy. He suggested that offering a broad range of services was a political solution that gave each competing profession a slice of the pie, and helped neutralize criticism aimed at a purely pharmacological therapy.
441
The studies The first clinical study of the relationship between counseling and other supportive services and the outcome of methadone maintenance treatment was reported by Ramer et al. [ll] in 1971. Ramer attempted to evaluate treatment of a small group of San Francisco addicts, half of whom were to receive methadone and no other formal treatment. The rest were to receive methadone plus a variety of services, including group and individual psychotherapy, crisis intervention, and vocational guidance. The design was not adhered to, however, because “many addicts in the group receiving only methadone exhibited a patent need for other help in addition to chemical maintenance”. They were allowed to have access to other services. The service modality most widely used was crisis intervention (used by 79 percent of the patients), followed by vocational guidance (used by 48 percent). Curiously, the patients who most frequently received psychotherapy had a notably higher rate of attrition from the program. Ramer concluded that two-thirds of the patients required little more than occasional ancilliary services and suggested that the group of patients exhibiting severe adjustment difficulties could be more appropriately treated in a program which included intensive therapy in an inpatient facility, such as a therapeutic community. In 1972, Senay et al. [12] reported results of a study of 157 voluntary Chicago patients randomly assigned to either a full-service methadone unit or a dispensary with no auxiliary services. About half of the full-service group received methadyl acetate instead of methadone in a double-blind experiment. Difficulties in adhering to the study design were again given as the most significant finding: the dispensary staff refused to withhold psychological support and counseling from the patients. The investigators were forced to proceed with minimal services on the “no service” unit. There were no significant differences in drug use, employment, or selfreported illegal activity among the patient groups during the 4%week course of the study. Retention was reported to be better among methadone fullservice patients than the minimal-service patients but the difference was not statistically significant, The full-service groups required significantly more changes in methadone dosage than the dispensary group. Senay noted that, because random assignment had resulted in substantial dissimilarities between the study groups, “more research is needed to assure that any differences exist”. In 1973 Willett [ 131 reported results of an exploratory study designed to determine whether group therapy as an adjunct to methadone was more effective in producing “therapeutic change” than methadone treatment alone. Thirty patients were divided into three groups of ten, with one group designated as analytically orientated psychotherapy, one a “T-group”, and the third a control group receiving medication (methadone) only. The Tgroup sessions consisted of sensitivity training and role playing, with emphasis on the here and now. Drop-outs reduced the size of each group of patients to six. The control group patients were somewhat younger and had
442
fewer criminal convictions than therapy group patients. Changes in behavior were measured by a 128-item Interpersonal Check List (ICL). The only other measure of treatment outcome used was urinalysis results. Therapy sessions lasted eight weeks. The methadone-only patients recorded no significant changes in ICL scores at the end of eight weeks. The two therapy groups showed modest changes in scores. The analytical therapy group had the only statistically significant change on an individual sector of the ICL, an increase in the Rebellious-Distrustful sector. The group therapy patients had a mean of 0.48 positive urines per week against a mean of 0.35 for controls. The significance of the difference, if any, was not reported. Willett concluded that the results “generally supported” the contention that group therapy, together with methadone treatment, can effect changes in interpersonal behavior as measured by the ICL. No claim was made regarding the impact of therapy on the traditional indicators of program retention, illicit drug use, criminal behavior, and financial dependency. Willett warned that the short-term nature of the study, as well as the small sample size and equivocal nature of the results, precluded definitive conclusions. In 1976 Janke [ 141 reported a study of the effectiveness of maintenance with and without counseling services in a Portland, Oregon, program. He compared treatment outcomes for 887 patients during a 45-month period in which the program operated on a “purely medical” model, with outcomes for 878 patients during a subsequent 36-month period in which the program operated on a “heavily psychotherapeutic ” model. Pre-treatment characteristics of both groups were approximately the same. A successful outcome was defined as completing treatment by voluntary detoxification from methadone. Any other type of termination, such as incarceration, death, or dropping out, was considered a failure. Patients treated under the psychotherapeutic model were found to complete treatment successfully with nearly twice the frequency of patients treated without psychotherapeutic counseling (48% us. 25%). However, on other measures the two treatment groups did not differ significantly. No difference was found in the rate at which either group returned for treatment after termination. Retention rates were also similar: 26% of the patients in each group remained in treatment without interruption throughout each evaluation period. Except for tabulating the frequency of return to the treatment program, Janke obtained no follow-up data to indicate which group of patients did better after leaving the program.
Discussion There are important differences in design and implementation among the four studies cited. Ramer et al. attempted an experimental study using a small treatment group and a small control group of patients, but abandoned
443
the design. Senay et al. tried a similar experiment with larger numbers of subjects, but also failed to adhere to the design. Janke did a retrospective study of clinical records of two large groups of patients, but since this was a naturally occurring experiment, some variables were unknown or uncontrolled. His selection of a single criterion of treatment success (interrupted vs. completed treatment) makes it difficult to draw comparisons with other studies, as does Willett’s choice of ICL scores only. Willett’s study also suffers from small sample size and an ill-matching control group. Probably the most notable characteristic which these four studies had in common was a disclaimer that the results reported were not definitive, combined with a call for further investigation. A thorough search of the subsequent treatment literature revealed that no attempt to replicate the work of any of these investigators has been reported. There have been a few studies published which indirectly address the issue of counseling effectiveness. Rosenberg et al. [ 151 compared a group of Boston patients who received counseling during the waiting period for methadone treatment with a group who were merely put on a waiting list. The two groups of applicants (n = 100 each) were remarkably similar in background demographic characteristics and histories of drug use. The intervention of the intake counselor was related to a non-significant increase in percentage of patients who saw a physician and were admitted (50% US.41% of waiting-list controls). One month after admission, 31% of the counseled patients remained in treatment compared to 25% of controls. This difference was also non-significant. At the end of 20 weeks, the percentage of counseled patients still in treatment was significantly higher than controls who had not received counseling, 25% vs. 15%. Rosenberg found that retention in treatment was associated with duration of patients’ drug habits as well as pretreatment counseling. He concluded that the tendency to remain in treatment beyond twenty weeks “is related mainly to the length and severity of the drug abuse”, but that involvement in treatment (counseling) from the outset tends to hold more in the program. Note that Rosenberg et al. reported only differences between pre-treatment counseling and no counseling, not the difference between intreatment counseling and no counseling. Ball et al. [16] studied attitudes of both patients and staff toward treatment in a large Philadelphia methadone-maintenance program. Questionnaires were administered to 224 patients and 42 staff members. Approximately two-thirds of the patients were black males aged under 30. Findings suggested that the relationship between counseling activities and treatment outcome may be obscure in part because of disparities in staff-patient beliefs regarding the nature of addiction. For example, 95% of the staff thought that addicts were “mentally ill”, while 80% of the patients thought addicts were not mentally ill. Sixty percent of the patients reported a preference for non-professional staff (the ex-addict counselors), those least likely to take a psychotherapeutic approach to treatment. A minority of patients, 42%, agreed that professional staff are helpful in treatment.
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Ball et al. described the lack of consensus concerning etiology of addiction as their outstanding finding, and suggested that a “therapeutic impasse” existed between staff and patients. Brown and Thompson [17] compared a group of patients assigned to ex-addict counselors with a similar group assigned to non-addict counselors in a Washington D.C. program (not all patients were on methadone maintenance, but the proportion of maintenance patients in each group was the same). Ex-addict counselors were “not expected to have either academic or employment experience in the counseling field”, whereas the non-addict counselors were expected to be “therapists”. Over a twelve-month period no differences were found between the two groups of patients in terms of program retention, use of illicit drugs, employment, or rates of arrest. Brown and Thompson concluded that ex-addict and non-addict counselors did not differ significantly in terms of treatment effectiveness. They offered two hypotheses to explain their finding: (1) Counselors of both kinds who have the opportunity to interact within the treatment setting may come to resemble one another in the ways they perceive and perform in their role; and (2) the ex-addict’s background and experiences act in some way to offset the non-addict counselor’s superior academic and counseling experience. A third and simpler hypothesis apparently did not occur to them: Counseling may not be a critical factor in the outcome of methadone maintenance treatment. There is some clinical opinion in the literature to support such an alternative hypothesis. For example, Bourne [18] is openly skeptical of the impact of psychotherapeutic counseling. In a review of the literature on methadone maintenance treatment, he concluded “ . . . there is little evidence that methadone maintenance programs as presently operated are an effective means of achieving significant psychological change per se. Those changes that do occur appear to be the result of being rescued from the constant stress of life on the street, rather than being due to classical psychotherapy ’ ‘. Karkus [19] asserts that “Formal psychotherapy has little place in a methadone program, even with serious problem patients, provided that patients receive help in solving day-to-day problems and are allowed to develop self confidence and respect”. O’Malley et al. [20] described heroin to psychiatric intervention”. addicts seen in outpatient clinics as “refractory Recently, Brill [21] has also suggested that traditional psychotherapeutic After tracing the evolution of drug techniques are “minimally effective”. abuse treatment philosophies since 1930, he concluded, “ . . . most addicts were not capable of . . . personality changes, of probing into the unconscious, or of developing insight”. Nevertheless, many clinicians believe that a majority of chronic opioid drug addicts exhibit serious psychopathology, and require intensive therapeutic intervention in order to correct underlying personality problems [ 1, 22 - 241. Methadone is seen by advocates of the psychotherapeutic approach as a tool or lever with which to hold the patient in treatment. “Methadone
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may provide the same clinical opportunity in opiate addiction as Thorazine has in some schizophrenics”, says Perkins [ 251. “In both, the heavy burden of symptoms is so lightened by the medication that other interventional techniques from counseling to therapy may be employed as needed”. Kaufman and Blaine [26] also believe that, once stabilized on methadone, addicts’ chances for personality change increase. They suggest that this may be due to the psychotropic properties of methadone, which of aggressive “dampen primitive affects”, and thus facilitate the exploration and sexual feelings which is essential to ego-reconstructive psychotherapy. Khantzian [ 27, 281 has suggested that methadone may play a direct role in promoting improved psychological and behavioral functioning in patients maintained on methadone independent of concurrent psychotherapy : “By its stabilizing action [methadone] counteracts the disorganizing influences of aggression on the ego and thereby reverses painful regressed states and makes healthier adaptations possible”. Other clinicians [23, 291 have also suggested that methadone may be a bona fide psychotropic agent in itself, at least for some patients. Results of experimental studies [30 - 321 of the mood-altering properties of chronically administered methadone have been equivocal, but generally do not support this hypothesis. Most suggest that tolerance to the euphorigenic effects of methadone develops along with tolerance to other effects. Resume Divergent clinical opinions have been expressed regarding the value of counseling services in methadone maintenance programs. Review of the treatment literature has revealed a dearth of systematic studies of this question, and the few which have been done suffer from methodological weakness. Methodological problems encountered include failure to adhere to research design, small sample size, poorly matched control groups, loss of subjects during study, inadequate outcome criteria, and absence of posttreatment follow-up. Nevertheless, the studies seem to indicate that differences in outcome of methadone maintenance treatment with and without psychotherapeutic counseling may be small as measured by the usual, quantifiable, indicators of success. Since the cost of counseling services represents the major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies. Failure to conduct and publish such studies is a serious problem which should concern not only the treatment and research components of the mental health care services system, but the public and private entities which provide funds for these services as well. The push for counseling in conjunction with the dispensing of methadone will probably continue despite the lack of empirical evidence documenting its efficacy. Study of the individual, professional, and societal value judgements behind these attitudes, all of which help to shape policies on the treatment of drug dependence, is also needed.
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Acknowledgements This study was supported in part by the National Institute on Drug Abuse, Grant DA0083. The author wishes to thank James F. Maddux, MD, for helpful review and comment.
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