Controversies: drugs versus talking therapies

Authored by Henry Strick van Linschoten

Ingesting psychoactive, “mind-altering” or “mood-changing” drugs or substances has been a human option for millennia: there are records of the use of alcohol, opium and marijuana many thousands of years BC. Psychoactive drugs are substances, whether solid, liquid or gas and however introduced into the body, that change the way a person thinks, feels or behaves by changing (something in) the functioning of the brain. For the biological effect of substances it makes no difference whether they are prescription medicines, recreational drugs, legal or illegal, over-the-counter medication, alternative remedies, or not regarded as “drugs” at all, e.g. alcohol, smoking tobacco, coffee, tea, soft drinks or refined sugar.

All psychoactive drugs have effects that can be divided between the main desired effect(s) and “side-effects”. As drug use in the widest sense is so common as to be almost inevitable amongst clients, it can be expected that psychotherapists have a reasonable understanding of the range of the possible effects of drugs.

Substance Use

DSM-5 has made some small but important changes in their preferred terminology by putting (much) less focus on the terms “substance abuse” and “dependence”, and putting all substance disorders on a dimensional scale of severity. The main classes of problems about drug use focused on in DSM-5 are:

• Impaired control by the user over their drug-related behaviour, including craving
• Social impairment
• Riskiness of use, i.e. the difficulty the user has to respond to the problems caused by the drug use
• Tolerance and withdrawal symptoms

DSM-5 states that apart from the disordered drug use, there can also be mental disorders caused directly by using certain drugs: “substance-induced disorders” as opposed to “substance use disorders”. This is an important distinction: if drug use does not lead to separate (drug-induced) disorders, that still leaves the classes of physically determined tolerance and withdrawal symptoms, and the other criteria related to the harm done by the drug use. The classification also leaves open the possibility that drug use might not lead to symptoms of tolerance and withdrawal, and it is emphasised that only tolerance and withdrawal symptoms without harm are not sufficient for a drug use disorder.

Recreational drugs are obviously used for their effects: to stimulate (e.g. cocaine, amphetamines, caffeine); to produce hallucinations (e.g. LSD) or to sedate (e.g. barbiturates and alcohol). The effects of cannabis and of opioids are similar or identical to those caused by endogenous cannabinoids and opioids that the body itself produces. The effects of alcohol are relatively complex and imperfectly understood in terms of their mechanisms; it is known to influence a number of neurotransmitter systems.

Drug use has by now been well studied from a neurobiological perspective. This research makes it plausible that psychoactive drug use and the effect of drugs depend on an understanding of a wide range of factors: the user’s experience with the drug; physiological sensitivity to the drug, probably with an inherited component; the situational and relational context of drug use; and the user’s expectations.

An increasing problem is the use of prescription drugs, whether or not they were originally prescribed for good reasons. Benzodiazepines are a good example of this; they are effective, their effect is understood, they may be prescribed for very “normal” reasons, and they replace other anxiolytics, sedatives or hypnotics that may be much more dangerous or harmful. Until recently a number of major countries appeared to be overprescribing them, leading to what was considered to be such an undesirable degree of dependence that by now the great majority of doctors is cautious about prescribing them for any sustained time periods. There are by now a range of prescription drugs which people like using for reasons other than basic medically justifiable needs, and for which expert opinion differs greatly as to whether the use of these drugs constitutes a disorder or not, especially on a longer-term basis. This includes learning-enhancing and attention-focusing drugs. It is clear that this is not a new problem.

The effect of drugs can clearly overlap with the effects of psychotherapy. Affect regulation, and improving a client’s experience of mood and anxiety “disorders” are standard goals for therapy, and it is clear that affects and mood can be influenced by taking drugs. It would seem useful for a psychotherapist to have a good understanding of the intended effects, side-effects, complications and potential physical impact of drugs, whether legal, illegal, recreational, normally prescribed or freely available.

A few up-to-date sources about drugs are: Healy (2009), exclusively about psychiatric drugs; Erickson (2007), excluding psychiatric drugs; and three books with more of an emphasis on recreational drugs but also summarising psychiatric drugs: McKim & Hancock (2012); Meyer & Quenzer (2013); Brick & Erickson (2013).

The evidence for the effectiveness of medically prescribed psychoactive drugs is mainly in the form of randomised controlled trials (RCTs), as the regulatory agencies of major western countries make this a condition of approving the drugs for general prescription to the public. Over the past few decades these RCTs, especially the main ones for older and more recent antidepressants and antipsychotic drugs, have been heavily scrutinised and much criticised (Goldacre, 2012; Healy, 2009).

It may be true that the profit-based pharmaceutical companies have biased and at times manipulated their reporting of research, that some of the effectiveness of pharmaceutical drugs is not that impressive, that a significant part of the effectiveness is a placebo effect, and that the drugs usually have at least some negative side-effects. Nevertheless, there are many people for whom these drugs have delivered benefits or at least relief, and the fact that there are significant numbers of drugs screened out, i.e. rejected by the approval process, suggests that the screening via RCTs is not completely a wasted effort. Another key example worth analysing is the fact that drugs inspired by the neurobiology of PTSD have not done as well in trials as was hoped for, and certainly have not done as well as antidepressants for depression and anxiety.

A considerable amount of research has been devoted to comparing the effectiveness of psychoactive drugs and psychotherapy. It would be desirable to conduct more research in this area. Whilst for specific problems or disorders it has been found that either (forms of) psychotherapy or (certain) drugs are clearly superior to the other, it seems possible to make a broad generalisation, on current evidence, that there are many people and many disorders for whom a good choice of psychotherapy or a good choice of prescription drugs can produce about equivalent results – as it were a broadening of the “equal effectiveness” conclusion that most research into comparing different types of psychotherapy has led to. As these statistical results always hide a wide range of individual differences, this means that a psychotherapist should be as open to the possibility that drugs might be better for a particular client than therapy, as doctors and psychiatrists should be open to the option of psychotherapy. In practice this rarely means a one-off choice between drugs and therapy, but a sequencing over time in which first one and then the other is tried – just as for somewhat more difficult problems people often end up being in psychotherapy repeatedly and with more than one psychotherapist.

Much research has taken place into comparing drugs and therapy alone with a combination of the two. Here too, a reasonable generalisation can probably be made that, with exceptions, there is no clear pattern that usually the combination is more effective, or usually one or the other mono-therapy is better. All combinations of effectiveness are possible, and may need to be investigated, if sufficient resources to do careful research are available. In practice this means that in a case about which no research is known, there should be a presumption that all the options are open. Given that there is firm evidence that the client’s “theory of what is effective” can have a considerable impact, this means that being sensitive to what the client’s perceptions or suggestions are must be a significant part of good practice. The usage of sequencing of intervention options should be actively considered (Forand et al., 2013).

Two overview chapters about the comparison of drugs and psychotherapy are Forand et al. (2013) and Sparks et al. (2010). For individual disorders the chapters of Lambert (2013) contain summaries and references to research about the relative effectiveness.

The last few paragraphs most directly related to drugs prescribed by doctors. When a psychotherapist works with a client who uses prescription drugs but has obtained them otherwise than through a regular medically authorised prescription, or uses over-the-counter drugs, or drugs from the world of alternative or complementary medicine, the situation is different. It appears important in any case to be aware of what clients are using, to ask them why they are using it, and what is the source of the client’s conviction that the usage would be effective and safe at an acceptable level. Depending on the answers it may be appropriate to link this with issues about self-care. It becomes more difficult for the psychotherapist to form a view about the effectiveness and riskiness dimensions, but from a holistic point of view it seems difficult to ignore drugs that a client is taking.

References

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Text Revision (4th edition): DSM-IV-TR. Arlington, VA: American Psychiatric Association.

Brick, J. & Erickson, C.K. (2013). Drugs, the Brain, and Behavior: The Pharmacology of Drug Use Disorders (2nd edition). New York: Routledge.

Erickson, C.K. (2007). The Science of Addiction: From Neurobiology to Treatment. New York: W W Norton.

Forand, N.R., DeRubeis, R.J. & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th edition). Hoboken, NJ: John Wiley.

Goldacre, B. (2012). Bad Pharma: How Medicine is Broken, and How We Can Fix It. London: Fourth Estate.

Healy, D. (2009). Psychiatric Drugs Explained (5th edition). Edinburgh: Churchill Livingstone.

Kendler, K.S. (2006). “A gene for…”: the nature of gene action in psychiatric disorders. FOCUS, 4: 391-400.

Kendler, K.S. & Prescott, C.A. (2006). Genes, Environment, and Psychopathology: Understanding the Causes of Psychiatric and Substance Abuse Disorders. New York: Guilford Press.

Lambert, M.J. (Ed.) (2013). Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th edition). Hoboken, NJ: John Wiley.

Lewis, R. (2011). Human Genetics: Concepts and Applications (10th edition). New York: McGraw-Hill.

McKim, W.A. & Hancock, S.D. (2012). Drugs and Behavior: An Introduction to Behavioral Pharmacology (7th edition). Upper Saddle River, NJ: Pearson Education.

Meyer, J.S. & Quenzer, L.F. (2013). Psychopharmacology: Drugs, The Brain and Behavior (2nd edition). Sunderland, MA: Sinauer.

Sparks, J.A., Duncan, B.L., Cohen, D. & Antonuccio, D.O. (2010). Psychiatric drugs and common factors: an evaluation of risks and benefits for clinical practice. In B.L. Duncan, S.D. Miller, B.E. Wampold & M.A. Hubble (Eds.), The Heart and Soul of Change: Delivering What Works in Therapy (2nd edition). Washington, DC: American Psychological Association.