First Study: For the purpose of comparison, the Penn/VA researchers performed a follow-up study in three community-based methadone(Drug information on methadone) programs. Patients with moderate to high levels of psychiatric symptoms were identified as possible candidates since the first study showed that those with low symptom levels had no additional benefit from psychotherapy. In this study, a balanced design, in which patients were assigned to two drug counselors or to a counselor and a psychotherapist, was used. Only SE therapy was used because it had been found equally effective to CB; outcome measures and follow-up points were the same as before.
As in the first Penn/VA study, patients generally improved but here there were no differences between the groups at the 7-month evaluation point, implying that adding the second counselor helped. However, by 12 months the gains seen in the DC group at 7 months diminished and those in the SE group strengthened, so that there were now significant differences, including drug use, all favoring the SE condition (Woody et al., 1995). Here again, there were differences in outcome according to which individual therapists gave the treatment.
Second Study: A study by McLellan et al. (1993) conducted about the same time as the community-based project, built on the findings of the first psychotherapy study, but had different aims. It was developed when questions were being raised about delivering methadone maintenance with few or no psychosocial services (i.e., "minimal methadone"), and its focus was to determine the efficacy of different intensities of psychosocial therapy.
In this study, addicts who had been stabilized on 60 mg/day of methadone were randomly assigned to minimal services (MMS, one 10-minute counseling session/month); standard services (SMS, one 30- to 45-minute counseling session/week); or enhanced services (EMS, weekly counseling plus on-site medical, psychiatric, family-social and employment services). Results showed that there was a stepwise improvement as services intensified, with 69% of patients in the MMS condition needing to be "protectively transferred" to SMS due to unremitting opiate or cocaine use, or repeated medical or psychiatric emergencies. Though not focused on psychotherapy per se, the EMS group contained elements of psychotherapy and the results clearly showed differences between the MMS condition and the other two groups.Psychotherapy 'Effects'
Though differences favoring psychotherapy were found in the two Penn/VA studies, one cannot be certain that they were due to psychotherapy per se, because there were differences in outcome according to therapist (Luborsky et al., 1985). This result has been found in psychotherapy studies with other populations as well; thus, it was not unexpected. However, the fact that therapist differences exist makes it difficult to separate therapy from therapist effects.
On the other hand, from a practical point of view, the fact that therapist differences occurred suggests that "active" healing ingredients were associated with psychotherapy, at least in some cases. Whether these healing ingredients were related to the therapist/patient relationship, to technique or to some combination made little difference to the patients. However, a better understanding of the source of these benefits probably would make a difference to those who pay for substance abuse treatment, a point that is discussed below.Program Recommendations
Data from the Yale study suggest that additional psychotherapy is not very useful if few patients are interested and a powerful behavioral contingency program is in operation. However, the Yale and Penn/VA studies both indicate that participation in psychosocial treatment improves outcome and that patients with ASPD can benefit in very meaningful ways from methadone maintenance treatment (Woody et al., 1985; Gerstley et al., 1989).
The Penn/VA studies suggest that psychotherapy can be particularly useful for psychiatrically symptomatic patients when it is integrated into the ongoing services of methadone programs. This is not to say that drug counselors with little psychiatric training are unable to help the more psychiatrically impaired and difficult patients, only that the odds can be improved when these patients are assigned to therapists with more psychiatric training.
Few or none of the positive results that were seen in all of these studies would have been possible without methadone. As in the study by Nyswander et al. (1958), very few heroin addicts enroll voluntarily in outpatient psychotherapy when it is offered as a "stand alone" treatment without methadone. Thus, these studies combined an effective pharmacotherapy (methadone) with counseling and psychotherapy, and are best seen as pharmacotherapy/psychotherapy studies.What About Managed Care?
Current efforts to control psychiatric costs through capitation, HMOs and managed health care appear to use treatment models that are not consistent with research data for heroin addicts. The focus on brief and inexpensive interventions run counter to the data that addiction treatment, especially methadone maintenance, is long-term, and that results are best when it is integrated with appropriate levels of counseling, psychiatric and medical services.
Medical reimbursement plans that include methadone (many do not) seem to compete for contracts on the basis of costs, which are reduced by cutting back on services. Even without psychotherapy in the treatment package, many heroin addicts find that it is difficult to become enrolled in a program; if they succeed, they are lucky to get a good counselor who sees them regularly!
One cannot but wonder if these models truly save money or if they mainly shift the costs of addiction treatment, and of the psychiatric and medical services that improve outcome, to other parts of the health care and social service system.