Cocaine abuse and dependence continue to be widespread problems in the United States. In 2005, 33.7 million Americans age 12 and over (13.8% of the population) reported lifetime use of cocaine, and about 1% of those age 12 and over (2.4 million people) report current use of cocaine (Substance Abuse and Mental Health Services Administration, 2006
). Cocaine use has a wide impact on society beyond the individual, especially in the area of drug-related violence (Chermack, 2002) and HIV risk behaviors (Tyndell et al, 2003). Successful treatments for cocaine use disorders therefore have the potential to significantly improve the health of cocaine users as well as address the larger social and medical problems associated with cocaine use.
In 1991, the National Institute on Drug Abuse (NIDA) initiated a large-scale multi-center clinical trial, the NIDA Collaborative Cocaine Treatment Study, to examine the efficacy of psychosocial treatments for cocaine dependence. One of the treatments selected for study was supportive-expressive psychodynamic therapy. The decision to include this treatment modality was based on two considerations: (1) the widespread use of psychodynamic therapies in clinical practice, and (2) previous research documenting the efficacy of supportive-expressive psychodynamic therapy for patients with opiate dependence (Woody et al., 1983
). The design of the study included four psychosocial treatment groups: cognitive therapy (CT) plus group drug counseling (GDC), supportive-expressive (SE) psychotherapy plus GDC, individual drug counseling (IDC) plus GDC, and GDC alone. In addition to comparing the main effect outcomes of the four treatment groups, the study was designed to test a specific attribute by treatment interaction hypothesis. The interaction hypothesis was that professional psychotherapies (both SE and CT), when added to GDC, would yield superior outcomes for the subgroup of patients who had concurrent psychiatric symptoms in addition to their cocaine use, but professional psychotherapy would not enhance outcomes if there was little or no co-morbid psychiatric symptomatology.
The version of SE therapy used in the study was developed by Lester Luborsky and David Mark (Mark & Faude, 1995; Mark & Luborsky, 1992
), and was based on extensive clinical experience in working with substance dependent individuals. Dr. Luborsky had served as the clinical supervisor and trainer on both of the early studies that examined supportive-expressive therapy for opiate dependence. Dr. Mark is a psychoanalyst trained by Dr. Luborsky in supportive-expressive therapy who provided clinical service and supervision in psychodynamic therapy for many years at a cocaine treatment facility. While the treatment model is based on standard supportive-expressive psychodynamic therapy as described in Luborsky’s (1984)
general treatment manual for this modality, a more detailed treatment manual provides the adaptations of the approach specifically for cocaine use disorders (Mark & Luborsky, 1992
). Like standard SE therapy, the treatment model utilizes the core conflictual relationship theme (CCRT; Luborsky & Crits-Christoph, 1998
) concept to formulate patient interpersonal themes. However, unlike other psychodynamic approaches to addiction (Flores, 1997), patient drug use is not linked to an “addictive” personality. Instead, the context for cocaine use, and attempts at cessation of cocaine use, are examined in relation to the person’s interpersonal and intrapsychic world (as represented by the CCRT). Thus, CCRT patterns are viewed as triggers for relapse or linked to avoidance of appropriate steps towards recovery, rather than being seen as the “cause” of drug addiction. In this way, the SE treatment package was viewed as a modern psychodynamic therapy that integrated biological and psychological perspectives on cocaine addiction. As with standard SE therapy, the model also includes extensive attention to the development and maintenance of the therapeutic alliance through the use of supportive techniques.
Results from the NIDA Cocaine Collaborative Treatment study have been published in a variety of publications focusing on main outcomes (Crits-Christoph et al., 1999
), secondary outcomes (Crits-Christoph et al., 2001
), adherence of therapist to the protocols (Barber et al., 2004
), mediators of outcome (Crits-Christoph et al., 2003
), predictors of outcome (Crits-Christoph et al., in press
), and other secondary topics (Weiss et al., 2003
). The main treatment outcome results showed that all four treatments decreased drug use considerably, with cocaine use in the last 30 days improving from a mean of 10.4 days (SD
= 7.8; mdn
=8.0) at intake to a mean of 3.4 days (SD
= 6.5; mdn
= 0) 12-months after randomization. One treatment, however, was found to be superior to the other three treatment packages: IDC+GDC treatment produced statistically and clinically superior outcomes compared to the other treatments. For example, 38.2% of patients in the IDC+GDC group achieved three consecutive months of abstinence during the six-month treatment period, compared to 22.9% of patients in CT+GDC, 17.8% in SE+GDC, and 27.1% in GDC alone. There was no evidence supporting the hypothesis that professional psychotherapy would be especially useful among patients with concurrent psychiatric symptomatology (Crits-Christoph et al., 1999
). Moreover, examination of potential mediators of treatment outcome failed to produce any evidence in support of the hypothesized mechanism of SE therapy, namely change in self-understanding of interpersonal patterns (Crits-Christoph et al., 2003
While at first glance these findings suggest that IDC+GDC is a superior treatment to SE+GDC, it may be premature to “close the book” on psychodynamic therapy for cocaine dependence for a number of reasons. First, it should be noted that although a difference in abstinence rates between the IDC+GDC and SE+GDC groups was detected, the majority of patients treated with either treatment package had very positive outcomes. The median patient in both treatment groups, for example, decreased from using cocaine 8 days per month at intake to using cocaine 0 days per month at the one year assessment. Thus, it was not the case that SE therapy did not help patients; it did substantially. While achieving abstinence may be an important clinical outcome, reducing drug use substantially is also clearly very important even if complete abstinence is not obtained. An equally important point is that IDC+GDC was not superior to SE+GDC in improving the associated problems of cocaine addiction, including psychiatric symptoms, employment, medical, legal, family/social, interpersonal, or alcohol use problems (Crits-Christoph et al., 2001
). In most cases, the four treatment groups yielded similar and large improvements on these secondary outcomes.
The purpose of the current article is to take a closer look at the outcomes of patients who received SE therapy in this study. Our goal is to provide a more thorough understanding of the outcomes of these treatments in order to better explain the study findings and potentially generate hypotheses and clinical guidance about the role, if any, of SE therapy in the treatment of cocaine dependence. Because the new analyses presented here were not part of the original hypotheses and statistical analysis plan for the study, the results should only be interpreted with caution and from an exploratory perspective.
For the current article, we generated several hypotheses about how treatment outcomes might be different in SE therapy compared to the standard 12-step drug counseling (IDC) approach. First, it would be expected that SE would yield better outcomes on measures of interpersonal and family/social functioning, particularly in terms of long-term outcomes (short-term improvements in these areas might be highly influenced by the higher rates of abstinence that are achieved with IDC) and among those patients with some degree of interpersonal or family/social problems at baseline. Second, it has been suggested that psychodynamic psychotherapy is only useful for substance abusers after they have achieved abstinence (Khantzian, 1994). Once the patient is free from the pharmacological and motivational components of chronic drug use, attention can be turned to interpersonal conflicts and problems that SE therapy can effectively address. This hypothesis was examined by analyzing the differential treatment group outcomes of the subgroup of patients that achieved initial abstinence during the early phase of treatment. A third hypothesis was based on the concept that psychodynamic therapy addresses long-term conflictual issues that take time to uncover, address, and work through. It might be expected that patients in SE therapy progress more gradually over time, compared to the rapid achievement of abstinence in IDC. We tested this hypothesis by examining whether there were different patterns of change over time, and whether these patterns differed by treatment group. We also examined whether the patients who were most suited for SE therapy were predictable based on pre-treatment information. Data from the NIDA Cocaine Collaborative Study was used to address each of these exploratory hypotheses.