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.

Based on empirical results from the NIDA Cocaine Collaborative Study, what should a psychodynamic therapist do when a patient with cocaine dependence requests treatment? While exploratory and therefore in need of replication, these findings provide the beginning of a clinical strategy for the psychodynamic clinician. First, the psychodynamic clinician should evaluate the patient’s status at intake on the four prognostic variables. It is clinically useful that three of the four predictor variables are successfully measured with very brief scales (craving: three items; expectations: three items; acuity of biomedical problems: four items). The fourth variable, the Addiction Recovery Scale is somewhat longer (40 items). Based on previous analysis (Crits-Christoph, in press), if a patient scores below the median on all four of the scales, the probability of treatment success in any outpatient treatment modality (drug counseling, psychodynamic therapy, cognitive-behavioral therapy) is low (11%) and therefore other alternative approaches (residential treatment; intensive outpatient treatment programs) might be considered as referral options. Barring this, however, beginning SE therapy, in conjunction with a 12-step oriented group counseling, is a reasonable clinical option. The clinician then needs to monitor drug usage. If abstinence is achieved early in treatment (within two weeks), continuing SE therapy is at least as good an approach as individual drug counseling or cognitive-behavioral therapy. In fact, for cocaine dependent patients with family/social problems, SE therapy may be preferable, as greater long-term improvements in these problem areas might accrue. If early abstinence is not achieved, SE therapy is not indicated, as relatively poorer outcomes will be evident for such patients in SE compared to IDC. Thus, if a patient cannot get “clean” with a few weeks in SE therapy, the therapist should recommend that the patient begin a course of group and individual drug counseling at an addiction treatment program. Before making this recommendation, however, the psychodynamic clinician should be aware that if a patient has three or more of the prognostic attributes, there is a good chance (more than two-thirds of the time) that the patient will achieve initial abstinence in SE therapy (plus GDC). Some flexibility in the timing of the decision to refer or not is probably indicated if a patient has three or more of the predictive attributes and appears to be headed towards abstinence but has not yet achieved it.

We recognize that the above set of recommendations is based on exploratory analyses from one study, and therefore there is not a robust empirical basis for the proposal. Other studies have found non-encouraging results for SE and other therapies for cocaine dependence (Kang et al., 1991). Moreover, other treatment approaches such as community reinforcement (i.e., providing vouchers of monetary value to patients for clean urines) have shown efficacy in the treatment of cocaine dependence (Higgins et al., 1993) and should be considered as treatment alternatives. However, a relatively large portion of clinicians in the community identify themselves as psychodynamic or eclectic with a primary psychodynamic orientation (Jenson et al., 1990). Patients with cocaine dependence will therefore show up in the offices of psychodynamic therapists and some guidance to these clinicians about whether or not to offer psychodynamic therapy to such patients seems warranted. Any such recommendations will of course need to be modified as further empirical data accrues.

Of course, the clinical guidance that we are offering based on the findings reported here needs to be understood within the context of the limitation of this research. One important limitation is that there are actually many different forms of psychodynamic therapy; the NIDA Cocaine Collaborative Study investigated only one of these forms (supportive-expressive therapy). Other forms of dynamic therapy might yield better, or worse, outcomes. Related to this limitation is the fact that the SE therapists were carefully selected and trained for this study, and all had substantial previous experience in treating substance abuse. Thus, the results do not apply to psychodynamic therapists who are not trained, not supervised, and not experienced in working with a substance use disorder population. In addition to the type of psychodynamic therapy and the background/training of the therapists, another important limitation might be the session frequency. Regardless of the specific theoretical model, it is possible that a higher session frequency for individual therapy than the method implemented in this study (twice/week for 12 weeks followed by once/week thereafter) might help more patients achieve initial abstinence.

Another limitation is that the NIDA Cocaine Collaborative Study implemented an initial stabilization phase over a two week period before individual therapy began. Only patients who were motivated enough to attend clinic visits for education and assessments during this initial stabilization phase were randomized to treatment. Thus, the outcome results do not generalize to all patients who initially make contact with a treatment provider. Other aspects of the inclusion/exclusion criteria also limit generalizability of the findings. Most notable is the exclusion of any patient currently taking psychotropic medication. About 30% of screened patients were excluded for this reason. Since the collection of data for this study (1993 to 1996), even more patients are likely to be currently receiving medications because of the widespread increasing usage of selective serotonin reuptake inhibitors for both anxiety and depressive disorders over the past 15 years. It might be the case that such patients currently receiving psychotropic medications, but still in need of treatment for both substance dependence and psychiatric symptoms, are the prime candidates for benefiting from psychotherapy in addition to group drug counseling. Thus, the study may have excluded some of the best candidates for SE therapy. However, it should be noted that the sample of patients who did enter treatment was not free of co-morbid psychiatric symptoms. On the ASI Psychiatric Composite scale, the mean score at baseline for the current sample was very similar to that in another study of psychotherapies and pharmacotherapy for cocaine dependence (Carroll et al., 1994).

A final limitation is that other types of roles for psychodynamic therapy in the treatment of cocaine dependence were not explored in this study. For example, it may be that dynamic psychotherapy is most productive after cocaine dependent patients have first achieved a prolonged period of abstinence. Neuroimaging studies have found that three months of abstinence from cocaine is not adequate to return neurotransmitter systems to normal functioning (Volkow et al., 1993), and that, at least for methamphetamine dependence, as long as one year of abstinence appears necessary for recovery of brain neurotransmitters (dopamine transporter) functioning (Volkow et al., 2001). Perhaps psychodynamic therapy is best utilized after this brain recovery has occurred.