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Treatment manual for supportive-expressive dynamic psychotherapy: Special adaption for treatment of cannabis (marijuana) dependence

NDARC Technical Report No. 26 (1995)
Overview of Supportive-Expressive Dynamic Psychotherapy

Supportive-expressive psychotherapy was developed  at the Menninger  Foundation and  Clinic, Menninger School of Psychiatry,  Topeka,  Kansas  in the late 1940s and 1950s and originated  in the papers on technique by Freud (Freud, 1910a; Freud, 1910b; Freud,  1912a; Freud, 1912b; Freud,  1912c; Freud, 1913a; Freud, 1913b; Freud,  1914; Freud, 1915; Freud, 1916-17; Freud, 1919; Freud, 1926; Freud, 1937).  The treatment is systematically documented in a manual  (Luborsky, 1984) that includes  methods for evaluating adherence to the technique.

This present manual should be read in conjunction with the Freud papers on technique cited above and the general Luborsky (1984) SE manual.  A number of special versions of  the  main  SE manual exist  which  are  tailored   for  specific  disorders : opiate dependence (Luborsky,  Woody,  Hole & Velleco, 1995), depression (Luborsky  et al.,1993), cocaine dependence and now this version for cannabis dependence.  Although supportive-expressive dynamic  psychotherapy has been  established as an effective form  of treatment for opioid  dependence and  depression, its effectiveness  is as yet unevaluated for cannabis dependence. This manual was developed  for the purpose  of conducting a controlled study of SE psychotherapy of cannabis dependence.   A controlled  evaluation  is presently  being conducted  at the National  Drug and Alcohol Research Centre (1995-1996) and preliminary  results suggests it is of significant benefit to this drug  using population. However, final results and follow-up data are not yet in at the time of the publication of this manual.

The treatment can be either  time-limited  (with a set termination date)  or unlimited. The term 'supportive-expressive' (SE) refers to the two main treatment techniques  of this approach.  Supportive techniques are ones developed  by the therapist  to create a positive, helpful and empathic relationship with the patient.  Expressive techniques are those  used  by the therapist that are aimed  at helping  the patient  to express  and  to understand and change problems.   The focus is on identifying and interpreting each patient's  recurring problematic interpersonal  relationship themes as they occur (a) with the therapist (transference),  (b) in relationships with other  people, such as partners, family, friends  and  parents, and  (c) around  specific behaviours (e.g. drug  taking)  as attempts at finding solutions to the life problems.

The treatment has been  repeatedly and  successfully  evaluated over  the past  thirty years.    For example,  the  Penn  Psychotherapy Project  (Luborsky,  Crits-Christoph, Mintz & Auerbach, 1988) evaluated the treatment  on 73 mixed diagnosis  patients and found a high mean Effect Size of 1.05. It has been used in the treatment of Chronic and Major Depression  with even higher mean Effect Sizes of 1.80 and 2.75 respectively  on the Global Assessment Scale (Luborsky, et al, 1993; Luborsky et al., in press).  It was a key  treatment  in  the  VA-Penn   psychotherapy study  of  treatment for  opioid­ dependence (Woody  et al., 1983), the largest  and  and  most  successfully  conducted study of  its  type.    In  this  study, SE psychotherapy plus  drug   counselling was compared to cognitive-behavioural (CB) therapy plus  drug counselling and  drug counselling  (DC) alone.  At one month follow up, pre vs post differences tended  to be significant for the SE  and CB groups  and slightly less often for the DC group.   The SE and  CB groups reduced  drug  use more than  the DC group.  The SE patients  made significantly greater  improvements than  the CB group on  measures of psychiatric functioning and employment, whilst the CB group had greater improvements in legal status.   These gains were maintained at 12-month  (Woody, et al. 1987) follow up  for the SE group, with further  improvement in psychiatric  functioning, legal status  and employment. The CB group  also maintained  gains with further improvements in drug use and psychiatric condition.  Supportive-expressive psychotherapy is currently being compared  to cognitive-behavioural therapy in a large scale NIDA-funded collaborative study  of treatment of cocaine abuse.