NREPP: Supportive-Expressive Psychotherapy

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Supportive-Expressive Psychotherapy
Date of Review: October 2007

Supportive-Expressive Psychotherapy (SE) is an analytically oriented, time-limited form of focal psychotherapy that has been adapted for use with individuals with heroin and cocaine addiction. Particular emphasis is given to themes related to drug dependence, the role of drugs in relation to problem feelings and behaviors, and alternative, drug-free means of resolving problems. SE comprises two main components. The first component uses supportive techniques designed to allow patients to feel comfortable in discussing their own personal experiences. In this phase, the therapist focuses on developing a helping relationship with the patient and on identifying and bolstering the patient's strengths and areas of competence. The second component involves the use of expressive techniques to assist the patient in understanding his or her problematic relationship patterns, so that the patient can work through these themes within the context of the patient-therapist relationship. To achieve this goal, the therapist employs unreflective listening, evaluative understanding, and responding to identify the problematic relationship themes. SE helps patients explore the meanings they attach to their drug dependence and address their relationship problems more directly, thus allowing the patients to find better solutions to life problems than drug use.

Descriptive Info Outcomes Ratings Study Populations Studies/Materials Contacts

Descriptive Information

Topics	Substance abuse treatment
Outcomes	Outcome 1: Psychological functioning Outcome 2: Severity of addiction Outcome 3: Methadone dosage Outcome 4: Use of prescribed psychotropic drugs Outcome 5: Drug abuse
Study Populations	Age: 18-25 (Young adult), 26-55 (Adult) Gender: Female, Male Race: Black or African American, White (See Study Populations section below for percentages by study)
Settings	Outpatient
Implementation History	The original trials of SE conducted in the 1980s involved about 200 patients in 4 sites. Implementation of this intervention since the original trials has not been tracked by the developer.
Replications	No replications were identified by the applicant.
Adaptations	No population- or culture-specific adaptations were identified by the applicant.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the applicant.
Public or Proprietary Domain	Public
Costs	Staff time is the primary cost involved in implementing SE. In original trials, the intervention was implemented by doctoral-level staff with psychiatry or medical degrees and training in analytical therapy.

Outcomes

Outcome 1: Psychological functioning

Description of Measures	Psychological functioning was assessed using self-report psychological tests measuring affect, cognition, and other psychiatric symptoms, including the Beck Depression Inventory (BDI), the Maudsley Personality Inventory, and the Hopkins Symptom Checklist.
Key Findings	In one study, patients who received SE evidenced lower levels of depression as measured by the BDI at 7-month follow-up (p = .01) compared with patients in cognitive-behavioral therapy (CBT) and drug counseling (focused on external services and needs as opposed to intrapsychic processes). SE patients also exhibited improved psychological functioning compared with the two other groups as measured by the Maudsley Personality Inventory (p = .01). The SE group showed improved psychological functioning as measured by the Hopkins Symptom Checklist (p = .01), although they did not differ on this outcome from the CBT group. The addition of psychotherapy (SE or CBT) to drug counseling was most effective in patients with high psychiatric severity. High-severity patients who received SE or CBT plus drug counseling improved significantly compared with patients who received drug counseling alone as measured by the Beck Depression Inventory (p = .01) and the Maudsley Personality Inventory's neuroticism score (p = .04). In another study, patients receiving SE showed improved psychological functioning from baseline to 1- and 6-month follow-ups as measured by the BDI (p < .001) and by the Maudsley Personality Inventory's measure of neuroticism (p < .01).
Studies Measuring Outcome	Study 1, Study 2 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 2: Severity of addiction

Description of Measures	Severity of addiction was measured using the Addiction Severity Index (ASI), a clinical/research interview that assesses problem severity in areas of functioning commonly impaired in drug-dependent patients. The outcomes reported here focus on the employment and drug use areas of the ASI. The interview uses both objective and subjective questions to measure the number, extent, and duration of problem symptoms over the patient's lifetime and during the past 30 days.
Key Findings	In one study, SE patients evidenced fewer and less severe problem symptoms in the employment area as measured by the number of days worked and the amount of money earned at 7-month follow-up (p = .01) compared with patients in CBT and drug counseling (focused on external services and needs as opposed to intrapsychic processes). Relative to the drug counseling group, the SE group also exhibited fewer and less severe problem symptoms in the drug use area at follow-up as measured by the number of days in which opiates and sedatives were used (p = .05); no differences were found relative to the CBT group on this outcome. The addition of psychotherapy (SE or CBT) to drug counseling was most effective in patients with high psychiatric severity. High-severity patients who received SE or CBT plus drug counseling improved significantly in the employment area compared with patients who received drug counseling alone (p = .02). In another study, SE patients showed fewer and less severe problem symptoms in the employment area as measured by the number of days worked and the amount of money earned at 6-month follow-up (p < .05). SE patients also exhibited fewer and less severe problem symptoms in the drug use area as measured by the number of days opiates, depressants, and stimulants were used at 1-month (p < .01) and 6-month follow-up (p < .001); this change was not exhibited by the drug counseling group.
Studies Measuring Outcome	Study 1, Study 2 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 3: Methadone dosage

Description of Measures	Methadone dosage was assessed using standard clinical records. Dosage changes are typically requested by the patient in therapy and then recommended by the therapist to the physician (if the therapist believes such change is warranted). Decreases in methadone dosages are indicative of improved functioning.
Key Findings	In one study, although the SE group did not differ from the CBT group in the average methadone dose prescribed over the course of study, the SE group did have a significantly lower average dosage compared with the drug counseling group (p < .01). The addition of psychotherapy (SE or CBT) to drug counseling was most effective in patients with high psychiatric severity. High-severity patients who received SE or CBT plus drug counseling improved significantly in average dosage compared with patients who received drug counseling alone (p < .01).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 4: Use of prescribed psychotropic drugs

Description of Measures	Use of prescribed psychotropic drugs was assessed using standard clinical records. Changes in prescriptions for psychotropic medications are initiated by patients through describing their symptoms (most commonly depression, anxiety, or insomnia) to the therapist, who refers the patient to a physician for a final determination.
Key Findings	In one study, although the SE group did not differ from the CBT group in terms of the average percentage of patients receiving psychotropic medications, the SE group had a significantly lower average compared with the drug counseling group (p < .01). In addition, over the course of the study the proportion of patients in the SE group who were prescribed ancillary psychotropic medications decreased (p < .01) while this proportion increased in the drug counseling group (p < .01). The addition of psychotherapy (SE or CBT) to drug counseling was most effective in patients with high psychiatric severity. High-severity patients who received SE or CBT plus drug counseling improved significantly compared with patients who received drug counseling alone in terms of the frequency of prescription of psychotropic medications (p < .01).
Studies Measuring Outcome	Study 1 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Outcome 5: Drug abuse

Description of Measures	Screening for 24 different drugs was performed using urinalysis a minimum of once (more typically twice) per week.
Key Findings	Over the course of one study, groups receiving SE, CBT, and drug counseling (focused on external services and needs as opposed to intrapsychic processes) showed significant decreases in positive results related to the abuse of various drugs (p < .05), but there were no differences among the three groups. The addition of psychotherapy (SE or CBT) to drug counseling was most effective in patients with high psychiatric severity. High-severity patients who received SE or CBT plus drug counseling improved significantly in the proportion of drug-positive urine tests relative to patients who received drug counseling alone (p < .01). In another study, SE participants had a lower percentage of urine samples testing negative for cocaine across the study compared with the drug counseling group (22% vs. 36%; p < .02).
Studies Measuring Outcome	Study 1, Study 2 (Study numbers correspond to the numbered citations in the Studies and Materials Reviewed section below)
Study Designs	Experimental
Quality of Research Rating	2.7 (0.0-4.0 scale)

Ratings

Quality of Research Ratings by Criteria (0.0-4.0 scale)

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
Outcome 1: Psychological functioning	4.0	3.5	3.5	2.5	2.0	2.5	3.0
Outcome 2: Severity of addiction	4.0	3.5	3.5	2.5	2.0	2.5	3.0
Outcome 3: Methadone dosage	4.0	3.5	3.0	2.5	1.5	1.5	2.7
Outcome 4: Use of prescribed psychotropic drugs	4.0	3.5	3.0	2.5	1.5	1.5	2.7
Outcome 5: Drug abuse	4.0	3.5	3.0	2.5	1.5	1.5	2.7

Study Strengths: The studies were among the very first of their kind, using state-of-the-art clinical trials methodology for behavioral therapy, with training manuals, treatment fidelity assessments, and state-of-the-art client assessments. The measures used in these studies have excellent psychometric properties, are widely used today, and are considered excellent measures. The studies showed a strong emphasis on treatment fidelity, particularly in the use of tape recordings (a precursor to what is typically used today and rare at the time these investigations were completed).

Study Weaknesses: The studies used unbalanced designs (unequal number of participants in the conditions) that may have introduced bias that is difficult to quantify or measure. With respect to contemporary standards in the field, the methods for handling missing data, data analysis in general, and the assessment of intervention fidelity were weak.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

Implementation Materials	Training and Support	Quality Assurance	Overall Rating
1.5	0.5	2.8	1.6

Dissemination Strengths: The program materials describe the broad elements of the intervention from intake through discharge, addressing a difficult-to-treat population. Detailed therapist adherence scales are available to support quality assurance. The developers offer assistance to implementers in using these scales.

Dissemination Weaknesses: The materials assume that implementers have completed previous training in dynamic psychoanalytically oriented psychotherapy. The book chapter provides a general overview of the clinical approach but lacks the detail of a complete training manual. No formal training or support is available to potential implementers or supervisors. It is unclear who would administer adherence scales.

Study Populations

The studies reviewed for this intervention included the following populations, as reported by the study authors.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult)	100% Male	60% Black or African American 40% White
Study 2	26-55 (Adult)	60% Male 40% Female	57% Black or African American 43% White

Studies and Materials Reviewed

The documents below were reviewed for Quality of Research and Readiness for Dissemination. Other materials may be available. For more information, contact the person(s) listed at the end of this summary.

Quality of Research Studies

Study 1

Luborsky, L., McLellan, A. T., Woody, G. E., O'Brien, C. P., & Auerbach, A. (1985). Therapist success and its determinants. Archives of General Psychiatry, 42(6), 602-611.

Woody, G. E., Luborsky, L., McLellan, A. T., O'Brien, C. P., Beck, A. T., Blaine, J., et al. (1983). Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry, 40(6), 639-645.

Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1985). Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42(11), 1081-1086.

Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1987). Twelve-month follow-up of psychotherapy for opiate dependence. American Journal of Psychiatry, 144(5), 590-596.

Woody, G. E., McLellan, A. T., Luborsky, L., O'Brien, C. P., Blaine, J., Fox, S., et al. (1984). Severity of psychiatric symptoms as a predictor of benefits from psychotherapy: The Veterans Administration-Penn study. American Journal of Psychiatry, 141(10), 1172-1177.

Study 2

Woody, G. E., McLellan, A. T., Luborsky, L., & O'Brien, C. P. (1995). Psychotherapy in community methadone programs: A validation study. American Journal of Psychiatry, 152(9), 1302-1308.

Quality of Research Supplementary Materials

Woody, G. E. (2003). Research findings on psychotherapy of addictive disorders. American Journal on Addictions, 12(Suppl. 2), S19-S26.

Readiness for Dissemination Materials

Barber, J. (1997). Adherence/Competence Scale for Supportive-Expressive Therapy for Cocaine Dependence (ACS-SEC).

Barber, J. (n.d.). Penn Adherence Scale for Supportive-Expressive Therapy for depression.

Barber, J. (n.d.). Preliminary manual for the SE Adherence Scale. Version 1.2.

Luborsky, L., Woody, G., Hole, A., & Velleco, A. (1995). Supportive-expressive dynamic psychotherapy for treatment of opiate drug dependence. In J. P. Barber & P. Crits-Christoph (Eds.), Dynamic therapies for psychiatric disorders (Axis I) (pp. 131-160). New York: Basic Books.

Submission of Supportive-Expressive Psychotherapy for Methadone Maintained Patients With High Levels of Psychiatric Symptoms for Consideration of Inclusion in NREPP (two-page overview of intervention, research findings, and training and dissemination)

Contact Information

For information about implementation or studies:

George E. Woody, M.D.
Professor and Vice Chair of Psychiatry
Department of Psychiatry
University of Pennsylvania
600 Public Ledger Building, 150 South Independence Mall West
Philadelphia, PA 19106
Fax: (215) 399-0987
E-mail: woody@tresearch.org

The NREPP review of this intervention was funded by the Center for Substance Abuse Treatment (CSAT).