Drug addiction is often seen as an excessively simple problem ; addicts are criminalized, assuming that they have “chosen” to lead their lives along that path, and that if they do not change for the better it is because they lack willpower.

However, the reality is much more complex than that. Substance dependence has several dimensions, and one of the most important has to do with how context influences the person. That means that not everything is reduced to the will power of the addict or to making wrong decisions, and fortunately it also means that by modifying the context, recovery can be achieved, overcoming the addictive disorder.

In the following lines you will find an interview with Pablo Carbajosa, a psychologist specialized in Clinical Psychology, who works at the Centro Psicológico Cepsim (located in the Chamberí area, Madrid) helping patients with drug addictions of all kinds, among other things. Let’s see how placing patients in other contexts and training them to modify their environment in their favour can help them to leave drugs behind.

Interview with Pablo Carbajosa: the psychology of drug addiction

Pablo Carbajosa is a psychologist specialized in behavioral and mental health disorders related to adverse contexts: sequels of family violence, sexual abuse and drug addiction. From the Centro Psicológico Cepsim, psychotherapy clinic in Madrid, he helps patients whose interactions with their close environment have led them to develop psychological alterations such as substance dependence, trauma or extremely low self-esteem.

What are the most commonly used drugs among patients with addiction problems who come to the psychologist for help?

In our center the most common in adults are alcohol, cocaine and hashish. Among younger users the main problem is the use of hashish and designer drugs, and on weekends others like ecstasy and cocaine.

Can one speak of a profile of the regular drug user with addiction problems? Or are there several profiles?

There is no single profile of a drug user. Research shows different typologies of users depending on sociodemographic variables, the drug of consumption, severity of dependence and personality traits.

Today we know that there are certain personality traits such as impulsivity, sensation-seeking or self-control that are related to the age of onset of consumption and the severity of the addiction. Also important is the high prevalence of borderline and antisocial personality traits and disorders, especially in cocaine users. The presence of these factors is related to a higher probability of abandoning treatment.

A thorough case evaluation with special attention to how these factors are configured in each person is essential for designing an effective intervention.

What are the main reasons why people with drug addiction problems start using these substances?

Consumption usually begins in adolescence or youth, associated with leisure activities on weekend trips. It usually begins with the consumption of alcohol, and in the peer group they seek to try new experiences by trying hashish, cocaine or designer drugs.

And the reasons why they start going to psychotherapy?

Although each case is unique and the motivations are multiple, in general the reasons are related to some type of negative consequence derived from the continued consumption of substances.

Consumption begins to generate family, economic, work and mood problems. In adolescents or young people, it is common for parents to discover this due to changes in mood, isolation, school problems, aggressive behaviour or unjustified excessive spending of money.

Initially these young people come basically because of family pressure, they have little motivation for treatment and very little awareness of the problem. Generating this motivation to change and increasing awareness of the problem will be one of the cornerstones of initiation and during treatment.

In adults, it is common that after years of weekly or monthly use and several failed attempts to control use and not be able to maintain abstinence, awareness of the problem begins to appear. Usually, the partner or family discovers the problem and treats it as a condition for continuing the relationship.

In other cases, consumption begins to generate work and economic problems, or affects general mood (depression, anxiety, irritability). In these cases it is common that the frequency of consumption in the last year has been increasing, and also the feeling of lack of control.

It’s hard to summarize the work of psychologists, but… what are the techniques and tools that psychotherapy professionals usually use to treat people with addiction problems?

The techniques will depend on the treatment approach we use and whether it was worked in a group or individual format, in a public outpatient facility or in a therapeutic community.

However, along with general techniques, motivational interviewing to address motivation and problem awareness is critical.

Cognitive behavioural model techniques such as relaxation, cognitive restructuring or current techniques such as the EMDR-based Detur protocol or Mindfulness will be fundamental for intervening on specific characteristics of this population, such as craving management or the urge to consume.

It is also necessary to use techniques directed at the lifestyle of the addict and the environments of consumption. It is important to agree with the person and to establish commitments in a gradual way of control to stimulate (economic control, avoiding environments and people associated with consumption, etc.) and management of contingencies to reduce as much as possible the stimuli that trigger the desire to consume.

At the same time, it is necessary to work on all personal aspects related to consumption. At the end of the treatment the techniques will focus on the relapse prevention approach.

In what ways do you think it is important for psychologists to be humane and close to substance dependent patients?

Fundamental in cases of patients with addictions. One of the specific characteristics of this type of person is that the motivation to change and awareness of the problem is usually low initially and fluctuates greatly throughout the treatment. This makes establishing a good therapeutic alliance a key to the success of the treatment.

Is it necessary to strengthen the self-esteem of these people so that they are confident in their ability to leave drugs behind?

In many cases there may be serious trauma or attachment problems prior to consumption. In addition, continued consumption itself puts the person at personal risk and erodes self-esteem. This causes the consumption itself to generate negative consequences at a personal, work and family level.

All this will affect self-esteem and the feeling of self-efficacy or ability to stop using. Strengthening self-esteem, motivating change and increasing the sense of self-efficacy will be an ongoing goal during treatment.

It is probably not easy for a patient who is addicted to substances to make a serious commitment to therapy. What can psychologists and family members of patients do to encourage them to stay in treatment?

Motivation and awareness of the problem are one of the keys to this issue. Motivation is fed by both positive and negative consequences. To promote awareness of the problem and motivate change, the family has to support the process at all times, but keep pressure on the negative consequences of abandoning it. The balance between these two aspects will help to maintain motivation.

In the case of professionals, continually strengthen the therapeutic alliance and be aware of fluctuations in motivation. For example, it is common for patients who achieve a time of abstinence, after a period of treatment, to feel that the problem is already overcome and to think about abandoning the treatment. Detecting these situations and reinforcing the need for further progress in the process of change, to maintain abstinence in the long term, will be critical.