Interview with Pablo Carbajosa: how does drug addiction work?

This psychologist speaks from his experience helping patients with substance dependence.

Drug addiction is often seen as an excessively simple problem; addicts are criminalized, assuming that they have "chosen" to lead their lives.addicts are criminalized, assuming that they have "chosen" to lead their lives down 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 the context influences the person. This means that not everything is reduced to the addict's willpower or the fact of making the wrong decisions, and fortunately it also means that by modifying the context it is possible to achieve recovery, to overcome 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 area of Chamberí, 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 favor 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: after-effects of family violence, sexual abuse and drug addiction. From Centro Psicológico Cepsim, a psychotherapy clinic in Madrid, helps patients whose interactions with their close environment have led them to develop psychological disorders 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 consumption of hashish and designer drugs, and on weekends others such as ecstasy and cocaine.

Is it possible to speak of a profile of the habitual drug user with addiction problems, or are there several profiles?

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

We now know that there are certain personality traits such as impulsivity, sensation seeking or self-control that are related to the age of onset of use and the severity of 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 treatment dropout.

A comprehensive case assessment with special attention to how these factors are configured in each person is essential to design an effective intervention.

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

Consumption usually begins in adolescence or youth, associated with leisure and weekend outings. 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 kind of negative consequence derived from continued substance use.

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

Initially these young people come basically because of family pressure, they present little motivation to 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 at the beginning and during treatment.

In adults, it is common that after years of weekly or monthly consumption and several failed attempts to control consumption and not being able to maintain abstinence, awareness of the problem begins to appear. Often the partner or family discovers this and treatment is made a condition for continuing the relationship.

In other cases, consumption begins to generate work and economic problems, or affects the 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 is complicated 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 we work in a group or individual format, in a public outpatient center or in a therapeutic community.

However, along with the general techniques, motivational interviewing to address motivation and awareness of the problem are fundamental.

Cognitive behavioral model techniques such as relaxation, cognitive restructuring or current techniques such as the Detur protocol based on EMDR or Mindfulness will be essential to intervene on specific characteristics of this population, such as craving management or urgency of consumption.

It is also necessary to use techniques aimed at the addict's lifestyle and consumption environments. It is important to agree with the person and gradually establish commitments to stimulate control (economic control, avoidance of environments and people associated with consumption, etc.) and contingency management to reduce as far as possible the stimuli that trigger the urge 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 human 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 low motivation to change and awareness of the problem is usually low initially and very fluctuating throughout the treatment. This means that establishing a good therapeutic alliance is key to the success of the treatment.

Is it necessary to reinforce the self-esteem of these people so that they have confidence in their ability to leave drugs behind?

In many cases there may be traumas or serious attachment problems prior to drug use. In addition, continued use itself puts the person in situations of 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 sense 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 substance addicted patient to make a serious commitment to therapy. What can psychologists and patients' families do to encourage them to stay in treatment?

Motivation and awareness of the problem are one of the keys to this problem. Motivation is fueled by positive and negative consequences. To promote awareness of the problem and motivate change, the family must support the process at all times, while maintaining pressure on the negative consequences of abandonment. The balance between these two aspects will help to maintain motivation.

In the case of professionals, continually reinforce the therapeutic alliance and be attentive to fluctuations in motivation. For example, it is common for patients who achieve a period of abstinence, after a period of treatment, to feel that they have already overcome the problem and think about abandoning treatment. Detecting these situations and reinforcing the need to continue advancing in the process of change, in order to maintain abstinence in the long term, will be fundamental.