Addiction and related disorders are chronic lapsing and relapsing disorders where the combination of long term pharmacological and psychosocial managements are the mainstay approaches of management. Among the psychosocial interventions, the Relapse Prevention (RP), cognitive-behavioural approach, is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours. Here the assessment and management of both the intrapersonal and interpersonal determinants of relapse are undertaken. This article discusses the concepts of relapse prevention, relapse determinants and the specific interventional strategies.

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Addiction is the term employed not only for excess consumption of substances, but also for problem behaviours like eating disorders, pathological gambling, computer addiction and pathological preoccupation with video games and sexual acts. No clear diagnostic criterion has been established with validity for behavioral addictions. Sexual addiction, including addiction to pornography is not included as a separate entity because of a lack of strong empirical evidence in this area. Different scales can be used for assessment of sexual addiction. Since there is an absence of established diagnostic criteria, the significance of validity of these scales is doubted. Several of the questions in these scales do not yield information about whether the diagnostic criteria are met or not. Pharmacotherapy, together with psychotherapy proves to have a better outcome in such patients as it helps to synthesize the role of developmental antecedents, reduce current anxiety, depression, guilt and to improve social adjustment.

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This article provides an overview of the tools for psychosocial assessment of substance use disorders. Various psychosocial factors need to be assessed for effective management of individuals and to carry out research in the field. These factors include socio-demographic characteristics, neuropsychological functions, psychiatric co-morbidities, psychological vulnerabilities such as personality traits, motivation, and cognitions related to drug use, and the psychosocial functioning of the individual and his family. The various tools used to assess these aspects have been outlined below and the brief descriptions provided can help in choosing the right tool based on the characteristics that need to be measured and logistics.

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Over the past four decades, psychiatric social workers have been conducting group interventions for persons with substance use disorders at NIMHANS. In this article, the authors highlight the brief history of group therapy, differences between group therapy and group work, and purpose and indicators of group therapy. This article sheds light on practical aspects of conducting group interventions for persons with substance use disorders and skills required by the group therapist for conducting the same andbenefits of attending group interventions. Research studies carried out at NIMHANS on group intervention for persons with substance use disorders, assessing group processes, dynamics and outcome of group interventions have been highlighted as well.

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Substance abuse is a family disease that adversely impacts both the user and the user's family. The family can act as a risk factor for the development of substance abuse among children and adults. The family can also be involved in therapy to either help the recovery process or prevent substance abuse. Marital and family therapy have been found to be effective in reducing the severity of substance use, lowering marital and family conflict, improving family communication and cohesion as well as effective parenting practices. Behavioural Couples Therapy has been found to have good empirical support for bringing about the desired changes in both substance abuse and marital relationship. While targeting entire families, the most common evidenced based family interventions are Brief Strategic Family Therapy, Multidimensional Family Therapy, Family Behaviour Therapy, Functional Family Therapy and Community Reinforcement Programme. Marital and family therapy have to be sensitive to gender and culture. Effective use of marital and family therapy requires adequate training to equip practitioners in adequately treating not only substance use disorders and family pathology, but also in treating co-morbid mental health conditions.

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Increase in the use of technology has led to an increase in various kinds of technological addictions. A range of psychological and behavioural theories has been proposed to explain technology addictions. These include learning theories, reward-deficiency hypothesis, impulsivity, cognitive-behavioural models and social skills deficiency theories. While no particular form of psychological intervention has been suggested as being the golden standard for its treatment, the most frequently investigated approaches have been cognitive behavioural therapy (CBT) and motivational enhancement therapy. Given the need for the use of technology in daily living, controlled use has taken precedence over complete abstinence as the goal of treatment for technology addictions. Therapeutic techniques suggested for internet addiction include practicing the opposite, using external stoppers, setting goals, selective abstinence from certain applications, using cues, making personal inventories, joining support groups and family therapy interventions.

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Cognitive behaviour therapy is a structured, time limited, psychological intervention that has is empirically supported across a wide variety of psychological disorders. CBT for addictive behaviours can be traced back to the application of learning theories in understanding addiction and subsequently to social cognitive theories. The focus of CBT is manifold and the focus is on targeting maintaining factors of addictive behaviours and preventing relapse. Relapse prevention programmes are based on social cognitive and cognitive behavioural principles. Interventions for preventing relapse include, behavioural strategies to decrease the valence of addictive behaviours, coping skills to deal with craving, arousal, negative mood states, assertiveness skills to manage social pressures, family psychoeducation and environmental manipulation and cognitive strategies to enhance self-efficacy beliefs and modification of outcome expectancies related to addictive behaviours. More recent developments in the area of managing addictions include third wave behaviour therapies. Third wave behaviour therapies are focused on improving building awareness, and distress tolerance skills using mindfulness practices. These approaches have shown promise, and more recently the neurobiological underpinnings of mindfulness strategies have been studied. The article provides an overview of cognitive behavioural approaches to managing addictions.

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Unhealthy substance use lies on a wide range that extends from occasional mild risky/harmful/hazardous use to severe substance use disorder. Brief intervention (BI) is a technique, used to initiate change for an unhealthy or risky substance use. It can be delivered by a vast array of trained professionals, in opportunistic settings (i.e. in people seeking help not for their substance use, but either its consequences or for completely unrelated physical or psychiatric disorders), and across substances, age and ethno-cultural groups. The six common elements of BIs are summarized by the acronym FRAMES, consisting of Feedback, Responsibility, Advise, Menu for change, Empathy, and enhancing Self-efficacy. BI has also been strategically combined with referral to appropriate treatment services. BI has shown efficacy for reducing substance use and its harmful consequences. The evidence for post-BI improved functionality and quality of life are also emerging.

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The expanding use of digital technology in mental health has widened the scope of emerging addiction interventions. This review focus on the use of technological advances in the field of addiction and mental health. We discuss about how these advances has been implemented in addiction treatment and research. Further, we also mention about the utilisation of these services in India.

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While guidelines for psychosocial interventions in addictive disorders in India were earlier rooted in clinical experience and global empirical evidence, recently there have been efforts to develop guidelines for intervention based on the local needs assessments of specific populations and more appreciably, a testing of the effectiveness of the interventions. This supplement on psychosocial interventions for addictive disorders covers some of the important aspects of psychosocial interventions in five sections. Section I covers the general principles of management and specific assessment approaches, screening for cognitive dysfunction and assessment of co-morbidities. Section II focuses on specific psychosocial interventions including brief interventions, relapse prevention, cognitive behavioural interventions, psychoanalytical interventions, cognitive rehabilitation, interventions in dual disorders, marital and family therapy, psychosocial interventions for sexual dysfunction and sexual addictions. Section III describes innovative approaches including third wave therapies, video-based relapse prevention, digital technology as a tool for psychosocial interventions as well as psychosocial interventions in technological addictions. The latter part of this section also deals with psychosocial interventions in special populations including children and adolescents, women, sexual minorities and the elderly. Section IV pans into community based psychosocial interventions including community camps and workplace prevention. The need to develop task sharing through the involvement of trained health workers to deliver community and home-based interventions is highlighted. Section V underscores the ethical issues in different aspects of psychosocial intervention and the need for research in this area. Although there is a tendency to formulate addiction in either biomedical or psychosocial terms and to view interventions either as pharmacological or psychosocial, these dichotomies neither exist in the affected individual's mind, nor should be present in the treating clinician. A comprehensive understanding of addiction requires an understanding of the person in his/her environment and needs a personalised holistic approach that addresses the diverse physical/mental health, occupational, legal, social and aftercare needs.

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Psychoanalytic psychotherapy can afford a viable treatment option for certain carefully chosen patients whose needs go beyond the immediate control of substance use. Though the evidence base specifically for addictions is lacking, an emerging body of evidence has demonstrated good effect in the commonly seen co-morbid conditions such as depression, anxiety and personality pathology.

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Management of patients with dual diagnosis (Mental illness and substance use disorders) is a challenge. A lack of improvement in either disorder can lead to a relapse in both. The current consensus opinion favours an integrated approach to management of both the disorders wherein the same team of professionals manages both the disorders in the same setting. The role of pharmacotherapy for such dual diagnosis patients is well established but the non-pharmacological approaches for their management are still evolving. After stabilization of the acute phase of illnesses, non-pharmacological management takes centre stage. Evidence points to the beneficial effect of psychosocial approaches in maintaining abstinence, adherence to medication, maintenance of a healthy life style, better integration in to community, occupational rehabilitation and an overall improvement in functioning. Psychosocial approaches although beneficial, are difficult to implement. They require teamwork, involving professionals other than psychiatrists and psychologists alone. These approaches need to be comprehensive, individualized and require training to various levels that is difficult to achieve in most Indian settings. In this article we provide a brief review of these approaches.

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Substance use disorders in children and adolescents are a significant cause of concern as they can have long term implications in practically every sphere. The etiological factors that contribute to substance use disorders are complex and the formulation must amalgamate and synthesize all the different factors including the predisposing, perpetuating, precipitating and protective factors in order to plan management. Interventions must stem from this comprehensive formulation and must be child-focused, multidisciplinary, multisystemic, with strong family participation and community involvement. The treating team must actively collaborate with the young person and help him/her understand the rationale for treatment in order for them to engage in it. Assessment and treatment of comorbidities are an important part of intervention package. Skill training for problem solving, emotional regulation, social skills, and communication are an essential part of the treatment for substance use disorders in adolescents. Relapse prevention strategies, including how to seek help when there is a lapse must be part and parcel of the interventions delivered to the young person. Substance use disorder interventions must be part of a larger plan that addresses other areas of concern in the young person's life. While there are few studies, and so a relatively weak and preliminary evidence base for pharmacotherapeutic interventions, early evidence shows that their combination with psychosocial interventions may have a synergistic effect on substance use reduction. Substance use disorders affect the entire family and the community at large and thus must be treated holistically, but by individualising the treatment to suit the needs of that particular child and family.

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Prevention in the community and at the workplace is a vital component in substance use disorder treatment and management. Mobilizing the community, creating awareness that addiction to substances is a disease, that it is treatable and that treatment is available are all essential. A cost-effective prevention and treatment approach plays a major role in creating drug free communities. Workplace prevention policies to prevent and manage substance use disorders leads to safer work environments, better motivated teams of workers and a productive workforce.

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Chronic use of mind altering substances can lead to a wide variety of neuropsychological deficits, affecting the domains of attention, learning, memory, reasoning. Executive functions such as working memory, cognitive flexibility and inhibitory control may specifically be impaired. These deficits can impact engagement in effective psychosocial interventions. Mild to moderate cognitive dysfunction may not be picked up in routine clinical examination or through commonly used tests like the mini-mental state examination (MMSE). Detailed neuropsychological tests, although extremely valuable, are time and human-resource intensive and are not readily available to the clinician. This study attempted to devise a brief cognitive screen (BCS- AUD) for alcohol use disorders. Ninety subjects who fulfilled ICD-10 criteria for alcohol use disorders were assessed on the MMSE and selective tests from the NIMHANS neuropsychological battery. While 79 (87.78%) of patients had adequate scores on the MMSE (>25), cognitive deficits were noted with relatively high frequency on finger tapping (92.22-93.33%), auditory verbal learning test delayed recall AVLTDR (37-63%) and Tower of London 5 move subtest (42%). Statistically significant associations were found between MMSE and Digit symbol total time (0.05), Finger tapping right hand (0.01), Tower of London total number of problems solved with minimum moves (TNPSMM) (0.05), Verbal working memory two back hits (VM2BKHIT) (0.01), AVLTDR (0.01), and complex figure test-copy (0.01). Principal component analysis helped to identify three tests that merited inclusion in the BCS-AUD, namely Finger Tapping Test, Verbal Working Memory N Back Test and Auditory Verbal Test (AVLT). The utility of the BCS-AUD in identifying cognitive dysfunction in other substance use disorders needs to be examined. Patients rating positive on the cognitive screener would require in-depth evaluation, monitoring and remediation.

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A large proportion of patients with substance use disorders have clinical comorbidities, either medical or psychiatric. An initial assessment is necessary initially for prompt identification and management of any psychiatric or medical emergency, and thereafter a more detailed assessment for the comprehensive understanding of the individual. This should be done keeping in mind the goals of both immediate and long term assessment so that a comprehensive but individualized, context and culture sensitive, reality based, recovery-oriented management plan can be formulated. Assessment should consist of not only history-taking, physical and mental status examination but also laboratory and instrument based assessment as needed. During assessment, collateral reports and past medical records are valuable additions along with self-report. Since substance use disorders influence various aspects of daily life, hence medical, social, occupational, religious, spiritual, financial and legal aspects should be evaluated. Overall, the assessment needs to be diagnosis and management focused, covering the various bio-psycho-social domains relevant to the individual.

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Recent research points to a shift from categorical diagnoses to a dimensional understanding of psychopathology and mental health disorders. In parallel, there has been a rise in newer psychosocial treatment modalities, which are inherently transdiagnostic. Transdiagnostic approaches are those that identify core vulnerabilities and apply universal principles to therapeutic treatment. As treatment of substance use disorders (SUD) must invariably accommodate such vulnerabilities, clinicians are finding such interventions useful. Therapies like Acceptance and Commitment Therapy (ACT), Dialectical Behavioural Therapy (DBT), Metacognitive Therapy, Mindfulness-Based Relapse Prevention (MBRP) use a transdiagnostic framework and are backed by evidence in the last 3-5 years. In this paper we first highlight the conceptual understanding of SUD through these frameworks and then discuss their clinical applications along with specific techniques that have been particularly useful with this population.

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Substance abuse and addictive disorders are very common in the community. Patients with addictive disorders frequently experience sexual dysfunctions and chronic use of substances tends to adversely affect all stages of sexual response, in both male and female abusers. An important aspect in the management of sexual dysfunction is psychosocial intervention. In addictive disorders, sexual dysfunction is of high clinical relevance, as it often leads to treatment non adherence and sexual or marital disharmony. Instead of a disease-centred approach, a couple and relationship centred approach of management is desirable. A detailed history about the sexual dysfunction, the addictive disorder and enquiry into various psychosocial aspects is mandatory for adequate management of the same. Sexual therapy, behavioural techniques, systematic sensitization and desensitization are some of the techniques used in the management of sexual dysfunction in addictive disorders.The assessment and treatment need to be tailored depending upon the various psychosocial aspects of the individual.

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Alcohol use disorders (AUD) are a significant and growing public health problem in India. However, health services for AUD remain largely confined to large institutions and a significant proportion of people with AUD do not having access to help for their alcohol related problems. One way of changing this status quo is making evidence based psychosocial interventions available in communities and closer to people's homes. There is extensive evidence supporting the effectiveness of a range of psychosocial interventions for AUDs. This is further augmented by the growing evidence for the effectiveness of contextually appropriate psychosocial interventions, such as Counselling for Alcohol Problems (CAP) from India, that are designed to increase access to care through delivery by non-specialist health workers. The effective implementation of such interventions integrated into collaborative care models will go a long way in reducing the treatment gap for AUDs in India.

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Substance use disorders are frequently associated with neuropsychological deficits. A comprehensive assessment of attention, memory, executive functions, language and mental speed is often warranted. Cognitive rehabilitation is a therapy programme designed as an intervention to help people with cognitive, behaviour and emotional deficits. Using systematic approaches such as cognitive retraining and EEG neurofeedback, the individuals are helped to be integrated into society.

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With the growing understanding of substance use problems among special populations like women, gender minority groups, as well as in the geriatric population, there is a drive to develop sensitive interventions catering to their unique needs. This chapter is a short review of psycho-social interventions targeted towards these individuals with specific needs.

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Addictive disorders have a strong psychosocial component in their etiogenesis, and hence psychosocial approaches form a significant part of management planning with a role in prevention, treatment, relapse prevention and long term rehabilitation. Due to a number of myths and misconceptions associated with addictive disorders, there is often strong resistance from the patients as well as the families towards treatment. The disorder is often perceived as a bad habit and hence not requiring treatment. It is very important to break this barrier to bring the patient and the family in treatment engagement. This article summarizes the need for psychosocial management of the addictive disorders, dealing with treatment resistance building therapeutic alliance, and improving the long term outcome.

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A major goal of long-term management of substance use disorders is to empower recovering individuals in resisting drug use when confronted with real-world high-risk situations (cues). Since opportunities to reproduce and learn from real-life situations are limited in treatment settings, the key is to bring those real-world drug use cues to the treatment setting through vicarious learning. Cue-exposure approaches achieve this by presenting these cues while the usual drug-use response is prevented. This provides opportunity to practice how to deal with the cues before being discharged from the treatment setting. Videos are one way to present the cues as well as demonstrate how to deal with them successfully. In this article, we discuss our experiences with the use of videos to model relapse prevention strategies for specific cues, and provide some future directions for the use of video-based interventions for relapse prevention in substance use disorders.

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A number of research designs have been used to study the efficacy of psychosocial interventions in addictive disorders, including open label studies and randomised controlled trials. Only through a rigorously conducted research, evidence base for effectiveness of a psychosocial intervention can be established. However, research on these interventions are fraught with a number of challenges. It is imperative for researchers to ask appropriate research questions based on sound theoretical understanding of psychiatric disorders, psychosocial interventions and research designs. This would help in choosing the less studied, relevant areas for in depth study as well as in using pragmatic, realistic research designs. Defining intervention clearly is as crucial, as is its uniform implementation across various treatment arms. In addition, tapping the mediators, moderators and confounders of treatment using appropriate methods while assessing the factors that directly impact the outcome is important to determine actual effects of psychosocial intervention. Barriers at different stages must be gauged proactively and dealt with, wherever possible.

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It is important for health professionals to have an ethical framework to help take decisions regarding psychosocial interventions in patients with addictive disorders. As patients with addictive disorders are vulnerable to unethical actions in the name of treatment, therapists need to aware of their role in delivering ethical care - not just in their own clinical practice but in the setting in which they deliver the interventions. This article aims to sensitize the health professional to the various arenas in which ethical challenges may arise.

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