How Psychotherapies are Used in Addiction Treatment
For one thing, everyone is different. For another, so is every SUD and every substance.
Add another mental health issue (an SUD is itself a mental health disorder, but it can co-occur with others, such as anxiety, depression, and bipolar disorder), and it is more unlikely that one solution will solve them all.
More than one approach may be needed, but most treatment plans include psychotherapy.
What Is Psychotherapy?
Almost all treatments for substance use disorders—including medication-assisted treatment (MAT), in which low-level maintenance doses of drugs are used to control cravings without euphoric effects—incorporate or are based on classic psychotherapy. Also known as talk therapy, psychotherapy involves talking with a trained counselor, psychologist, psychiatrist, or some other trained professional to help deal with a substance use disorder, another mental health issue, or both.
Psychotherapy usually involves changing current behavior, understanding past problems, or both. The therapist and the client form an interpersonal relationship to help the client become an individual who can cope with life and solve problems in a healthy way without resorting to violence or substance abuse.
Psychotherapy isn’t just talking and it isn’t passive. Both the client and the therapist must work for the therapy to succeed.
Cognitive Behavioral Therapy
One of the most effective psychotherapies is cognitive behavioral therapy (CBT), which is widely used by itself or in conjunction with other therapies at many substance abuse treatment centers. CBT lends itself well to one-on-one counseling or group therapy. The therapy is not a cure for SUDs but its goal is to cope with and change behaviors.
SUDs and other mental health issues aren’t the only conditions that benefit from CBT. So do other emotional challenges—sleep disorders, sexual dysfunction, phobias—brought on by grief, abuse, or trauma. Even chronic pain, which can lead to substance abuse, can be reduced or managed through CBT.
According to people who practice CBT, how we think affects how we feel and behave. Thoughts, feelings, and behaviors are all connected. Automatic and negative thoughts give individuals a negative view of themselves, the rest of the world, and their future. So, the way to change self-destructive behaviors based on unhealthy feelings and thoughts is to actively think better, more positive, but realistic thoughts.
When people think, “I can’t do this,” often they can’t because they don’t try or subconsciously sabotage themselves. Instead, they need to think positive, fact-based thoughts, such as, “I can do this because I always have,” or “I have done similar or harder things before,” or “I studied and trained to do it.”
It’s more than just thinking happy thoughts. It’s about changing thought patterns and how you think. Some of it might sound like repeating mantras, but it could include other components, such as keeping a journal.
CBT requires clients to meet with therapists. During their sessions, clients and therapists can together root out negative thinking. This type of therapy can be emotionally painful in the short term but should not pose health risks.
It works in as few as five to 20 sessions. Studies of people undergoing CBT show changes in brain activity and possible improvements in brain functioning.
Rational Emotive Behavior Therapy
What is now known as rational emotive behavior therapy (REBT) was the first type of cognitive behavioral therapy. Psychologist Albert Ellis developed this approach in the 1950s.
REBT proposes that emotional and mental problems can arise from irrational beliefs and negative thoughts. The purpose of REBT is to replace them with rational and positive ones with the help of a therapist.
The gist of REBT is that people want approval and want to succeed. When we don’t, we can respond either rationally (it’s not the end of the world) or irrationally (I’m a bad person because I failed, you’re a bad person because you don’t approve of me, the world is a bad place because I didn’t succeed).
Because of this concern with success, REBT may be especially of use for athletes with mental health issues, including substance abuse.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is similar to CBT, except that it seeks understanding and acceptance of mental health issues, not necessarily changes.
While CBT has broad applications, dialectical behavior therapy was primarily (though not exclusively) used to treat people (initially mainly women) with severe borderline personality disorder (BPD) who were also suicidal. It has since shown some promise in treating co-occurring BPD and SUDs, among other mental health and behavioral issues.
There are four main components to DBT, starting with one-on-one sessions with a therapist. In those sessions, clients learn to control destructive behavior, experience healthy emotions, live life while setting and achieving goals, and build self-respect.
In addition to individual sessions with a therapist, DBT features 24 weekly skill-training “classes”—mindfulness and distress tolerance (acceptance), and emotion regulation and interpersonal effectiveness (change)—plus phone coaching with the therapist between sessions. The fourth component is for the therapist, a consultation team for when the therapist needs therapy or help with a client.
If the client has multiple problems, a common occurrence, the life-threatening problems (such as suicidal ideation) are addressed first, then those that might interfere with therapy, followed by quality of life issues. Finally, clients learn new coping skills.
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The purpose of motivational interviewing (MI) is to help clients overcome their resistance to change, which is to increase their motivation to change. To that end, the therapist is more actively involved in the therapeutic process than in traditional classic psychotherapy. That doesn’t mean that therapists are imposing their will on the clients.
With MI, the therapist and client aren’t exploring the issues that brought them together. The therapist is trying to get the client to want to change. If clients don’t want to change, they are far less likely to do so.
Through MI, therapists overcome this resistance by expressing empathy. They must be nonjudgmental. With MI, therapists reinforce that clients can achieve that goal by changing their behaviors.
When they encounter resistance, therapists will be better able to roll with it, accepting it instead of aggressively confronting or challenging it. They don’t argue, that can strengthen their clients’ resistance. Instead, they reframe the issue and explain that the behavior is inconsistent with the client’s stated goal (such as achieving sobriety, serving as a part of society, strengthening their families, and finding and keeping employment).
Motivational interviewing may show promise for increasing substance abuse treatment retention rates during the critical first month, particularly for those with alcohol use disorder.
If you’ve heard of Alcoholics Anonymous (AA), you probably are familiar with 12-step facilitation.
The 12 Steps are a formula devised by AA’s founders to help people become and stay sober by acknowledging their addiction to alcohol, making amends for the damage their drinking caused them and those around them, and helping others with their addictions.
Alcoholics Anonymous proponents say that people should work the steps in order, completing one step before advancing to the next. AA has freely shared the model with other groups, such as Narcotics Anonymous, and the steps are a part of many SUD rehab programs.
God or a higher power is mentioned several times, and prayers are recited (chiefly the Serenity Prayer and The Lord’s Prayer), but they are otherwise secular.
AA and other 12-step facilitation programs don’t only involve the 12 Steps. Meetings also include members relating stories of their successes and failures on the road to sobriety.
Such programs often offer mentorship services in which longtime sober members sponsor the newly sober to show them the ropes, serve as examples, and act as lifelines if they feel the need to drink or use other substances.
Although 12-step facilitation isn’t therapy per se, it is a useful adjunct or support group, is widely available in large cities, and is free.
Contingency management (CM) is also not a therapy itself but has proven to be a strong incentive for abstinence.
If you stay sober—verified by drug tests—you receive a prize or a chance at a prize as part of the contingency management process. It could be a voucher, a token gift, a more expensive gift, actual cash, or just a slip of paper saying something like “Attaboy!” The idea that this would help someone resist a relapse sounds silly or at least unlikely, but the evidence is there: it works.
In the United States, the Department of Veterans Affairs has adopted it widely in many areas, and so has Britain’s National Health Service. Unfortunately, the fear that this approach would bribe people for good behavior, lead to or exacerbate gambling, be too expensive, just wouldn’t work, or that the proceeds would be used to buy drugs and alcohol has stopped CM from becoming common practice.
True, the optics could be bad politically. Support the program, and opposing candidates and other opponents could run a scare campaign denouncing the program.
That hasn’t happened yet, however, and CM has improved abstinence. Providing “tangible rewards to reinforce positive behaviors” is a winning strategy.
Although initially intended for individuals with cocaine use disorder or people who abuse other stimulants (amphetamines, methamphetamine, MDMA, ADHD drugs such as Ritalin, Concerta, and Adderall), the Matrix Model is now also used for alcohol and opioid use disorders.
Devised by the nonprofit Matrix Institute on Addictions, the Matrix Model incorporates several different treatments: cognitive behavioral therapy, 12-step facilitation, contingency management, and motivational interviewing or motivational enhancement therapy (“a more structured, specific version” of motivational interviewing).
The Matrix Model involves only three psychotherapy sessions, more group therapy sessions, and education for clients and their families about the negative effects of continued substance abuse. Abstinence from all substance use is considered necessary, alcohol included, so there are regular breathalyzer and urine tests.
Clients are also told to plan their daily activities to avoid relapse triggers, which is good preparation for continued sobriety after treatment ends and aftercare begins.
Addiction, by the best current science, has no cure. Once people develop a substance use disorder, they will likely remain at risk of relapse for the rest of their lives.
That’s why some form of psychotherapy should be part of treatment. Psychotherapy gives people the tools they need to cope and continue to cope without relapse.
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