How Can Therapy Help Me?
The National Institute on Drug Abuse (NIDA) outlines several principles of addiction treatment based on data the organization has collected for the past 40 years.1 These principles aim to improve the odds of success in treatment by ending (or moderating) drug use, lowering the risk of relapse, and allowing the person with addiction to rebuild or restart their lives. These principles include:
- Addiction is a multifaceted problem, but one that can be treated effectively.
- Treatment should be directed to the individual person rather than to their drug(s) of choice.
- Treatment can be helpful even if the client initially goes involuntarily. (Eventually, the client’s voluntary participation in treatment will influence their recovery path.)
- Medications can be an important part of treatment to address drug misuse or the mental health aspects underlying substance use.
- Counseling and behavioral therapies are highly utilized and the best available treatment options for drug misuse.
This final principle is an important one. Many agree that behavioral therapies are an essential element to treat substance use, but with so many options, it can be challenging to know what forms of treatment are available, how they differ, and which is best for the individual. The NIDA does not believe that there is any one approach that is appropriate for every person.1 Here, we will take a look at the different types of therapy available to those seeking addiction treatment.
What is Behavioral Therapy?
Behavioral therapy is focused on obtaining goals directly related to the present life of the client. This therapeutic style works to examine behaviors that are unhealthy and undesirable while identifying the situations in place that support their continued presence.
In the example of substance misuse, the behavior is likely to continue because of the role the substance plays in creating feelings of euphoria, calming the body, or eliminating pain. This creates reinforcement for the drug use to continue. Even when negative consequences occur because of the drug use, the person still values the benefit of the use more than the risk of the consequence.
A behavioral therapist will use specific interventions to address the unwanted behaviors including:
- Psychoeducation and planning. The therapist will educate the client on the behaviors and contingencies (the rewards or consequences) that are maintaining their addiction. The therapist and client will collaboratively develop a plan to promote behavior change.
- Assertiveness training. This will be used to improve the client’s level of communication in an effort to move away from passive or aggressive communication and towards assertive communication where they can express themselves honestly while being respectful to others.
- Relaxation training. This intervention aids in the client’s ability to find calm and peace both physically and mentally. Relaxation approaches might also incorporate distress tolerance so that stressful events are less impactful.
- Functional analysis. This tool involves noting the unwanted behavior and working backwards to understand how it is reinforced, or maintained. By understanding the reinforcer, the client can begin to learn and modify their motivation before the progression is triggered.
- Exposure. Ultimately, the client must be able to expose themselves to the stimulus (the drug) while practicing a new behavior (not using the drug). Practicing this skill will increase the likelihood that their automatic, habitual impulse to use the drug will dissipate.
Cognitive-behavioral therapy (CBT) uses behavioral therapies as a base but assigns equal importance to thoughts and feelings. CBT is grounded in the idea that negative thinking patterns lead to unwanted feelings and behaviors, and problematic behaviors lead to unwanted feelings and negative thinking. This interconnectedness between thoughts, feelings, and behaviors is at the core of CBT.
In CBT, a therapist will act as a coach and a teammate to assess and understand the systems in place that lead to the thoughts, feelings, and behaviors that the client wishes to address. In the case of substance use problems, the therapist would go beyond the behavioral therapy principles of trying to learn the source of reinforcement to understanding the thoughts and feelings that lead to the use as well as the thoughts and feelings that occur following the use.2
The therapist will look for cognitive distortions that feed into these behaviors. Cognitive distortions are flawed ways of thinking that may sound rational at the time while being irrational and illogical.
For example, someone with an “all or nothing” cognitive distortion may think that their life is falling apart if it is not perfect. Since perfection cannot be obtained, they will be overly negative, hopeless, and depressed. Then, they learn that drug use can cover these feelings and allow for avoidance.
Contingency management is one specific type of behavioral therapy used in the treatment of substance misuse, especially for alcohol, stimulants, opioids, marijuana, and nicotine.3 In this approach, the client is given a tangible reward for accomplishing their desired behaviors. Commonly, the desired behavior is abstinence from substances, and the reward helps to build new behaviors. Examples of this include:3
- Voucher-based reinforcement. The program rewards the client with a voucher for negative drug tests. The vouchers can be collected and traded in for wanted items that support recovery. Initially, the value of the vouchers will be low but build over time to reward longer periods of being substance-free.
- Prize incentives. Rather than receive vouchers, clients are allowed a chance for a prize for completing a clean drug test or attending treatment. The value of the prize will vary with chance as clients participate in a lottery system.
- Natural contingencies. Sometimes, reinforcements come naturally when one abstains from using drugs or alcohol. This might be an internal sense of pride or joy. It might be an improvement in relationships with one’s partner, friends, or family, or an improvement in health. These natural reinforcements can have a powerful effect on one’s motivation to maintain sobriety.
Rational Emotive Behavior Therapy
Rational Emotive Behavior Therapy (REBT) is a therapy style that was formed about the same time as CBT, has many similarities, and has since been absorbed into CBT. Like CBT, REBT places less emphasis on the behaviors and more on the views of the individual.4 Instead of focusing on the thoughts, REBT focuses on the beliefs of the client. REBT views flawed, unrealistic beliefs as the center of psychological issues.
Common themes of irrational beliefs are:
- People in my life MUST love me and treat me fairly.
- I MUST perform perfectly well.
- I MUST get what I want at all times.
- I MUST avoid the things that are too hard.
To combat these faulty beliefs, a therapist using REBT within the CBT framework will use the ABC Model. This system works to communicate the notion that it is not the situation that creates the consequence; it is the belief about the situation that creates the consequence. In the case of substance use, someone would say that being offered the substance leads to the use. REBT would say that being offered the substance (A) leads to the belief that the substance would resolve a problem (B), and this would end in use (C).
Within this model, the therapist will work with the client to identify and challenge the faulty beliefs. Once this is accomplished, they will insert new beliefs grounded in logic and reality.
Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is another therapeutic style based on the influence of CBT. Since its beginnings, research has found DBT effective for other mental health issues like:5
- Mood disorders like depression and bipolar disorder.
- Posttraumatic stress disorder.
- Anxiety-related disorders.
- Eating disorders.
- Substance use disorders.
DBT believes that mental health issues present from a combination of emotional vulnerability and invalidating environments. Clients receive a balance of validation/acceptance and encouragement to move in more beneficial directions.
To achieve results, DBT uses a specialized treatment appropriate that utilizes:
- Group therapy focusing on building skills.
- Individual therapy focusing on past traumas and current stressors.
- Phone coaching that provides treatment interventions between sessions.
Using the above methods of treatment, DBT leads clients through 4 skill-building modules. The modules highlight dialectical thoughts that are based on the notion that opposing ideas can be brought together to find balance. Each one typically lasts 6 weeks and can be repeated as needed to receive the full benefit. The skills are:6
- Mindfulness. The act of being fully aware and engaged in your present situation.
- Distress tolerance.The ability to accept some level of distress without taking extreme measures to resolve.
- Interpersonal effectiveness.The ability to communicate clearly and concisely with others while building good listening skills.
- Emotional regulation. The act of identifying issues that trigger unwanted thoughts and feelings and working to effectively reduce them through positive coping skills.
Motivational interviewing is a specialized, modern form of person-centered therapy that was developed for addiction. The goal of motivational interviewing is to have the client find their own drive and desire to make appropriate choices rather than being forced into it by threats of legal recourse or guilt.7
A motivational interview works to accomplish this through:
- Collaboration. The therapist works to share the perceptions of the client rather than challenge them.
- Evocation. This is the production of change from within the client with the goal of stronger commitment and longer consistency with treatment.
- Autonomy. The client has the responsibility for himself and the power to make his own decisions.
The therapist is tasked with building the desire to change within the client by being empathic, managing client resistance, and illustrating the differences between what the client wants and what they are doing to achieve it. If someone wants to live a happy life, the therapist could ask if daily heroin use aids or provides a hindrance to this goal.
Motivational interviewing has been shown to be helpful in a number of settings, including:
- Initial intakes and assessments.
- Individual sessions as the primary therapeutic orientation.
- Individual sessions as an adjunct orientation.
- Mental health, substance use, gambling, obesity, and other addiction-related treatments.
Eye Movement Desensitization and Reprocessing
Eye Movement Desensitization and Reprocessing (EMDR) originated from trauma treatment to help those with symptoms of posttraumatic stress disorder (PTSD). This treatment style is based on a phased progression through treatment that helps to reprocess information from the trauma. EMDR believes that this information leads to unwanted symptoms when not processed sufficiently.8
The phases of treatment focus on:
- Assessing the symptoms.
- Identifying targets to reprocess.
- Providing relaxation and calming skills.
- Desensitization to reprocess the negative images and beliefs.
- Installation of new beliefs.
- Checks to ensure the treatment was successful.
An interesting component of EMDR is the eye movement used during the middle phases of treatment. Here, the therapist will ask the client to track the therapist’s fingers as they are moved laterally back and forth. EMDR believes that this stimulation helps to access parts of the brain used to reprocess information. Therapists may also use sounds or touches to produce this effect.8
In the case of substance use, EMDR can be helpful since trauma is commonly associated with addiction. Some will use substances to avoid or numb memories of traumatic events while others will experience trauma due to their use. In both cases, using EMDR to reprocess the traumatic information can lead to a reduction of symptoms. EMDR has the reputation of working quickly. Some find benefit after only one session.
Family and Community-Based Treatments
The previously mentioned therapies are primarily focused on working to elicit change by only working with the individual. This attention to the person using the substance or in recovery is crucial for enduring success, but it can be limiting as well since they are also part of wider family and community settings.
These settings can either aid recovery or serve as a hindrance based on the established routines, reinforcements, and communication styles. Because of this, many therapies will acknowledge and modify the influence of the family and community to improve the rates of success for the client. The treatment styles that focus on the client and their surroundings equally are referred to as family-based or community-based therapies.
These treatment styles include:
- The need for individuality as well as the need for togetherness.
- Relationship triangles where the client will be influenced by other relationships as much as they will influence others.
- The history of substance abuse in the family through a multigenerational assessment to identify past mental health or substance history occurring in family members.
This information will aid in building a thorough treatment plan.
Community Reinforcement Approach
Community reinforcement approach (CRA) broadens the focus beyond the client to the entire environment that impacts the client.9 Based on principles of CBT, CRA includes the functional analysis and behavioral skills training that one would find in CBT, but also includes job training, social/recreational counseling, and relationship counseling.
CRA incorporates the belief that success is more likely if these aspects of the person’s life are more stable and satisfying.
For example, the job training does not focus on finding the client the first available employment opportunity. Instead, it strives to find work that is rewarding and fulfilling to the client. By targeting family relationships in family therapy, the client as well as their concerned significant others (CSOs) work to identify the systems in place that damage the relationship and maintain substance use. During sessions, they will find new ways to communicate effectively. Lastly, chances are good that much of the client’s free time has been spent focused on acquiring and using their substance. The social/recreational counseling will provide sober activities and options for clients to use their time in drug-free ways.
One form of CRA involves a voucher system as described in the behavioral therapy section. It is called community reinforcement approach plus vouchers, and this 24-week program has been helpful for people with alcohol, cocaine, or opioid use issues.10 Also of interest, this program is available in a computer-based version called the Therapeutic Education System (TES). This form of treatment yields results that are on par with live, in-person CRA plus vouchers.10
The Matrix Model
The Matrix Model of treatment has been found clinically appropriate for people dealing with use of stimulants like cocaine, crystal meth, and ADHD medications.12 It works by including varied features to account for all contributors of substance use. The Matrix Model utilizes behavioral therapy, cognitive behavioral therapy, family-based therapy, and others to boost the benefit to the client and their family.
Treatment under this model will include:12
- Individual counseling.
- Group counseling addressing early recovery, relapse prevention, and family education.
- Urine tests and breath checks to assess for substance use.
- Relapse analysis.
- 12-Step meetings.
- Social supports.
The Matrix Model is a highly structured outpatient therapy program. It features treatment manuals loaded with information and homework sheets that guide the treatment. This style engages the client throughout the 16-week program when they are in and out of sessions, which places more focus on recovery.
The therapies that combine multiple facets of different styles tend to be successful in treating addiction and maintaining recovery. This combined style is called integrative therapy.11
Here, the therapy will select certain elements from a variety of approaches and add community, family, and social factors to build a well-rounded treatment.
Get Help Today
This information is not intended to be exhaustive, but rather a comprehensive starting point to provide information related to some commonly available treatment options for substance use.
Availability and fees for these services will vary according to the area and the abundance of service providers. Each person’s individual differences will dictate the form of treatment that is ideal for them. Treatment is available for those who seek it and can work for those engaged in it. To find a program right for you, call and speak to someone who can help you begin your road to recovery.