With addiction, an individual continues to use a specific drug or engage in a behavior despite experiencing significant functional impairment, distress, and other negative ramifications as a result of their actions. The American Psychiatric Association (APA) notes that many of these individuals are initially under the impression that they can control their behaviors without any assistance, but the vast majority of these individuals need some type of professional intervention.
There have been decades of research studies and investigations that have determined what types of interventions are best suited for the treatment of addictive behaviors. As a general rule, the approach to treating any type of addictive behavior falls under one of two major categories: medically assisted treatments and behaviorally based treatments.
Medically Assisted Treatments
At the time of this writing, there are no empirically validated surgical procedures, medications, or other medical treatments that can be used in isolation to treat addictive behaviors in most individuals. Some individuals who have developed addictive behaviors as a result of brain damage or some other neurological insult may benefit from psychosurgery or some other medical procedure. However, the majority of individuals with substance use disorders and behavioral addictions are not considered to have formal brain damage although there may be some differences in the structure of their brains that contribute to these behaviors. There are several medically assisted treatments that are commonly used to assist in the treatment of addictive behaviors.
Pharmacotherapy is a term used to describe treatment with the use of drugs or medications. Pharmacotherapy for addictive behaviors is the domain of addiction medicine physicians and psychiatrists. There are numerous medications that can assist in the treatment of addictive behaviors; however, there is no medication or group of medications that can be used effectively without also using behaviorally based treatments to address addictive behaviors.
The specific type of medication used will depend on the stage of recovery an individual is in, what symptoms are being addressed, and the individual’s ability to tolerate the medication. For instance, opioid replacement medications, such as methadone or Suboxone (acetaminophen and hydrocodone), are used almost exclusively to control opioid withdrawal syndrome. They have very little utility in addressing other issues that occur in recovery.
Certain benzodiazepines can be useful in helping individuals who are undergoing withdrawal from alcohol. The medication Antabuse (disulfiram) is only useful for helping individuals to control their use of alcohol by producing severe nausea and distress when the individual uses the drug and drinks alcohol. Antabuse has no utility for treating alcohol withdrawal symptoms. The drugs Catapres (clonidine) and ReVia (naltrexone) may assist individuals who are experiencing cravings to drink alcohol or use opiate drugs. Numerous other drugs can be used for specific purposes. Medications, such as antidepressant or stimulant medications, can be used to address specific symptoms that need to be suppressed during recovery.
One of the major issues with the use of medications in the treatment of substance use disorders is that individuals who are in recovery and relapse can simply stop taking their medication. For example, an individual using Antabuse to help them remain abstinent from alcohol can stop taking the medication 24-48 hours before they decide to drink alcohol again.
While compliance can be an issue with pharmacotherapy, research has determined that overall pharmacotherapy approaches do increase successful recovery rates in individuals with addictive behaviors. Pharmacotherapy complements other empirically validated forms of treatment for addictive behaviors. The use of medications to assist in the treatment of addictive behaviors may be best used for:
- The treatment of physical dependence (tolerance and withdrawal)
- Cravings reductions
- Those who are facing legal issues, as such treatment is viewed favorably by the judicial system
- Those who are committed to abstinence from their addictive behavior
Other types of medically assisted therapy available for individuals with addictive behaviors are therapeutic communities, inpatient treatment programs, residential treatment programs, and physician-assisted withdrawal management programs that can be either performed on an inpatient or outpatient basis. These medically based approaches to treating the complications associated with addictive behaviors often provide very close supervision (around-the-clock supervision for residential clients) and attempt to offer comprehensive treatment for individuals over multiple levels of intervention.
In some cases, residential treatment programs and therapeutic communities also attempt to re-socialize those with severe addictive behaviors. These programs are typically supervised by medical personnel, such as addiction medicine physicians, psychiatrists, or other physicians.
These types of treatments are often very organized and structured. They utilize a multidisciplinary team approach to treatment that includes professionals from medical and behaviorally based backgrounds, including physicians, social workers, therapists, nurses, occupational therapists, etc. They are often designed to treat specific issues, such as withdrawal management, and they are very effective at treating individuals who have co-occurring mental health problems or personal problems. They may utilize support from peers in recovery, and they can be very confrontational.
Individuals being treated in an inpatient unit are treated for a limited duration, most often 30-90 days, but in some cases, treatment can be much longer and could even last a year or more depending on the situation. These types of programs can also be adjusted to treat individuals who have special needs, such as individuals with severe co-occurring mental health issues, cognitive issues, and family issues.
Inpatient programs, residential programs, and therapeutic communities may also be particularly attractive to individuals who have become involved in the criminal justice system as a result of some type of addictive behavior. These programs may be used in place of incarceration, depending on the case. These programs are often focused on:
- Controlling withdrawal syndromes, especially in the early phases of recovery
- Providing intensive treatment for individuals who have co-occurring mental health disorders or who need very structured supervision
- Treating people who have serious legal issues
- Treating individuals who have made multiple unsuccessful attempts at recovery and relapsed
- Treating individuals who have living conditions that are toxic or that are not suited for abstinence from drugs or alcohol, such as those who are homeless, who come from abusive families, or who live in areas where there is significant drug abuse
Except in the above scenarios where the individual has a particular condition or circumstance that requires 24-hour monitoring, there is no specific reason to choose an inpatient or residential treatment program over an outpatient treatment program. Research indicates that inpatient and outpatient treatment programs are relatively equivalent in their goals and success rates.
Behaviorally Based Therapies
Behaviorally based therapies provide the foundation to the treatment of addictive behaviors.There are numerous behaviorally based approaches and therapies that can be utilized to treat addictive behaviors.
Psychotherapy is a form of intervention where a professionally trained therapist applies psychological principles to an individual in a therapeutic environment. There are literally hundreds of different types of psychotherapy. The most researched form of psychotherapy and the form of psychotherapy that is most often recommended for the treatment of addictive behaviors is Cognitive Behavioral Therapy (CBT).
CBT is a form of psychotherapy that was developed from two of the major schools in clinical psychology: the behavioral paradigm (school) and the cognitive paradigm (school). Cognitive Behavioral Therapy is an umbrella term that describes numerous forms of therapy, such as Rational Emotive Behavioral Therapy, Dialectic Behavior Therapy, etc. All of these therapies operate on the same basic assumptions and attempt to help the person address their addictive behaviors by understanding dysfunctional and maladaptive thoughts, beliefs, and attitudes, and helping the individual to restructure these. Once the individual’s dysfunctional or irrational belief systems have been restructured, the therapist helps the individual engage in proactive behaviors that are consistent with these new cognitions.
The major approaches used by therapies that are classified as CBT include:
- Identifying major irrational and dysfunctional beliefs or attitudes that individuals have about themselves, others, and the nature of world
- Challenging these irrational beliefs
- Helping the individual to restructure these irrational beliefs and change their behavior accordingly by exploring both the positive and negative consequences of their addictive behavior
- Teaching the person to identify situations that put them at risk for engaging in their addictive behavior again
- Helping the individual develop strategies to cope with stress and other triggers
- Helping the individual to develop positive relationships with other people
CBT is one of the most researched of all psychotherapies, and research evidence continues to document its effectiveness in treating numerous issues, including addictive behaviors. While it is the preferred form of substance use disorder and addictive behavior treatment, and it can be used in conjunction with medically assisted treatment such as medicines, CBT does have some limitations.
Individuals involved in CBT must have the cognitive capacity to view themselves and their behaviors in a rational manner and be able to reflect on their experience. People who are psychotic or have significant cognitive limitations may not be appropriate for many types of CBT. Individuals should be motivated to explore their attitudes and should be able to develop a relationship with their therapist. They will also be given homework assignments by the therapist, and these need to be completed in order to receive the full benefits of the therapy.
Certain types of CBT approaches have been developed to work with clients who have severe emotional distress (e.g., Dialectic Behavior Therapy for individuals who are suicidal or have borderline personality disorder). CBT techniques, like all psychotherapies, need to be tailored to meet the needs of the individual.
CBT is also time-limited; unlike Freudian psychoanalysis, it is not designed to continue for years on end. CBT therapists typically work with the client to establish goals for the therapy, address these goals, address any other issues that come up during the therapy, and then help the client to become autonomous. When the goals have been reached, the therapy is terminated.
Subsets of CBT
While CBT does work best for individuals who are motivated to change, many individuals with addictive behaviors are not initially motivated to change their behavior. A specific CBT approach, Motivational Interviewing (MI) has been developed to determine where an individual conceptualizes their need to change and to help them develop motivation and an approach to changing their addictive behaviors.
MI is based on the principles of motivation psychology, and it was originally developed to address individuals who had substance use disorders. Research on the technique indicates that it may be useful in treating addictive behaviors but may have less utility in treating other behaviors.
MET, or Motivational Enhancement Therapy, is a form of treatment for substance abuse that works in conjunction with the MI technique. This approach is based on CBT principles and may be particularly useful in individuals who are resistant to changing their addictive behaviors but are thrust into treatment from outside referrals.
One particular form of therapy that can be used as a community form of care for individuals who may have significant cognitive limitations is Contingency Management, which is heavily based on behavioral psychology principles. This approach provides reinforcement, typically in the form of vouchers that can be exchanged for items of interest, for abstinence from alcohol or drugs. These programs typically require that individuals consent to medical drug testing in order to demonstrate their abstinence; they then receive a voucher for their abstinence. Once an individual has established a level of abstinence over a significant period of time, other CBT techniques can be used to treat the individual. Research has indicated that this approach may be useful for individuals who do not initially respond to CBT for substance abuse.
Individual vs. Group Therapy
Psychotherapy can be performed on an individual or on groups of individuals with similar issues (group therapy). While treatment in individual therapy sessions allows the therapist to concentrate on the needs of the individual and focus specifically on the individual case, there are some advantages to the use of group therapy for the treatment of addictive behaviors.
Group therapy allows people at different stages of recovery to learn from people with experience and from sharing their experiences with others. Group therapies create a sense of unity that results in the individual not believing they are alone in their issues. Group therapy also provides individuals in recovery from addictive behaviors with a positive social support network.
Almost any type of psychotherapy that can be administered on an individual basis can also be administered in a group format. Group therapies may consist of individuals who have the same type of addictive behavior, different types of addictive behaviors, or individuals who are related to one another in some way (family therapy).
Couples therapy consists of family therapy that is provided to romantic partners while formal family therapy is provided to first-degree relatives or even relatives with less close ties. Family therapy is an attractive approach for individuals with addictive behaviors who have affected one or more family members. It can be very useful in helping individuals with addictive behaviors to address their problems and at the same time address issues associated with the family that may maintain and drive these behaviors.
Peer Support Groups
A specific type of group intervention that is not technically a form of psychotherapy is the social support group. Most people readily recognize these programs as 12-Step groups, such as Alcoholics Anonymous. These programs are very popular in the treatment of addictive behaviors, but they are not formal psychotherapy groups because they do not utilize the services of a trained therapist. Many of these programs offer a structured approach to dealing with an addictive behavior, a significant source of social support, and even instruction and guidance from a sponsor or individuals with experience.
Groups like Alcoholics Anonymous are not open to empirical research and the few research studies that have been done on their effectiveness have suggested that they are no more effective than any other form of behavioral intervention. Nonetheless, support groups have numerous advantages.
- Members in social support groups are very accepting and open to others.
- There is no membership fee or monthly dues. Most of these groups support themselves through donations by their members. For instance, individuals attending Alcoholics Anonymous meetings often donate $1 per meeting. Thus, these groups are inexpensive compared to formal psychotherapy.
- In many cases, these groups are extremely accessible. AA meetings occur nearly every day, and often several times a day, in major urban areas.
- These groups offer the advantages associated with working in groups, such as developing a sense of unity, learning from others, sharing with others, and developing a positive relationship with peers.
There are several potential disadvantages associated with 12-Step groups like Alcoholics Anonymous. The major downside is their heavy emphasis on religious-based philosophies that may not fit in with the personal feelings of many individuals. In addition, these groups cannot offer medical advice to individuals who need it and do not employ empirically validated techniques.
Other types of community support groups may be available in different areas. Individuals can check with their local community mental health center to determine what particular groups are available in their area.
There are other numerous behaviorally based interventions that are often referred to as complementary and alternative treatments. These are adjunctive treatments that are designed to be used in conjunction with formal psychotherapy for addictive behaviors. They include art therapy, music therapy, psychodrama, adventure and wilderness therapy, etc. These therapies are not psychotherapies, but they can be very useful in increasing the effectiveness of treatment for addictive behaviors when used in conjunction with formal psychotherapy and/or support group participation.
Other forms of treatment, such as relaxation training, yoga, martial arts, etc., can also be incorporated into an overall treatment program as long as the major focus of the program includes elements of medically assisted therapies, when needed, and psychotherapy and social support group participation for addictive behaviors.