To a degree, different psychotherapeutic techniques target different needs. For example, motivational enhancement therapy helps people sort through their feelings about their addiction and the influence it has on their lives to clarify and increase their motivation for change. Cognitive behavioral therapy, on the other hand, works to change the relationship between thought patterns and behaviors that can impede recovery.
The techniques described below are examples of the best-studied therapeutic approaches; many others can also be useful. In addition, these various techniques are not mutually exclusive. Good clinicians often use several different techniques for each of their clients.
1. Motivational enhancement therapy
Motivational enhancement therapy is a catch-all term for techniques that attempt to enhance motivation. Examples include motivational interviewing and resistance reduction.
The psychologists who developed motivational enhancement therapy recognized that people have a natural tendency to play devil's advocate. In other words, if one person pushes a particular viewpoint or agenda, those around him or her often naturally raise the opposing viewpoint.
Historically, most therapists treating people with addiction tried to convince their clients that addictive behavior was problematic, unhealthy, and detrimental. This approach sometimes alienated the client, further entrenching the problematic behavior.
Motivational enhancement therapies encourage clients to develop their own agenda and set their own goals. The therapist's role is to listen carefully and to ask provocative but judgment-free questions about the value of using the substance of addiction and how such use has affected the client. The answers should help the clients increase their motivation for stopping such use, identify reasons to change, and establish a recovery plan. Clinicians typically use this treatment strategy in conjunction with other therapeutic approaches.
Studies are backing up this approach. Six federally funded, multisite studies concluded that motivational interviewing was better than standard community treatment for drug problems and dependence on several measures, including reducing drug use and sticking with treatment. Findings from Project MATCH (see below) also found motivational enhancement therapies helpful for alcoholism. For quitting smoking, motivational therapy was most likely to help when sessions with a clinician lasted at least 20 minutes, and when the patient saw the therapist multiple times rather than just once.
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is the largest and most careful study of alcoholism treatment conducted so far. Researchers sponsored by the National Institute on Alcohol Abuse and Alcoholism compared 12-step facilitation with cognitive behavioral therapy and motivational enhancement therapy over a 90-day treatment period. Over all, the three treatments were about equally effective. Patients in all three groups had a higher rate of abstinence (not drinking) and a lower rate of binge drinking both immediately after treatment and a year later.
2. Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) works to identify and change thought patterns and the relationship between these thoughts and behaviors that might be contributing to addiction or interfering with recovery. For example, CBT works to dispel the belief many people with addiction have — that they cannot function without their object of addiction. It also helps people develop strategies to reduce the chances that they will have a relapse. Through CBT, people learn to avoid triggers (in the environment and in relationships) that are likely to lead to engagement with their addiction. CBT also teaches people to avoid risky situations, and how to anticipate, prepare for, and manage cravings when these emerge.
A specific form of CBT, called mindfulness-based cognitive therapy, helps people become aware of painful or negative thoughts and feelings. Clients are taught to experience and accept those thoughts and feelings without trying to avoid them. This form of therapy is useful for people who seek refuge from negative thoughts by turning to their object of addiction. It differs from traditional CBT in that it does not try to eliminate or reframe negative thoughts. Instead, mindfulness-based cognitive therapy attempts to weaken the effect those thoughts have on the person's mood and well-being.
3. Dialectical behavior therapy
Dialectical behavior therapy (DBT) is a specialized form of CBT originally developed to treat borderline personality disorder. It focuses on helping people develop skills to better tolerate stress and emotional discomfort. It also teaches people to become more aware of and comfortable with their emotions. Clinicians practicing DBT help their clients negotiate opposing forces; for example, by encouraging them to tolerate and accept difficult circumstances while also taking steps to change behaviors that might be contributing to those circumstances. This form of therapy might be especially helpful for people with addiction who also have borderline personality disorder.
4. Psychodynamic therapy
Rooted in Freudian theory, psychodynamic therapy focuses on putting the client in touch with his subconscious and identifying how it influences behavior patterns. During psychodynamic therapy, a person might explore childhood and past experiences to look for clues as to what's driving current behavior. A therapist using this approach might prompt the client to examine unresolved conflicts and failed relationships, in the hopes that resolving those conflicts or understanding those past failures might relieve psychic stress and thus alleviate the need to engage in the addiction.
Through psychodynamic therapy, a person also might examine what benefit the object of addiction offers, and then explore alternative approaches that might be less harmful.
5. 12-step counseling or facilitation
Another approach, known as 12-step counseling, is rooted in the AA philosophy (see "Peer support"). But while AA is a self-help group run by its members, without substance abuse counselors or other health professionals present, 12-step counseling emphasizes working with a therapist for a limited time while attending AA meetings. Like AA, 12-step counseling adheres to the following principles:
People with addiction have lost the ability to control their use of the substance or behavior.
There is no effective cure for addiction. People with addiction must abstain completely.
There's hope for recovery if people accept that they don't have control over their addiction and put their faith in a higher power.
In this approach, the client meets with a clinician for 12 sessions, usually over 12 weeks. A spouse or partner may be included in some of these sessions. During the structured program, the therapist discusses AA — or whichever offshoot of AA is appropriate — with the client, encourages him or her to attend meetings, suggests certain reading materials, and assigns specific recovery tasks, such as making amends for problems resulting from addiction and making a list of one's personal strengths and weaknesses. Once the sessions are done, you continue to draw support by staying involved in 12-step meetings.
6.The matrix model
Compared with the techniques described so far, the matrix model of psychotherapy takes a more didactic approach. Therapists using this approach play the role of teacher and coach. They inform their clients about the implications of their addiction and — when psychoactive substances are involved — they use urine tests to detect lapses in abstinence. Therapists using the matrix model also might offer education for family members affected by the addiction.
7. Individualized counseling
Individualized counseling focuses specifically on getting the client to stop or reduce the use of a substance or an addictive behavior. It also helps him or her deal with the adverse repercussions of addiction, which can include joblessness, legal trouble, and family or social conflict. Rather than delve into the psyche of the client, individualized counseling sets discrete short-term practical goals and helps the client develop strategies for coping with craving and for maintaining abstinence.
8. Contingency management
Contingency management is often used in combination with other techniques. It involves the use of rewards — either monetary or symbolic, in the form of tokens — given when a person completes abstinence milestones. In AA, for example, people receive chips of various colors after they are sober for a month, six months, etc. This form of positive reinforcement seems to promote continued abstinence.
Harm reduction therapy remains a controversial form of addiction treatment for some; however, research tends to support its use. Harm reduction works to reduce the harms that might be associated with a person's drug use or activity. For example, a needle exchange program limits the harms that are associated with intravenous drug use (such as HIV infection or sepsis), but does not focus on stopping drug use.
Nevertheless, it's not unusual for many people who seek harm reduction therapy to eventually realize — on their own — that total abstinence is appropriate, necessary, and often easier than trying to regulate involvement with a substance or behavior. For them, harm reduction therapy can serve as a good stepping stone to more radical change.
Those opposed to harm reduction therapy say that it amounts to endorsing use. Those in favor argue that a militant attitude often has counterproductive consequences. Proponents also point to evidence that people can learn to use alcohol or drugs safely.
9. Behavioral therapy for adolescents
Adolescents often need specialized treatment for addiction. Behavioral therapy for adolescents focuses on helping young people develop skills (for instance, developing healthy relationships and good study habits) that might not have had a chance to flourish before they turned to their object of addiction. This form of therapy uses positive reinforcement to guide the acquisition of new skills. Youths participating in this form of therapy may have to complete homework assignments, keep records of their progress, and actively practice their skills. The therapist, in turn, offers praise and privileges when the client meets the mutually established goals. If drugs are the problem, most therapists will also arrange a plan to collect urine samples to monitor drug use.
During treatment, adolescents learn to avoid people or situations that might promote their addiction. They learn instead to spend time doing things that are incompatible with their pattern of addictive behavior. They also learn urge control, meaning that they learn to adjust the way they view and cope with urges and cravings so that they develop restraint over their behavior.
During this form of therapy, parents or others close to the client might be asked to participate in group sessions and to better understand and help steer the adolescent away from harmful behaviors.
10. Multidimensional family therapy for adolescents
This form of therapy acknowledges that many people, including family members and peers, influence the client's experience with addiction and vice versa. Sessions often include these people and can take place at home, in a clinic, at school, or in other community locations.
During individual sessions, the therapist and adolescent work on ways to develop and improve decision-making, negotiation, and problem-solving skills. Teenagers acquire new skills for communicating their thoughts and feelings, as well as vocational skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.
Treatment of co-occurring disorders
Many studies have found evidence that addiction and psychiatric disorders, such as depression or anxiety, commonly occur together. Treatment of two or more mental health problems (referred to as co-occurring disorders) can be particularly challenging because the conditions often interact and feed into each other. For example, depression can increase the craving for drugs, which can lead to even more drug use and more severe depression. Researchers have found that using psychotherapeutic techniques to target both the psychiatric disorder and the addiction within a single treatment plan tailored to the individual offers the greatest chance of success.
In cases of mood disorders (such as depression or bipolar disorder), anxiety disorders (such as panic disorder), or schizophrenia or another psychotic thought disorder, treatment usually involves a combination of psychotherapy and medication.