A number of different methods are used to treat substance abuse. The most common method often used by treatment facilities is 12-step counseling, although little is known about its effectiveness. Treatment modalities include inpatient, day treatment, and outpatient care, usually followed by aftercare. Twelve Step Facilitation Therapy has been scientifically validated but is rarely adopted for use in 12-step treatment facilities. Motivational interviewing has been determined to be an effective means to motivate clients to seek therapy and change substance use and can be particularly effective with unmotivated clients. Numerous cognitive-behavioral therapies have been effective as interventions in substance use disorders. Relapse prevention therapy is the most widely used cognitive-behavioral approach. Twelve-step counseling, cognitive-behavioral therapy, therapeutic communities, and even Vipassana meditation have been used in jails and prisons to intervene in substance use disorders and recidivism.
Substance Abuse Treatment and the Criminal Justice System
Evidence exists that quality substance abuse treatment can lead to lower recidivism and relapse rates among substance users in the criminal justice system. In addition, court-ordered treatment has been found to be extremely cost-effective when compared with incarceration as an alternative. Many jurisdictions now have drug courts that generally offer treatment as an alternative to imprisonment, but the type of treatment available to participants varies widely across the country. Traffic courts often include mandated treatment courses for DUI offenders, but the evidence that these programs change drinking and driving behavior is inconsistent, perhaps because the content of these courses vary widely across jurisdictions. Treatment outcomes are often used by mental health courts, probation officers, and parole boards as evidence to determine the success of rehabilitation efforts.
Typical Care at Treatment Facilities
The prevailing model of treatment in the United States uses 12-step counseling (often referred to as the Minnesota Model). Although many of these programs have abstinence as a requirement for entry into the facility and as a goal for treatment, researchers find that many clients do not remain abstinent but will reduce their substance use. Although most treatment centers use a similar model, the quality and content of the 12-step counseling across treatment facilities is not consistent. In addition, the 12-step counseling provided by many treatment centers has not been tested under controlled conditions to determine if it is in fact effective.
Addiction counselors are certified by state boards. The process often requires documentation of counselor education in Minnesota Model principles and an exam-ination of counseling skills by peers. Although some addiction counselors have undergraduate and graduate degrees, many states do not require these credentials for a counselor to be certified. Addiction counselors often have personal experiences in 12-step recovery.
Treatment modalities vary. Treatment can be conducted in inpatient or outpatient settings. In the past, most treatment was provided in 28-day inpatient stays, until research showed that outpatient care is just as effective as inpatient care for most clients. Since those findings, the insurance industry has pushed the treatment toward a predominantly outpatient model. People with substance use disorders and co-occurring severe mental disorders (such a debilitating depression or psychoses) may benefit more from the structured environment of an inpatient stay. Day treatment also is available in some communities to provide structured treatment and care during business hours (clients return home during the evening). Many treatment facilities provide medical care, family programs, and sometimes nutrition and fitness programs. Counseling format varies between individual sessions with a primary counselor to group sessions with peers and counselors. In addition to inpatient and outpatient services, treatment centers generally provide aftercare to provide ongoing support to clients who have completed treatment.
Treatment providers generally encourage support group participation as an adjunct to therapy. Support groups vary in terms of philosophies. Twelve-step groups operate under the assumption that substance use disorders are chronic incurable diseases that require a lifetime of working the 12 steps to facilitate abstinence. Other groups such as Rational Recovery understand substance use disorders as a problem of disordered thinking and behavior that can be changed permanently with aid of the group and the Rational Recovery Program (based on the work of Albert Ellis). Moderation Management is an example of a support group that works with individuals who do not necessarily have abstinence as a goal but, instead, want to reduce substance use. Each program seems to be successful for participants when program philosophies closely match the values and worldview of the participants.
Evidence-Based Substance Abuse Treatment
Researchers have developed and tested a great variety of therapies that have proved effective as interventions in substance use disorders. To provide quality and consistent care for psychological disorders, including substance use, the therapy used has to have two characteristics. The first is demonstration that the treatment has worked better than nothing at all by comparing outcomes in a particular therapy with a no-therapy or care-as-usual control group. The second important characteristic is conducting therapy using a manual. Manualized therapy promotes adherence to the scientifically validated treatment protocol to prevent drift. The following sections review therapies that have been tested under controlled conditions or have manuals or guidelines available for use by physicians/therapists to provide best practices to clients.
Research supports a biopsychosocial model for addictive behaviors. Successful models of treatment incorporate biological (physiological), psychological, and social (environmental) interventions to modify biopsychosocial processes associated with substance misuse. For example, physiological (biological) treatment methods typically involve pharmacological means. There is evidence that certain medications may be helpful to promote treatment success among clients with alcohol use disorders. Disulfiram (Antabuse) has been used as a disincentive to alcohol use among people at high risk for relapse but with mixed results. Disulfiram blocks metabolism of alcohol and causes clients to become violently ill when they drink, which sometimes persuades clients to remain abstinent when they are tempted to drink. However, clients have been known to drink when on disulfiram, and client compliance for taking the medication is a problem. Naltrexone and acamprosate have been shown in some studies to help reduce cravings and improve treatment outcomes. Methadone has been used as a safe substitute for heroin. For clients with co-occurring mental disorders, such as depression, bipolar disorders, and schizophrenia, psychiatric medications can help reduce substance use. Many clients believe that substance use helps with psychiatric symptoms. When prescribed medications function to control psychiatric symptoms, it may reduce the desire to self-medicate with illicit substances.
Several types of psychological therapies have been found to be efficacious for the treatment of substance use disorders. Twelve Step Facilitation Therapy has been found to be efficacious in treating substance use disorders. This is a 12-session therapy that includes a manual to promote consistency in the delivery of the treatment. The therapy incorporates principles from 12-step programs (such as Alcoholics Anonymous and Narcotics Anonymous). Although Twelve Step Facilitation Therapy has been found to be an effective treatment under controlled conditions, many treatment centers across the country do not use this therapy, even though the manual is readily available from the National Institute of Alcohol Abuse and Alcoholism. Use of this therapy manual would likely increase quality and consistency of care in treatment centers dedicated to the 12-step model.
Cognitive-behavioral therapy, which involves the use of scientifically developed and tested cognitive and behavioral modification methods to change behavior, has been found to be an effective means to intervene in substance use disorders. Many psychologists use cognitive-behavioral therapy in individual psychotherapy with clients who have substance use disorders. As its name would suggest, cognitive-behavioral therapy includes change strategies described subsequently that target cognitions and behavior chains associated with substance use patterns in clients.
Cognitive change strategies challenge and modify beliefs about substance use behavior. For example, beliefs about substance use influence motivation to change behavior, which in turn predicts whether a client will take steps to change behavior. Client motiva-tion levels vary widely in treatment; so assuming that a client is ready to change is unreasonable. In addition, client motivation changes over time so that one minute he or she can appear committed and then uncommitted the next. Ambivalence about change is normal, especially early in therapy, and reflects the reality that clients are weighing beliefs about the pros of substance use against the cons. The Transtheoretical Stages of Change Model, a widely used model to understand addictive behavior change, indicates that commitment to change will occur when clients resolve their ambivalence in favor of resolve to take action.
Motivational interviewing and motivational enhancement therapy have been found to be very helpful to enhance motivation to change among clients. Motivational interviewing is a scientifically validated therapy that uses strategic methods to help clients to explore and resolve their ambivalence about continued substance use and that enhances motivation to change. Research has found that use of motivational interviewing can be very effective to encourage reductions in substance use and can be used effectively in conjunction with other therapies. Motivational enhancement therapy is a scientifically tested therapy conducted over four sessions and includes the use of motivational interviewing along with other change strategies. Motivational interviewing seems to be especially effective with clients uncommitted to therapy.
Other beliefs associated with substance use include expectancies and self-efficacy. Expectancies are beliefs that people have about the expected outcomes of substance use, and they have been found to be a good predictor of substance use pre- and posttreatment. The research suggests that interventions that increase negative expectancies and decrease positive expectancies may be helpful to improve treatment outcomes. Therapists use various cognitive strategies to accomplish this goal. Self-efficacy, or confidence and competence in being able to negotiate particular situations without substance use, is another consistent predictor of treatment outcome. Therapists teach, rehearse, and reinforce new skills to cope effectively with high-risk situations to establish competence and to develop confidence in appropriately using the skills to enhance self-efficacy so as to avoid substance use in those situations.
Several behavior modification strategies have been found to be effective to foster change. Aversion therapy pairs substance use with aversive agents to discourage the use of the substance. Typical methods are pairing the smell or taste of the substance with electric shock or an emetic agent to condition avoidance of substance use. Studies have found that aversion therapy can result in successful outcomes initially, but those posttreatment gains may be lost over the long term without concurrent use of relapse prevention (see below). Contingency management strategies have been used successfully to encourage positive outcomes in treatment. Contingency management modifies client behavior by providing incentives to successfully engage and complete targeted tasks in therapy. Incentives have been used to increase attendance and participation in sessions as well as promote reduction targets or cessation of substance use. However, contingency management is not widely used, perhaps because of the costs involved with incentive-based care.
Coping skills therapy has been supported by science as well. New skills are taught to aid clients to cope effectively and solve problems without the use of substances. Therapists may also teach anger management, daily life management, assertiveness training, and relaxation methods (including meditation) to increase the repertoire of skills available to clients. Relapse prevention methods developed in the cognitive-behavioral model have been shown to be highly successful to reduce the severity and duration of relapse events when they occur. Relapse prevention teaches clients that relapse is normative rather than a failure and can be used to identify and correct problems in posttreatment behavior. Relapse prevention also teaches substance refusal skills, develops and rehearses plans to cope with relapses, and uses cognitive and behavioral modifications previously mentioned in this section. In addition to one-on-one methods with clients, cognitive-behavioral interventions that target couples, family relationships, schools, and other peer groups have been associated with changes in substance use.
- Blume, A. (2005). Treating drug problems (Treating Addictions Series, Vol. 1, R. H. Coombs & W. A. Howatt, Eds.). New York: Wiley.
- Kadden, R., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams, D., et al. (1999). Cognitive-behavioral coping skills therapy manual (Project MATCH Monograph Series, Vol. 3, M. E. Mattson, Ed.). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
- Marlatt, G. A., & Donovan, D. M. (Eds.). (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). New York: Guilford Press.
- Miller, R., & Rollnick, S. (2002). Motivational interviewing (2nd ed.). New York: Guilford Press.
- Nowinski, J., Baker, S., & Carroll, K. (1995). Twelve Step Facilitation Therapy manual (Project MATCH Monograph Series, Vol. 2, M. E. Mattson, Ed.). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.