Models of Intervention
Addiction – or, as it is clinically defined now by the American Psychiatric Association, substance use disorder – is a chronic disorder where an individual continues to use a substance despite continual negative problems associated with its use (this article will use the terms addictionand substance use disorder interchangeably).
From the onset, a good number of individuals with substance use disorders who decide that they need to stop their behavior initially believe that they can control their behavior; however, many people find that they are unable to successfully address their issues with addiction without some form of intervention or outside help. This article attempts to outline the major types of treatment interventions for addiction and to suggest the type of individual who may be suited to specific types of intervention.
This article is offered as a general guideline to assist individuals to find a particular treatment program or style of treatment that may be suited towards their needs. Even though the goal of this article is to outline empirically validated treatment programs no specific claims regarding any specific successes/failures for any individual are intended or inferred. Success in treatment for substance use disorders is dependent on number of factors, both relating to the individual in treatment and to the program itself.
General Issues in Treatment for Substance Use Disorders
There are some general issues gleaned from the research that should be considered regardless of the specific treatment program a person chooses:
- The length of time in treatment is predictive of the outcome of the treatment (people who remain in treatment longer tend to be more successful).
- Relapse appears to be the rule rather than the exception; individuals need to learn from their relapse and move forward.
- Dropouts from treatment programs are also the rule rather than the exception; individuals who drop out from treatment can always return to treatment, and individuals in treatment should not be discouraged if others drop out.
The issues regarding relapse and dropouts from treatment should not be taken as excuses to relapse or to drop out, but instead represent realizations that no one who enters recovery has a flawless recovery, and that everyone in recovery will have issues. Common issues that occur in recovery are relapse and quitting treatment for a time. These experiences should be used to allow the person to learn and grow in an effort to achieve their goals in the long-term.
A popular model of recovery from substance abuse/addiction termed The Developmental Model has outlined six stages that individuals with substance use disorders go through as they reach long-term recovery. This model is a useful guideline that outlines the process that individuals may experience regardless of the treatment program they choose:
- The first stage is the Transition Stage: This stage represents a particular time period when individuals realize that they are unable to use their drug of choice in a recreational or “normal” manner.
- The Stabilization Stage occurs when individuals begin to experience medical issues, such as withdrawal symptoms or other issues such as cravings, and learns how to isolate themselves from people and conditions that foster their drug usage.
- The Early Recovery stage occurs when people address their need to establish a drug-free lifestyle and engage in relationships that support their long-term recovery.
- Middle Recovery comprises developing a balanced style of living and continuing to address the issues that occurred with substance use disorder.
- Late Recovery involves identifying and changing personal impressions and worldviews that contributed to thinking when individuals were using the drug of choice.
- Maintenance involves the long-term, often lifelong, management of living without using drugs.
Most people find that recovery is long, can be very complex, has issues with relapse and learning from relapse, and requires perseverance in order to be successful. Different people have different issues in recovery that make the recovery process even more complex, such as co-occurring psychiatric issues/diagnoses, family histories that helped promote substance use, personal stressors that also require attention, relationship issues, and so forth.
Different treatment programs can be tailored to the specific needs of the individual.
It is important to identify and address the particular needs/stressors that one faces when one is in treatment and then work on understanding and living with or changing them if possible.
Empirically Validated Treatment Models
The term empirically validated refers to the notion that there is sufficient research-based evidence to indicate that the model is effective in treating substance use disorders. The following discussion is a general discussion regarding general models of addiction, most of which empirically validated, and a few models that may lack good research validation, but remain in the forefront of recovery for many people.
Pharmacotherapy refers to the treatment of substance use disorders by using specific medications such as Suboxone, methadone, or Antabuse. The specific type of medication used depends on the type of drug the individual is attempting to stop using. For the most part, pharmacotherapy is used as an adjunct form of treatment; it is not a standalone treatment.
There are several different forms of pharmacotherapy that vary depending on the type of drug that the person is addicted to and the need to control withdrawal symptoms. Drugs like Suboxone and methadone are used to assist individuals with negotiating through the potential severe withdrawal symptoms and cravings that often come with stopping use of opiate drugs. Drugs like Antabuse and naloxone are designed to trigger specific averse reactions when an individual takes a specific type of drug. Antabuse makes people violently ill if they drink alcohol; naloxone triggers severe opioid withdrawal effects if people take a narcotic drug. Similar types of therapy are used for nicotine addiction and several other drugs of abuse.
Most of these medications need to be taken under the supervision of a physician and cannot be purchased legally without a prescription. Some of them, like Suboxone, also have the potential for milder physical dependence and need to be discontinued gradually under the physician’s supervision. In general, these types of drugs are successful in accomplishing their purpose, assisting an individual in engaging in a recovery program while not using the drug of choice; however, compliance can also be an issue. For instance, users of Antabuse can simply stop using the medication and 48 hours later drink alcohol without serious ill effects.
However, research indicates that these drugs are generally effective in assisting people recover. For instance, a study in The Journal of Community Hospital Internal Medicine Perspectives found that heroin addicts treated with Suboxone had relatively good outcomes and better quality of life.
While pharmacotherapy is often an effective tool for some individuals, at this time, there is no reason for a person to think that engaging in a program that involves pharmacotherapy as a standalone treatment will be successful. At this time, all pharmacotherapy treatments should be supplemented with other types of recovery programs. Pharmacotherapy and other forms of empirically validated treatment operate by different but complementary mechanisms.
Pharmacotherapy is best suited for:
- Individuals who might experience severe withdrawal symptoms from the drug of choice and individuals with severe addiction issues are best suited for this type of adjunct treatment.
- Individuals who have issues with the legal system often engage in pharmacotherapy in order to communicate their commitment to their recovery to a judge or officer of the court.
- Since pharmacotherapy requires the supervision of a physician, individuals who prefer to “go it alone” may not find this alternative a suitable form of treatment
Therapeutic Communities, Residential Treatment, and Inpatient Medical Detox Programs
Residential treatment provides 24-hour care, most often in nonhospital settings; however, some hospitals may offer this type of treatment. The focus of these programs is typically to re-socialize the individual and offer comprehensive treatment at multiple levels. The treatment is often:
- Highly structured
- Utilizes a multidisciplinary approach (e.g., physicians, counselors, nurses, etc.)
- May even be confrontational
- Can be designed to assist clients as they undergo medical detox
- Treat co-occurring psychiatric issues
- Designed to address dysfunctional belief systems regarding substance use
- Designed to develop a sense of personal responsibility and accountability
- Attempts to help adopt a new more functional way for people to cope with their lives
Inpatient treatment is typically time-limited and can last from 30 days to as long as 12 months, depending on the needs of the individual, the situation, the individual’s ability to pay, and so forth. These programs can be modified to treat individuals with special needs. They are particularly useful for individuals caught up in the criminal justice system as a result of their substance use, since they provide documentation of the individual’s treatment progress and structure while at the same time separating the person from society.
While these types of inpatient programs are able to provide empirical evidence of positive results, individuals in them will need to continue an active recovery program once they are released. These programs are not standalone programs that “cure” patients; there is no cure for addiction. Thus, it is important that individuals released from these programs have a structured program of therapy and supervision in order for their success to be continued. These types of programs are best suited for:
- Individuals who require medical detox from a drug
- Individuals with co-occurring psychiatric disorders who need specialized treatment and structured supervision
- Individuals with living conditions that are not conducive for recovery (e.g., homelessness, severely dysfunctional families, situations of abuse, etc.)
- Individuals with potentially severe withdrawal issues
- Individuals with legal issues
- Individuals with multiple instances of relapse who need to develop a structured approach to recovery
Some individuals have specific needs that require 24-hour supervision. That being said, a good number of individuals are able to experience the same benefits from treatment by utilizing outpatient recovery programs.
The interventions under this heading are not meant to refer solely to interventions from the psychological paradigm of behaviorism. Behavioral therapies include the majority of therapies used to treat substance use disorders that attempt to help people to understand their incentives and motivations, develop coping skills, modify attitudes, identify triggers, and so forth. There are hundreds of recognized forms of therapy, and a discussion of some of the major categories of therapy follows.
Cognitive Behavioral Therapy
Many of the treatment interventions use the principles of Cognitive Behavioral Therapy (CBT), which combines two of the major psychological paradigms, cognitive psychology and behavioral psychology, in order to approach treatment from a holistic perspective. CBT actually refers to a number of different types of therapies as opposed to one singular approach, but all of these approaches attempt to challenge a person’s maladaptive behavior patterns and learning patterns by examining their thoughts, beliefs, and attitudes, and then help the person restructure them in real-life situations.
One of the central principles of CBT is to help people to anticipate issues and enhance their ability to cope with the development of effective coping strategies. Central techniques used by most types of CBT in the treatment of addiction include:
- Identifying and assisting with the change of dysfunctional attitudes, beliefs, and expectations
- Self-monitoring to identify triggers/cravings and situations that put one at risk for relapse or use
- Exploring positive and negative consequences of continued use
- Developing strategies for coping with stress, cravings, and other triggers
- Concentrating on developing positive relationships with others
The evidence from research indicates that the skills developed in CBT continue to be applied by people even after they complete the course of treatment. CBT approaches are suited for people who:
- Are motivated to explore their feelings and attitudes
- Are willing to engage in “homework” outside the therapy sessions and apply principles learned
- Are willing to look at themselves in an open-minded fashion
- Can reflect on their experiences
CBT can work with individuals who are initially very guarded and defensive; however, the therapist will need to apply the therapy towards those issues initially. Thus, CBT can be tailored for the individual (and most often is), and these approaches allow for quite a bit of variability and individualized restructuring in therapy. CBT is typically time-limited. Individuals who engage in CBT therapy will often get involved in support groups (see below) in order to continue a lifelong recovery program.
Motivational Interviewing (MI) is based on motivational psychology principles. As the name implies, the therapy attempts to increase the motivation to change for people who demonstrate resistance to understanding that they have a substance use disorder or need to change their behavior. The research on this technique is mixed, indicating that in some cases, it may assist in treating substance abuse, and in others instances, it is not effective. The result of the research suggests that MI might be effective for individuals initially resistant to change when it is combined with CBT.
Motivational Enhancement Therapy
Motivational Enhancement Therapy (MET) assists individuals in addressing their ambivalence regarding stopping substance abuse as opposed to guiding the individual to recovery. The treatment is typically brief and designed to use the approach provided by Motivational Interviewing (see below) to strengthen motivation and help individuals to begin to build a plan for change. People in MET are often encouraged to bring significant others to the treatment sessions.
MET appears to be particularly effective for people who abuse alcohol, and evidence for its use with other drugs, such as heroin and cocaine, appears to be mixed. This type of intervention may often be the choice of the therapist as opposed to the choice of a person seeking treatment because individuals who are resistant to changing their habits typically do not seek treatment.
Contingency Management Interventions
Contingency Management involves giving people with substance use disorders tangible rewards to reinforce behaviors that are suited to promote recovery, such as abstinence from their drug of choice. The rewards can consist of vouchers that can be exchanged for money, food, or other items, or can be actual cash rewards.
Typically, this is a strictly behaviorist approach (meaning that the focus is on the person’s actual behavior/actions as opposed to the person’s thinking) that appears to be useful in helping individuals with substance use disorders significantly decrease or even stop using their substance of choice. Once abstinence is established, it appears that the use of CBT techniques can assist with maintenance. For instance, a study in the Journal of Counseling and Clinical Psychology found that this type of intervention was useful in reducing cannabis use in individuals and that the addition of CBT did not help initially, but was useful in maintenance of abstinence and continued recovery following the program.
Contingency Management programs need to require objective documentation that the individual is maintaining abstinence such as a urine test. Thus, individuals who attempt to trick the therapist tend not to do well in these programs.
These types of programs are typically very short-term and designed to help individuals curb their use or establish abstinence. They are particularly useful for individuals who are in need of a particular commodity, such as money, food, or housing, but can be tailored for the use of other rewards, such as being publicly recognized for one’s accomplishments.
Individuals seeking treatment can often choose between individual therapy, group therapy, or combination of both. Most any type of therapy that is offered in an individual format is also offered a group format. There are various advantages to group therapy:
- Group therapy offers a chance for individuals in various stages of recovery to learn from one another.
- Group therapies offer a chance for one to share and help others.
- Group therapies offer a variety of different opinions that may not receive exposure in individual treatment.
However, some individuals may not initially be suited to certain types of groups, such as individuals with severe psychiatric issues or other special needs (but these might function better in groups of individuals with similar issues), extremely shy and withdrawn individuals, and those who are enormously embarrassed regarding their substance abuse and wish to remain private.
There are numerous different types of support groups offered by private institutions, community organizations, and hospitals. Support groups range from 12-Step groups, such as Alcoholics Anonymous (AA), to specialized support groups offered by hospitals and the community in general. While there is ample empirical evidence for certain types of formal group therapy and family therapy in assisting to treat various substance use disorders, the research for many of the popular support groups such as AA is limited. Nonetheless, groups like AA have a very large membership and are readily available. These groups offer some advantages:
- For the most part, community support groups are inexpensive or free, whereas many forms of therapy can be expensive and may not be covered by a person’s insurance.
- These groups are often held every day of the week and at multiple times during the day, making them very accessible.
- These groups offer advantages, such as learning from others, making one feel as if one is not alone in recovery, the opportunity to develop relationships with individuals who are abstinent, and so forth
However, many of these groups embrace philosophies that certain individuals may not find attractive, such as philosophies with religious connotations, certain “steps” that are touted as being crucial to recovery (such as confessing one’s wrongdoings to other individuals), and so forth. Since most of these groups are free and donations to support them are voluntary, individuals who are interested in recovering from addiction can attend many different groups in order to find a group that fits their specific needs. Moreover, support groups offer individuals the lifelong opportunity to continue to participate in programs that help them focus on ongoing issues in their recovery. In addition, individuals can maintain contacts with others who face similar problems, whereas many of the other interventions for addiction are time-limited.
A special form of group therapy that includes family members, family therapies have a number of specific uses in the treatment of addiction. There are many different forms of family therapies, ranging from couples therapy where married couples or romantically involved partners engage in therapy to family therapies that include members of the immediate and/or extended family. These therapies can apply principles from any of the major psychological paradigms and generally have solid empirical support regarding their effectiveness.
A recent review article in the Journal of Marital and Family Therapy found that the overall research findings investigating the use of different types of family therapies was encouraging and that family therapy was especially useful in assisting the treatment of adolescents with issues relating to addiction/substance abuse. Family therapy can be very useful in situations where individuals have severe issues or dysfunction in the family, with children with substance use issues, or when a spouse or significant other wants to be involved in treatment.
These interventions certainly do not represent the entire scope of available interventions but represent the major categories of interventions that are useful in the treatment of substance use disorders. The use of support groups is often helpful in the long run in maintaining lifelong sobriety and recovery, whereas formal interventions, such as CBT, represent shorter-term interventions that assist individuals in developing new habits and positive lifestyles. Recovery is a lifelong process, and most individuals will want to have ties to other individuals in recovery long after their initial treatment is completed.