The Substance Abuse and Mental Health Services Administration (SAMHSA) lists the major types of interventions used in the treatment of substance use disorders as:
- Individual and group psychotherapy (therapy or counseling)
- Medication management
- Inpatient or residential treatment
- Intensive outpatient treatment
- Partial hospitalization treatment
- Case management services
- 12-Step groups and other peer support measures
- Recovery support services
Individuals may not need to become involved in every one of these particular services; however, most of the major organizations involved in the research and treatment of the substance use disorders agree that the use of psychotherapy should be the cornerstone of any recovery program.
What Is Psychotherapy?
The Book Research in Psychotherapy provides one of the most quoted definitions of psychotherapy that is paraphrased here:
Psychotherapy is a term that applies to the planned and informed application of techniques that are derived from established psychological principles by individuals qualified through training and experience to understand and apply these techniques with the intention of helping others to modify personal characteristics, including attitudes, feelings, values, and behaviors, which have been judged by both the therapist and the client to be maladaptive or maladjusted.
This definition of psychotherapy originated from research studies attempting to determine the effectiveness of psychotherapy in treating certain types of psychological disorders. This is also the overall definition of psychotherapy that the major psychological organizations, such as the American Psychological Association, use when defining various types of psychotherapy.
Psychotherapy (therapy) has several important features:
- It is the planned and informed application of techniques that are derived from formal psychological principles.
- Psychotherapy can only be practiced by individuals trained in these psychological principles. Psychotherapists have to be licensed by the state where they practice in order to be able to deliver their services. Licensure typically requires obtaining some level of graduate education (training beyond a bachelor’s degree), meeting the requirements for some form of internship (getting experience before practicing), and passing a formal licensure examination. The majority of psychiatrists in the United States are no longer trained in the practice of psychotherapy, but instead are trained in the application of medical management (particularly, use of medications) in treating behavioral problems. Individuals practicing psychotherapy are typically licensed psychologists, counselors, and social workers.
- Psychotherapy has specific goals.
- Psychotherapy attempts to address situations that are maladaptive or maladjusted in either an individual or a group of individuals.
The formal definition of psychotherapy rules out certain types of other treatments that are used for substance use disorders, such as the use of medications (the domain of psychiatry and not psychology), occupational therapy, peer support and peer counseling (12-Step groups), and case management services. Certain types of adjunctive or complementary and alternative therapies may not meet the formal definition of psychotherapy, such as yoga therapy, art therapy, psychodrama, etc.
The terms therapy and counseling are often used interchangeably, and very often, they are indistinguishable from one another. Traditionally, the difference between counseling and psychotherapy was subtle, but identifiable. Counselors typically focused on specific problems that a person or group, such as a family, may have and worked out solutions to one singular problem. Psychotherapists typically worked on a range of specific problems that presented as some type of the disorder or syndrome. The application of counseling was originally designed to help individuals work through everyday problems, whereas psychotherapy was designed to work with more severe manifestations of behavior. However, therapy and counseling programs have developed over the course of time to include many similarities and address many of the same issues. Currently, these terms are used interchangeably in most contexts.The development of psychotherapy has a long and interesting history that indicates that its origins actually came from areas of philosophy and medical doctors, such as Sigmund Freud, who attempted to use talking methods to help individuals with severe adjustment issues or even severe psychiatric disorders. Not all psychotherapy approaches use or focus on the same types of psychological principles.
Within the field of clinical psychology, through which formal psychotherapy was refined, there are typically five different paradigms, or schools of thought, that have emerged. These paradigms, or schools, focus on different approaches and principles believed to be responsible for the manifestation of the behavior in individuals. The major paradigms in psychology are:
- The psychodynamic paradigm, which is often attributed to Sigmund Freud but has its roots in much early philosophical thought
- The behavioral paradigm, which grew out of experimental psychology
- The cognitive paradigm, which developed as a response to both the psychodynamic and behavioral paradigms
- The humanistic paradigm, which also developed as a reaction to the mechanistic viewpoints of the psychodynamic and behavioral paradigms
- The biological paradigm, which developed out of a better understanding of brain and behavior relationships and helped researchers to associate certain types of behaviors with specific neurobiological correlates.
With respect to psychotherapy, the major paradigms that drive the majority of approaches come from the psychodynamic paradigm, a combination of the cognitive and behavioral paradigms, and the humanistic paradigm.
Psychodynamic Therapy and Substance Abuse Treatment
The psychodynamic paradigm (psychoanalytic paradigm) owes its development to the neurologist Sigmund Freud. Freud became interested in treating individuals who developed different types of neuroses, particularly hysteria (now referred to as conversion disorder). Patients with hysteria displayed a significant neurological issue in the absence of any physical abnormality or disease. Most often, these neurological issues were puzzling because they often made no medical sense. Individuals would display sudden blindness, paralysis, mutism, memory loss, etc.
Freud first began working with hypnosis along with the French physician Jean-Martin Charcot, but later found that he could better treat his patients with a form of talk therapy known as psychoanalysis. Freud encouraged his patients to say whatever was on their mind, and he attempted to interpret their ramblings as manifestations of their unconscious mind. Freud developed elaborate theories of behavior that were focused on his notion that the unconscious mind, the part of the mind that we are not aware of or able to consciously recall or bring to the surface, contains numerous conflicts that developed as a result of an individual’s upbringing. These conflicts and early experiences typically shaped an individual’s personality. Sometimes, these conflicts resulted in dysfunctional issues with anxiety that lead to dysfunctional and illogical or neurotic types of behaviors.
Freud concentrated on early relationships, sexually based motivations, and how anxiety symbolically played out in behavior. Although the psychodynamic paradigm is still alive and well today, many of Freud’s original notions have been replaced with more modern interpretations. Nonetheless, it is important to understand that Freud made numerous contributions to the conceptualization of human behavior that are still held by many researchers and therapists today. Some of these are outlined below.
- The idea that childhood experiences can deeply affect behavior, and these effects can persist well into adulthood, came from Freud.
- The notion of defense mechanisms is primarily Freudian. This notion suggests that people use certain types of psychological defenses to protect themselves from their true feelings.
- Sometimes, people do not understand why they act in certain ways, and the explanation for their actions may represent certain types of unconscious or hidden factors.
- Getting people to talk about their feelings, experiences, and beliefs can be a form of treatment to help individuals change their behaviors.
Freudian psychoanalysis typically was lengthy and slow to progress. Today, most of the psychodynamic therapists practice a much briefer form of therapy than Freud and most of his early followers practiced.
Psychodynamic therapy for substance abuse conceptualizes substance use disorders as defensive strategies to cope with feelings of powerlessness or helplessness. Psychodynamic therapists approach drug abuse as a way for the individual to compensate for feelings of emptiness or pain (e.g., low self-esteem, anxiety, doubt, etc.). When a person uses drugs or alcohol, they begin to have temporary feelings of confidence and even acceptance. Individuals with substance use disorders often create an imaginary situation where they believe they are in control, but this relief is only short-lived as the effects of drugs wear off. Psychodynamic therapists attempt to explore these issues and help clients find more constructive ways to deal with them.
Another specific type of psychodynamic therapy used in the treatment of substance use disorders is Supportive Expressive Psychodynamic Therapy, a brief form of therapy that attempts to fortify the client’s capacity to deal with various life stressors. Therapists achieve this in various ways as they help clients to:
- Better understand their motivations
- Explore options available to them to facilitate change
- Build self-esteem
- Strengthen their ability to face challenges
- Positively express feelings
Therapists listen intently, display empathy, and interact with the client. Clients are encouraged to express themselves, and therapists help them to reach their goals (e.g., abstinence). This therapy has been shown to be useful in the treatment of numerous substance abuse issues, including issues with opiates, cocaine, and alcohol.
Cognitive Behavioral Therapy for Substance Use Disorders
Cognitive Behavioral Therapy developed from two major paradigms in psychology: the behavioral paradigm, which originated from experimental psychology, and the cognitive paradigm, which also has its roots in experimental psychology but developed as a reaction to the mechanistic notions of Freud and behavioral psychology. The behavioral paradigm of psychology focused on the observable actions that individuals produced. The majority of the research in the behavioral paradigm was performed with animal models of behavior that used rodents, birds, and other animals. These models set up conditions to shape different types of behavior and then generalized these findings to humans.
Even today, the most well-known of the individuals in the behavioral paradigm is B.F. Skinner who developed very intricate theories of learning and behavior based on the results of animal research. Skinner’s primary contribution to the understanding of behavior was the notion of how reinforcement shaped learning and behavior. Reinforcement occurs when any stimulus or condition results in the probability that a specific behavior will be repeated. Reinforcement can either be:
Positive in the form of a reward: When an individual or animal completes a behavior and is reinforced, the probability is increased that they will repeat that behavior.
Negative in the form of the removal of some aversive stimulus or condition: For example, when a particular behavior reduces pain or anxiety, individuals are more likely to repeat that behavior when they feel pain or anxiety.
The notion of punishment in Skinnerian terms is any condition or stimulus that results in an increased probability that a behavior will not be repeated. For example, animals given a shock after they press a lever are less likely to press the lever again. The behavioral paradigm developed numerous models and theories regarding the antecedents (conditions that occur before the behavior is performed) and the consequences (conditions that occur after the behavior is performed) that resulted in the behavior either being more likely to be repeated or not to be repeated. Strict behaviorism as practiced by Skinner did not consider attitudes, thoughts, or beliefs as these could not readily be directly observed. There are very few strictly behavioral psychotherapists due to this particular aspect of behaviorism. Instead, many of the techniques developed by behaviorists to increase or decrease certain types of behaviors were combined with cognitive psychology.
The cognitive paradigm developed as an alternative to the major assumptions of both the behavioral and psychodynamic paradigms. Early research in cognitive psychology using animal models demonstrated that even rodents could make “cognitive maps” of their surroundings in order to remember where food, water, or other important resources were. Before this research, the behavioral school of psychology had been so influential that it was believed by many that learning could not occur in the absence of reinforcement or punishment. Cognitive psychologists went on to develop numerous intricate theories about how attitudes, beliefs, and information processing contribute to how people behave, including how certain types of psychopathologies, such as substance use disorders, develop and are maintained.
By far the most prominent school of therapy being practiced today is some type of Cognitive Behavioral Therapy (CBT). CBT combines the principles of both the behavioral and cognitive paradigms to produce numerous types of therapies that focus on treating different types of conditions. Cognitive Behavioral Therapy is an umbrella term to describe numerous types of therapies that focus on an individual’s pre-existing beliefs, expectations, and attitudes, and identify attitudes that drive dysfunctional behaviors. In using both cognitive and behavioral principles, therapists attempt to help individuals restructure their way of thinking and behaving into more functional and adaptive means.
Numerous professional sources, including professional clinical texts such as Kaplan & Sadock’s Synopsis of Psychiatry, recommend CBT as the preferred approach to treating substance use disorders. There are numerous types of CBT that have been used in the treatment of psychiatric disorders, including substance use disorders. Some of these approaches are outlined below.
- Rational Emotive Behavior Therapy (REBT) is an early form of Cognitive Behavioral Therapy that attempts to identify mistaken or irrational beliefs that drive a person’s dysfunctional behaviors (e.g., substance abuse). Then, through the use of numerous cognitive and behavioral techniques, such as cognitive restructuring, stress management, the development of coping skills, these beliefs and behaviors are replaced with more realistic and productive behaviors.
- Self-Management and Recovery Training (SMART Recovery) is an international organization that provides free supportive care for substance abuse. The program is based on the principles or REBT.
- Motivational Interviewing and Motivational Enhancement Therapy are based on a model of how individuals change their behavior and the importance of understanding where a person is regarding their awareness of their need to change their use of drugs or alcohol before attempting to use CBT techniques. Numerous research studies have found that these approaches are useful in treating individuals with cannabis use disorders, nicotine use disorders, alcohol use disorders, and other forms of substance use disorders.
- Contingency Management treatment approaches involve giving clients tangible reinforcers to induce positive behavior, such as abstinence. These behavioral practices are often used in combination with cognitive approaches to restructuring irrational beliefs, thoughts, and expectations.
- There are also numerous specific applications of CBT that are tailored to issues with specific types of drugs of abuse or alcohol, such as CBT techniques for alcohol use disorders, opiate use disorders, stimulant use disorders (e.g., cocaine, methamphetamine, etc.) cannabis use disorders, etc.
The Humanistic Paradigm
Theorists such as Abraham Maslow believed that many of the approaches used by other paradigms in psychology ignored many of the qualities that make people who they are as well as issues with an individual’s sense of self and their need to be recognized. The humanistic paradigm focuses on the subjective emotions, attitudes, and expectations of individuals that drove them to deal with their environment and to improve themselves.
The famous therapist Carl Rogers developed a humanistic approach to psychotherapy known as client-centered therapy that focused on the unique relationship between the therapist and client, and how this relationship could help clients achieve their goals. Rogers was the first major therapist to actually apply research methodology to test the results of his paradigm. His approach revealed several key elements that other research studies have found to be crucial to the success of psychotherapy despite the paradigm being used:
- The therapist maintains empathy for the client throughout treatment.
- The therapist is genuine (honest and open) with the client throughout treatment.
- The therapist displays unconditional positive regard for the client throughout treatment.
These three elements are often key components to what researchers referred to as the therapeutic alliance – the strength of the working bond, respect, and understanding that both the therapist and the client have for one another, and their commitment to making the therapy a success. Humanistic approaches have been successful in treating substance use disorders, but for the most part, therapists who treat substance abuse issues attempt to incorporate many of the techniques from client-centered therapy into their own paradigm, such as Cognitive Behavioral Therapy or psychodynamic therapy as opposed to defining themselves as “client-centered therapists.”
The Biological Paradigm
Within the biological paradigm, numerous findings that were directly related to the understanding of substance abuse were discovered (e.g., the reward system, the contribution of neurotransmitters to mood states and in drug use, neuroplasticity or how the brain changes in response to experience, etc.). Psychiatrists focus on the biological paradigm as the main approach to treatment by administering medications or performing different types of psychosurgical techniques.
The CBT approach uses numerous techniques that have grown out of the biological paradigm, such as exposure, relaxation training, diaphragmatic breathing, stress management, etc., to assist in its approach.
Other therapists also use these techniques, and principles from the biological paradigm are applied in nearly every form of psychotherapy that is in practice today.
Psychotherapy can be applied to a single individual or to a group of individuals. All of the above paradigms can be incorporated into group therapy. Group therapy for substance abuse can consist of groups that contain only family members, groups that contain members who are only abusing a particular type of substance (e.g., alcohol), or groups composed of individuals who have numerous different types of substance use disorders. Any time therapy is habitually delivered to more than one individual, it is a form of group therapy.
Group therapies have several advantages.
- Individuals in groups develop a shared sense of identity and do not feel alone. This allows them to get support from both the therapist and other group members.
- Group therapy is often broader in scope and more flexible than individual therapy.
- Group therapy may help individuals who are hesitant to discuss their issues with others open up as they learn to identify with members of the group.
Individual therapy offers a more focused and intense delivery of treatment that is geared toward the needs of the individual. Group therapy is broader in scope. Thus, clients who are being treated for substance use disorders often attend combinations of individual and group therapy sessions to glean the benefits of both. Group therapy can consist of:
- Family therapy, which concentrates on family conflicts and issues associated with substance abuse in one or more family members
- Marital therapy, a specialized form of family therapy where the clients are either married or romantic partners
- Group therapy that involves individuals from a specific type of background like a shared occupation, such as group therapy for physicians with substance use disorders, attorneys, individuals in the restaurant business, etc.
- Group therapy where the members are not related but have some significant shared problem that is the focus of treatment, such as a substance abuse issue, depression, a personality disorder, etc.
Integrative or Eclectic Therapy Approaches
Recently, many therapists are starting to describe themselves as “holistic” or “eclectic” in their approach. This means instead of focusing on a specific paradigm, such as CBT or psychodynamic therapy, the therapist attempts to incorporate principles from many different sources in order to develop a holistic approach to treatment.
There is certainly nothing wrong with combining the strengths of different types of psychotherapies to develop an approach that can better assist the client; however, it is important that the therapist has adequate training in these techniques before using them. Any individual who is considering getting involved in psychotherapy should always ask the therapist about their credentials, training, experience, and overall approach to ensure that the therapist is adequately trained in the techniques they use.
Effectiveness of Psychotherapy
In general, research indicates that there is empirical evidence to support all the different types of therapies from the major paradigms, and that group therapy and individual therapy are generally effective for treating substance use disorders. The specific type of therapy that an individual becomes involved in is often limited to their geographical area (e.g., some areas may not have therapists with strong psychodynamic backgrounds) and their own preferences. For instance, some individuals may be more interested in understanding how their early experiences are contributing to their substance abuse issues, whereas other individuals may be more interested in just dealing with practical ways to help them recover.
Because psychotherapy is a collaborative intervention that involves the interplay between the therapist and the client, it is important that the client understands that therapy requires substantial work and commitment. Therapists should always have goals for therapy, continually check therapeutic progress, and frequently reassess the treatment plan.
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