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Behavioral Addiction Treatment

Table of Contents

Behavioral Treatments For Addiction

One of the primary goals of behavioral therapy, when used to treat addiction, is to help people examine unhealthy behaviors that may lead (or have led) to substance abuse. By helping those in recovery better understand their thoughts and feelings, they can begin to utilize healthier coping mechanisms and recognize potential triggers.

Two terms regularly discussed when speaking about therapy are research-based and evidence-based. Although they sound similar, there are subtle differences between the two.

Research-based means that the treatment is built on observable and measurable theories and outcomes as demonstrated in a research setting. Evidence-based means that treatment teams use the best available knowledge to make treatment decisions—it is often based on research, but also draws upon clinical expertise and a person’s own preferences. It acknowledges that the best form of treatment is usually based on the opinion and experience of industry experts, even if little or no research exists on the topic.1

Why Do I Need Behavioral Therapy?

Drug addiction is a complex and pervasive disease characterized by compulsive use despite their harmful effects and long-lasting brain changes.16 Behavioral therapies focus on changing a person’s maladaptive behaviors that lead to substance abuse by helping to promote healthy life skills and coping mechanisms that could prevent relapse in the future.1

Treatment centers use various behavioral modalities that can vary by the specific addiction being treated. In many cases, behavioral therapy is combined with medication to help ease the transition from drug use to sobriety. Specifically, opioid, alcohol, and nicotine addictions are usually treated with a combination of medication and behavioral therapy. Other types of addiction, such as those that involve the abuse of stimulants or cannabis, are generally treated with behavioral therapy alone, as there are no approved medications to treat these addictions.2

When it comes to rehabilitation programs, there are a variety of options to choose from such as inpatient treatment—which is helpful for people who require a high level of structure and supervision and for those with severe addictions—or outpatient treatment. The latter is usually best for those who do not require a high level of supervision or those who cannot commit to an inpatient stay.

Regardless of which setting you choose, you may be exposed to more than one type of behavioral therapy—in both group and private counseling sessions—as well as medication treatment, 12-step meetings and other types of program-specific assistance.

What Kind Will I Experience in Treatment?

Motivational Interviewing
The following are some of the evidence-based therapies that can help treat addiction. In addition to one-on-one therapies, you may also see some of these techniques used in different settings, such as group and family sessions. These therapies may also be used to complement medication-assisted treatment.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a form of treatment that helps address the maladaptive thoughts and feelings that a person may be struggling with. It aims to assist individuals in making positive cognitive changes that can lead to healthier behaviors and better maintenance of emotional distress.

Though cognitive-behavioral therapeutic approaches may vary, some general characteristics include:3

  • Shorter session times, as opposed to longer, more traditional psychotherapy sessions.
  • A focus on the idea that a person’s thoughts affect their emotions and behaviors.
  • A collaboration between the therapist and the client.
  • Structure and directive (i.e., you have specific goals and are taught specific techniques).
  • An education model with the understanding that because you learned certain behaviors and responses, you can also unlearn them.
  • Rational thinking. You are encouraged to look at the facts, rather than your emotional interpretation of events.

CBT is focused on the present, geared toward your specific problems, and helps you achieve measurable goals. The average total number of CBT sessions a person receives is relatively low. Unlike some other forms of psychotherapy, with their more enduring time-commitment and numerous sessions, you won’t have time to delve into an extensive examination of your past. This may be a challenge for some people, as many benefit from a deeper look into the influence of their childhoods and early lives on the present. Unlike depth psychotherapy, a typical CBT session is instructive and educational, and you may receive homework assignments from your therapist. Your therapist will listen to your concerns and help you set specific, measurable goals.3

Research has shown CBT to be effective for treating addiction, with studies showing the highest level of efficacy for cannabis addiction, followed by cocaine, opioids, and then polysubstance abuse.4 Studies have also shown that it has a number of strengths, including a lower level of dropout in treatment, its short-term basis, and its ability to help reduce relapse.5 However, some of the drawbacks are that people must commit to the process (attend all sessions) and complete homework assignments, which can take a considerable amount of time.  

Motivational Interviewing

Motivational interviewing (MI) is a form of time-limited behavioral treatment designed to help reduce a person’s ambivalence to treatment. It focuses on the motivational processes that help a person make lasting change by focusing on their values and concerns. MI is based on a respectful and positive client-therapist relationship, in which both parties can identify, examine, and resolve the client’s ambivalence to making changes.6

The key elements of MI are collaboration, evocation—meaning the therapist helps draw out the client’s thoughts and ideas, rather than impose their own—and autonomy (i.e., the therapist is not the authority figure but rather recognizes the client as the instigator of change). Autonomy helps reduce ambivalence because resistance is usually seen as the result of a conflict between the client’s view of the problem, solution and the therapist’s viewpoint. The goal is to increase the client’s intrinsic motivation to make positive and lasting change.7

A typical MI session might involve several components, such as:8

  • Being asked open-ended questions that allow you the freedom to respond however you wish, without fear of judgment.
  • Being affirmed for your successes and accomplishments.
  • Reflective listening, in which your therapist will make sure that they have correctly heard and understood what you’ve said.
  • Summarizing, in which your therapist recaps the session, so you have the chance to correct any potential misunderstandings.

MI recognizes five stages of change and helps to resolve potential motivational conflicts associated with them, such as:6

  • Precontemplation: You are not quite sure why your addiction is a cause for concern, but are willing to give treatment a chance.
  • Contemplation: You can imagine how quitting drugs will improve your life, but you might not be able to yet picture a sober life.
  • Preparation: You’re preparing to quit but you may have your doubts.
  • Action: You’ve already quit using drugs but aren’t entirely sure if you can stay clean.
  • Maintenance: Making progress toward recovery and abstaining from drug use, even if you aren’t sure if abstinence is necessary.

MI’s strength lies in the fact that it works with your own desire for change, instead of being externally imposed on you. It is up to you to make the change, which can be both a strength and weakness of this treatment, as you are completely responsible for your recovery. Other strengths include being low-cost and that it improves treatment adherence, which improves treatment outcomes.6 

Matrix Model Addiction Treatment

Contingency Management 

Contingency management (CM) is a type of behavioral therapy that relies on positive reinforcement to reward abstinence and modify behavior.9 CM involves identifying a target behavior (like abstinence), arranging for a way to measure behavior change (e.g., negative urine test), and providing reinforcement whenever the target behavior occurs (token for a negative urine test).10 The most common rewards for positive behaviors are vouchers, prizes, clinic privileges, or monetary compensation.10 

CM can be very effective for improving treatment outcomes, such as increased treatment retention and decreased drug use. A large body of research on the efficacy of CM has demonstrated benefits for cocaine addiction; but studies have also shown it to be effective for treating addiction to heroin, benzodiazepines, marijuana, alcohol, and nicotine.10, 11 

CM is beneficial for helping to maintain abstinence and improve treatment retention, not only in people with isolated substance addictions, but also in those who have a dual diagnosis (a co-occurring mental health disorder and substance use disorder).9 However, some of the challenges of this form of treatment are that it is sometimes compared to “bribery.” Critics have voiced concerns that positive behaviors might only persist with the continued delivery of CM rewards and have indicated that, in some instances, there may be a risk of people trading their rewards for drugs.12

Matrix Model

Originally developed to treat the widespread cocaine addiction that became prevalent in the 1980s, the Matrix Model is intended mainly for users of the substance and other stimulants like methamphetamine.13, 14 It is a comprehensive form of addiction treatment that occurs in an intensive outpatient setting (you’ll attend treatment several times per week).15 You can expect to participate in relapse prevention groups, social support groups, education groups, individual and group counseling, and urine and breath testing. Therapy is highly structured and usually takes place over the course of 16 weeks.18

People who participate in the Matrix Model have stayed in treatment longer, attended more groups, provided more methamphetamine-free urine samples during treatment, and had longer periods of abstinence from meth.14

Strengths of this model include its comprehensive approach, the use of a manual so therapists can follow specific instructions and exercises, and its extensive use and proven effectiveness in treating stimulant addiction. Weaknesses include the need for modification of treatment materials when working with people who are cognitively impaired, the requirement for specific staff training and supervision, the highly structured content which may not appeal to everyone, and the time-limited structure, which doesn’t always allow for the identification and discussion of other underlying issues.15 

Other Supplemental Therapies

In addition to the aforementioned evidenced-based behavioral therapies, other supplemental therapeutic approaches you may encounter during rehabilitation include:

  • Rational Emotive Behavior Therapy (REBT)
  • Eye Movement Desensitization and Reprocessing Therapy (EMDR)
  • Dialectical Behavior Therapy (DBT)
  • Community Reinforcement and Family Training (CRAFT)
  • Multidimensional Family Therapy
  • Integrative Approach
  • Person-Centered Therapy

Sources

[1]. American Educational Research Institute. (2008). AERA offers definition of scientifically based research.

[2]. National Institute on Drug Abuse. (2018). Drugs, brains, and behavior: The science of addiction: Treatment and recovery.

[3]. National Association of Cognitive-Behavioral Therapists. (2016). What is Cognitive-Behavioral Therapy (CBT)?

[4]. McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disordersThe Psychiatric Clinics of North America33(3), 511-25.

[5]. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analysesCognitive Therapy and Research36(5), 427-440.

[6]. Center for Substance Abuse Treatment. (1999). Enhancing motivation for change in substance abuse treatment. (Treatment Improvement Protocol [TIP] Series, No. 35.) Chapter 3—Motivational interviewing as a counseling style. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[7]. UMass Amherst. (n.d.). Retrieved November 12, 2015.  Motivational Interviewing Definition, Principles, Approach.

[8]. Stewart, E. & Fox, C. (2011). Encouraging patients to change unhealthy behaviors with motivational interviewing. Family Practice Management, 18(3), 21-25.

[9]. Petry N. M. (2011). Contingency management: what it is and why psychiatrists should want to use it. The Psychiatrist, 35(5), 161-163.

[10]. Petry, N. & Stitzer, M. (n.d.) Contingency management: Using motivational incentives to improve drug abuse treatment. West Haven, CT: Yale University Psychotherapy Development Center.

[11]. McPherson, S., Burduli, E., Smith, C., Herron, J., Oluwoye, O…Roll, J. (2018). A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies. Substance Abuse and Rehabilitation, 9, 43-57.

[12]. Petry N. M. (2010). Contingency management treatments: controversies and challenges. Addiction, 105(9), 1507-9.

[13]. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition): The Matrix Model (Stimulants).

[14]. Hazelden Publishing. (n.d.) The Matrix Model.

[15]. Center for Substance Abuse Treatment. (2006). Substance abuse: Clinical issues in intensive outpatient treatment. (Treatment Improvement Protocol [TIP] series, no. 47.) Chapter 8. Intensive outpatient treatment approaches. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[16]. National Institute on Drug Abuse. (2018). The Science of Drug Use and Addiction: The Basics.

[17]. Center for Substance Abuse Treatment. (2006). Substance abuse: Clinical issues in intensive outpatient treatment. (Treatment Improvement Protocol [TIP] series, no. 47.) Chapter 8. Intensive outpatient treatment approaches. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[18]. Obert, J., McCann, M., Marinelli-Casey, P., Weiner, A., Minsky, S… Rawson, R. (2000). The matrix model of outpatient stimulant abuse treatment: History and description. Journal of Psychoactive Drugs, 32(2), 157-64.