Issues of Concern
Motivational Interviewing
Many patients caught in the cycle of addiction are aware of the mounting medical and psychosocial consequences of their substance use yet continue to resist change. Motivational interviewing (MI) is a therapeutic technique used to draw out ambivalence and motivate change in a patient who has not yet begun recovery or is struggling. MI is an approach that can be used for patients in "denial," using a conversational style of discourse, taking opportunities to underscore any reason for change the patient might verbalize. This promotes a focus on the patient's motivation to change over the reasons for persisting in addiction.
The goal of motivational interviewing is to explore the patient's beliefs, motivations, and concerns regarding the change and underscore the patient's statements in favor of a change. A directive style that attempts to confront the patient and force change will likely be met with opposition and is unlikely to be effective. MI relies on the idea that their motivation to change strengthens when patients verbalize the need to change themselves. Therefore, the therapist's task is to listen to patients for ambivalence and reflect on their desire to change while simultaneously respecting their autonomy and choices, including the desire to continue using substances.[7][8]
Motivational interviewing utilizes open-ended questions to explore the patient's motivations and affirmations to build rapport and strengthen the patient's self-efficacy, reflections, and summarizing to confirm the therapist's understanding of the patient's view of their substance use.[9] These techniques enable the therapist to bring out and focus on the patient's statements indicating resolve for change. By reflecting and preferentially focusing on these statements rather than statements that indicate a desire to continue use, the therapist strengthens internal motivation and desire to change and helps the patient build a discrepancy between their goals and their current behaviors.[9] While MI depends on finding existing motivation, it is much more effective than attempts to educate or shame patients into changing.
MI can be used as a standalone technique or in combination with medication and other psychotherapies. MI is also used in various settings, including primary care offices and psychiatric outpatient clinics.[10] MI has been shown to decrease substance use, at least in the short term. A 2011 Cochrane review showed a significant post-intervention effect on substance use compared to no treatment, with smaller effects at 6 to 12 months and no significant difference compared to no treatment after one year, indicating that the beneficial effects of MI were most apparent immediately after patients received the intervention and that ongoing MI even after remission of the SUD may be useful.[8]
MI has also been shown to have larger effect sizes in reducing substance use in patients from non-white ethnic minority populations.[11][12] However, in other groups like adolescents, MI has not been shown to decrease substance-using behaviors.[13]
Notably, while MI was initially developed for addiction treatment, its concepts apply to a variety of different contexts. In individuals with type II diabetes, MI has been shown to reduce systolic and diastolic blood pressure and decrease hemoglobin A1c levels.[14] MI has also been shown to improve medication adherence in chronic health conditions such as asthma, diabetes, and hypertension.[10]
Mutual Help Groups
Mutual help groups, more commonly known as 12-step groups, have been a cornerstone of addiction treatment for decades and include alcoholics anonymous (AA), narcotics anonymous (NA), cocaine anonymous (CA), and many groups for other disorders. 12-step groups are a valuable, accessible, no-cost resource for individuals with SUDs to receive treatment in a community-based setting and meet others experiencing similar struggles. 12-step groups are peer-led and, for many individuals, are valuable sources of emotional support, community, and learning practical coping strategies.[15] AA is by far the most common type of 12-step program; in 2012, there were over 64,000 groups and 1.4 million AA members in the United States and Canada alone.[16]
The only requirement to join 12-step groups is a desire to stop using substances. 12-step groups emphasize that addiction is a disease that can be treated and mitigated but not cured. These groups create a community, with members sharing personal, intimate stories of addiction and recovery while providing sponsorship, mentorship, and support to more junior members in earlier stages of recovery.[16]
The 12 steps are a series of activities that members undertake during recovery and begin with the acknowledgment that a substance use disorder is present, as well as the admission of personal powerlessness over substance use and the need for outside intervention. Individuals then progress to taking a moral inventory, admitting wrongs, creating a list of people they have wronged, and making amends to those people.[16] 12-step programs foster fundamental shifts in self-conception and interpersonal relationships to achieve permanent abstinence from substances.[15]
Individuals with SUDs receiving treatment in addiction clinics often concurrently attend 12-step groups. Up to 60 to 75% of addiction clinics use 12-step principles in their therapies and promote the patient's engagement in a 12-step community group. This has been termed 12-step facilitation and has been associated with improved outcomes. The 12-step participation is usually encouraged when receiving other forms of treatment due to the association with improved outcomes.[16]
A recent Cochrane review demonstrated the effectiveness of AA in increasing the percentage of abstinent days, reducing the intensity of drinking over the long term, improving psychosocial functioning, decreasing health care costs, and promoting long-term abstinence.[16][17]
AA is the most studied 12-step program. There are less data regarding the effectiveness of 12-step programs in addressing other SUDs. One 2020 study pooling results from six clinical trials reported decreased cocaine, heroin, and cannabis use over the previous 30 days in individuals attending 12-step programs. The same study noted that 12-step engagement might be more difficult in individuals with opioid or stimulant use disorders than in those with alcohol use disorders. This is primarily due to the lower availability of 12-step groups for substances other than alcohol and generally lower quality of life early in recovery from opioid/stimulant use, which often necessitated more intensive treatment methods.[15]
The philosophy of 12-step programs presents a barrier to participation by some patients. Notably, the religious and spiritual themes and the need for "surrender" and admission of powerlessness can be a barrier for adolescents and individuals from groups that have historically experienced oppression. Despite these barriers, 12-step groups are a necessary, readily available intervention that healthcare professionals should consider familiarizing themselves with to counsel and refer patients appropriately.[16]
Cognitive-behavioral Therapy
The cognitive-behavioral theory is the conceptual foundation for the psychotherapeutic treatment of various psychiatric disorders, including depressive disorders, anxiety disorders, and substance-use disorders. Cognitive-behavioral interventions explore the relationship and interactions between thoughts, feelings, and behaviors perpetuating ongoing substance use.[18] Cognitive-behavioral therapy (CBT) for substance use disorders is a structured, generally time-limited therapy focused on changing behaviors and building skills for avoiding substance use. CBT was initially developed for alcohol use disorder but has since been adapted to most other substances.[19] CBT can be administered in both individual and group formats.[20]
The framework for CBT involves structure, a clear plan, goal setting, and engaging in homework outside of sessions. A core focus of CBT is on developing methods to mitigate strong positive reinforcement from substances.[20] Early in treatment, functional analysis is performed in which triggers or antecedents for substance use episodes are identified. For instance, in a patient with alcohol use disorder, a trigger of social situations involving friends who use alcohol may be identified. Early identification of triggers helps clinicians identify whether substances are used primarily in social situations, to enhance positive activities, or to decrease negative emotions associated with stressful situations. The CBT therapist then thoroughly explores the chain of events with the patient, from triggers to substance use and consequences. The therapist then teaches the patient to notice and interrupt the cognitive-affective-behavioral chain of events to produce more adaptive responses.
Cognitive restructuring also occurs when maladaptive cognitive distortions can be challenged and altered. For example, self-defeating beliefs like "I will never be able to stop using alcohol" can be elicited and restructured. Skills training involves improving emotion regulation skills and strengthening problem-solving abilities. Emotion regulation skills training involves developing sober activities for decreasing distress. The therapist may work with the patient to develop a plan to engage in pleasurable activities like exercise to cope with anxiety rather than using alcohol. Learning to set smaller goals to accomplish future long-term goals is a key focus, as individuals with SUDs commonly favor the pursuit of short-term gratification, which impairs the accomplishment of long-term goals. The overall length of a CBT intervention can vary greatly, ranging from relatively brief interventions to longer, longitudinal skills-focused groups.[20]
CBT has been considered an evidence-based treatment for SUDs for decades and has been applied to multiple SUDs.[18] Marijuana, opioid, cocaine, and alcohol use have evidence demonstrating the efficacy of CBT, although there is less evidence supporting efficacy in patients with multiple concurrent substance-use disorders.[20] A recent 2019 meta-analysis of 30 randomized trials examined the effectiveness of CBT and demonstrated that CBT is more effective than no or minimal treatment but is not more effective than other evidence-based interventions for substance-use disorders, like supportive psychotherapy, group therapy, motivational interviewing, and contingency management.[19]
The effects of CBT on substance use were also durable at both early (1 to 6 months) and late (greater than eight months) follow-ups.[19] This effect may be due to CBT focusing on relapse prevention and improving psychosocial functioning, leading to long-term gains even after the end of therapy, which may be a fairly unique benefit of CBT. One recent systematic review examined mechanisms of change in patients undergoing CBT-SUD, demonstrating that the development of increased coping skills is possibly responsible for the sustained reduction in use.[18]
Family Therapy for Substance Use Disorders
Family therapy for substance use disorders places the identified patient's problems within the context of the family. While the definition of family can vary, the unit of interest is a group of people with shared affection and responsibilities.[21] Family therapy recognizes that addictive behaviors are part of an interactive and dynamic system. Substance use disorders impact an individual's social and economic functioning, and the family, in turn, attempts to maintain an allostatic balance by adapting to and accommodating the individual's substance use. Often this accommodation perpetuates continued substance use. Conversely, a family can promote recovery. For example, the family of an individual recovering from alcohol use disorder may work to reduce shaming the recovering individual and reward incremental improvements.[22]
The primary targets of intervention are the patterns of communication within the family. During sessions, the family therapist facilitates open communication between the family and the substance-using individual and engages in collaborative problem-solving. The goal is to help the entire family understand what the family dynamics are and help family members work together to meet the individuals' personal goals.[21][23] The family therapist mediates conflicts between family members and encourages the discussion of emotionally charged topics in a safe setting. Fears and frustrations can be safely expressed and validated, and the family can be empowered by understanding the substance use and each other.[22]
Family therapy effectively reduces substance use in adults and adolescents, although the data is more robust in adolescents. A 2013 meta-analysis analyzed the comparative effectiveness of different treatments for adolescent SUDs and found that family therapy was the most consistently efficacious intervention compared to other interventions like CBT, psychoeducation, motivational enhancement therapy, and group therapy.[23]
Family therapy also has the advantage of promoting therapeutic alliance and treatment attendance, which are significant issues in adolescents and adults receiving substance use treatment.[24] In adults, the involvement of a partner through couples therapy has shown efficacy in reducing alcohol use in multiple populations, including women, gay and lesbian patients, and veterans with post-traumatic stress disorder.
Contingency Management
While recovery from addiction results in improved physical and mental health, increased employment opportunities, and improved social relationships, individuals with SUDs often are attuned to immediate rewards over more significant rewards in the future.[25] This phenomenon, known as delay discounting, is circumvented by contingency management (CM).[26]
Contingency management relies on the principles of operant conditioning in which individuals are rewarded directly for behavioral change. In CM, patients are typically rewarded using monetary incentives, commonly in the form of prizes or vouchers, to provide positive reinforcement for abstinence which is usually verified through urine drug screens. Three key principles in implementing contingency management are 1) the magnitude of the reward, 2) the frequency of the reward, and 3) the immediacy of the reward.[26] Generally, rewards greater in size and given immediately after the desired behavior provides stronger reinforcement than lower magnitude, delayed rewards.[26][27]
One example of successful CM implementation is at a Veterans Administration (VA), where veterans came to the program twice weekly and earned "draws" for each negative urine specimen. Urine specimens were tested with point-of-care testing for immediate results. Each consecutive negative urine result earned an increasing number of "draws," up to a maximum of eight. Each draw then allowed a patient to select a slip from a bowl consisting of rewards that ranged from simple praise to vouchers worth $100.[28]
CM has a large body of evidence demonstrating its efficacy and cost-effectiveness.[26] CM is currently regarded as one of the most effective psychosocial interventions for reducing substance use and has demonstrated effectiveness in promoting abstinence from a variety of different substances, including marijuana, stimulants, opioids, tobacco, and alcohol.[29][30] A 2022 meta-analysis compared long-term treatment outcomes (up to one year) between patients who received CM and patients who received other psychosocial interventions for substance use. CM demonstrated a 22% greater likelihood of abstinence than the comparator treatments.[30]
CM also appears to be effective in treating stimulant use disorders and may be particularly valuable for this purpose, as no effective pharmacological treatment exists.[28][29] Prior studies have indicated that CM is effective regardless of patient demographics, comorbid mental illness, or medical comorbidities.[29]
Despite its well-documented efficacy, CM is among the least likely psychosocial treatments to be offered to patients due to significant implementation barriers.[26][29] These barriers consist chiefly of logistical issues and the high cost of implementing CM programs but also encompass ethical concerns and conflict with usual treatment approaches that clinics have greater familiarity with.[29]
Psychodynamic Psychotherapy
Psychodynamic psychotherapy draws from psychoanalytic concepts and seeks to uncover the unconscious motivations, desires, and conflicts that may drive maladaptive behaviors like substance use. Unlike other forms of therapy, the emphasis is not necessarily on discrete symptoms but on exploring defense mechanisms that the patient uses to manage distress. The goal is to bring about awareness of these unconscious factors and use this knowledge to avoid the repetition of unhelpful patterns.[31]
Traditional psychoanalysis has an exploratory framework. In a traditional psychoanalytic format, treatment is very intensive, taking place multiple times per week for potentially years, and with the therapist acting as a guide in the self-exploration process. Modern psychodynamic psychotherapy most commonly takes place once weekly and can be brief (10-20 sessions) or long-term.
Psychodynamic theory conceptualizes addiction as a practical means to manage intense and painful effects.[32] Psychodynamic therapists guide patients to examine their tolerance of feelings and their pattern of coping with painful effects. One theory is that patients defend themselves from discomfort and pain through narcissistic defense mechanisms that involve a distorted illusion of having total control and simultaneous denial of having a problem.[31] Psychodynamic therapists help patients examine distortions in their self-image and their unconscious representations of others. One commonly used approach is to examine the feelings the patient develops towards the therapist, known as transference.
Individuals with addiction may not be prepared for the emotionally challenging work of psychodynamic therapy. Therefore, psychodynamic therapy is best applied as a supplement to other forms of substance use therapies, reserving exploration and developing psychodynamic insights when personality-related issues hinder progress. Psychodynamic therapy also has a role in addressing psychiatric comorbidities, which are often found in patients with substance use disorders.
Traditionally psychodynamic therapy has been difficult for researchers to study empirically due to the open-ended nature of the therapy. Therefore, the evidence base for psychodynamic psychotherapy is less robust than for manualized interventions like CBT. Relatively brief supportive-expressive psychodynamic therapy has shown efficacy in treating cocaine and opioid use disorder.[33][34] Psychodynamic psychotherapy has been found beneficial in patients with comorbid anxiety, depression, and personality pathology that may contribute to ongoing use.[31]
Supportive Psychotherapy
Supportive psychotherapy is likely the most ubiquitous form of therapy but is less studied than other forms of treatment due to persistent difficulties in defining its framework relative to other therapies. Supportive psychotherapy draws from psychodynamic and psychoanalytic concepts, but the focus of the treatment is different. Therapists originally began using the term supportive therapy to refer to patients unsuitable for psychoanalysis but still required some treatment. In the current day, supportive psychotherapy refers to therapies that are focused on symptom reduction, enhanced self-esteem, and avoidance of immature defense mechanisms like denial and splitting.
The overall goal is to stabilize the patient and not to create insight or change maladaptive personality traits. Therefore, the therapist is nonjudgmental and avoids criticizing or confronting the patient. The overall tone of the sessions is conversational, and the sessions are generally unstructured and do not involve homework assignments.[35]
Supportive psychotherapy may be useful for individuals who experience a stressful life event and require short-term stabilization. Supportive psychotherapy may also benefit patients who are severely impaired or unable to tolerate more intensive forms of therapy, such as an unhoused patient with severe SUD and severe psychiatric comorbidity. In substance use treatment, major life stressors can be a significant trigger for relapse, even in patients who are in initial remission from a SUD. In these patients, it may be helpful for therapists to adopt a more supportive stance. Empirical research is limited, but one study demonstrated reduced alcohol use in patients receiving supportive psychotherapy.[36]
A 2019 Cochrane review attempted to evaluate the effectiveness of supportive psychotherapy and other treatments in comorbid depression and SUD but could not draw any conclusions due to the included studies being too few and of low quality.[37]
Virtual Psychotherapy
The coronavirus disease 2019 (COVID-19) pandemic resulted in a significant shift in addiction treatment to encompass virtual delivery methods through telehealth platforms to facilitate increased access to care while maintaining social distancing protocols. Telehealth currently primarily includes synchronous appointments over video and audio-only telephone encounters. Most therapies can be delivered virtually, although some therapies like CM may be harder to deliver without in-person contact.[38]
There has been substantial concern raised over the potential risks of telehealth encounters. When addiction treatment providers were surveyed about telehealth, they noted the benefits and drawbacks of virtual addiction treatment. Benefits included the elimination of transportation barriers and opportunities to observe the patient in their home. Drawbacks included challenges keeping patients focused and engaged during sessions, increased difficulty establishing connectedness with peers during group therapy, and problems gathering important clinical information over audio-only appointments.[39]
A 2022 review identified eight studies comparing telehealth outcomes with in-person outcomes in patients with alcohol or opioid use disorders. Seven of these studies demonstrated equivalency between in-person and telehealth encounters in terms of a therapeutic alliance, retention in treatment, and substance use. One study suggested that patients with opioid use disorder who received a combination of telehealth and in-person treatments were more likely to stay in treatment than patients who only received in-person appointments. Another study of over 1000 patients in an intensive outpatient treatment program found no outcome differences between patients treated through telehealth and in-person appointments.[40]
There is currently no known optimal combination of in-person and telehealth care. Therapists should keep in mind the potential social benefits of in-person care, including greater support and connection with peers while balancing the practical benefits of virtual care.
