(Section 2 of 3 on Addiction Treatment Modalities)
B.1. LEARNING THEORY MODALITIES
The learning theory model focuses not so much on the internal workings of addiction such as physiology but, rather, on the thoughts (cognitions) and actions (behaviors) of individuals with addictions. The learning theory model asserts that addictive behaviors are developed in response to one’s environment. The learning theory model includes (a) behavioral modalities, (b) cognitive modalities, and (c) cognitive-behavioral modalities, which is an integration of behavioral and cognitive modalities.
B.1.1 BEHAVIORAL MODALITIES
B.1.1.1 Classical Conditioning
The conditioning models assert that, basically, addiction is a learned habit. Conditional models include classical and operant conditioning.
Classical conditioning is best known by the “Pavlov’s dog” experiment where Ivan Pavlov demonstrated how conditional reflexes resulted in salivation when repeated feedings were timed to coincide with a ringing bell. For individuals with addictions, classical conditioning experiments have demonstrated withdrawal symptoms or cravings simply by being shown external cues such as videos of drugs or talking about prior drug use ¹. In addition, internal cues such as depression or anxiety can often interact with external cues to motivate addicted individuals towards the use of drugs or alcohol. As a result, a variety of techniques, collectively known as relapse prevention, have been designed to break the pattern of automatically response to internal and external cues ².
The other conditioning model, known as operant conditioning, contends that behaviors are determined by positive effect (euphoria and relaxation) or by the removal of negative states such as depression and anxiety ³. Theorists of operant conditioning focus on the properties of alcohol and drugs to create positive or negative effect. Importantly, operant conditioning also recognizes that immediate effect is more compelling than effect that is delayed. Therefore, clinicians and programs that utilize operant conditioning tend to reward clients with immediate, positive benefits that encourage new coping skills. A form of treatment that uses operant conditioning is known as the Community Reinforcement Approach (see below).
(1) Source: Classically conditioned factors in drug dependence. A. R. Childress,R. Ehrman, D.R. Rohsenow, S.J. Robbins, C.P. O’Brien. Substance Abuse: A Comprehensive Textbook (2nd ed.), pp. 56-69.
(2) For more information refer to the Relapse Prevention Facts section.
(3) Source: Behavioral theory of substance abuse treatment: Bringing science to bear on practice. F. Rotgers. Treating Substance Abuse: Theory and Technique. Pp. 174-201.
Extinction & Cue Exposure
Counterconditioning & Aversion
B.1.1.2. Operant Learning
Modeling behavior asserts that an individual with an addiction observes another individual dealing with his/her own addiction more effectively, the first person will adapt by modeling the second. This important contribution to learning theory was first developed by Albert Bandura in his book, “Social Learning Theory.” The likelihood of modeling behavior to occur, however, is determined by the following principles:
- the model enacting the behavior is similar to the observant, is admired by the observant, and the modeled behavior is useful to the observer
- the modeled behavior has an outcome valued by the observant
- describing or explaining the observed behavior will help the observer more than simply observation.
Modeling behavior has been used to explain the initiation of substance use, especially in adolescents (1). Relaxation, anger management, and social skills approaches are all examples of modeling behavior.
(1) Source: Social Learning Theory (1977) A. Bandura
Community Reinforcement Approach (CRA)
Behavioral Self-Control Training
B.1.2. COGNITIVE MODALITIES
B.1.3. COGNITIVE-BEHAVIORAL MODALITIES
The cognitive-behavioral model goes one step further than the conditioning model by theorizing that conditioning not only affects behaviors but also leads to the development of thoughts and feelings that shape behavior. Similar to modeling behavior, the cognitive-behavioral model also focuses on techniques to enhance an individual’s confidence that he/she can manage their environment. These techniques attempt to identify triggers and high-risk situations as part of a relapse prevention plan.
Finally, two models for treatment, rational-emotive therapy (Albert Ellis) ¹ and cognitive therapy (Albert Beck) ² suggest that irrational thoughts and feelings contribute to addiction. Changing these irrational thoughts and feelings is the target of treatment for these two models.
(1) Rational-emotive Therapy with Alcoholics and Substance Abusers (1988) A. Ellis, J.F. McInerney, R. DiGuiseppe, R.J. Yeager.
(2) Cognitive Therapy of Substance Abuse (1993) A.T. Beck, F.D. Wright, C.F. Newman, B.S. Liese.
Coping Skills Training
B.2. PSYCHOANALYTIC APPROACHES
Psychoanalytic theory is the version of psychology made famous by Sigmund Freud, considered the “Father of Psychoanalysis.” While many of its concepts and techniques are found in other approaches, psychoanalysis (or “psychodynamic psychotherapy”) has often been criticized for treating uncontrolled drinking or drug use as a symptom of a deeper issue rather than as the central problem. Furthermore, opponents argue that this fixation on the “root” cause of addiction (especially in early stage addiction) results in clients (1):
- wasting therapy time focusing on their life story instead of on the imminent danger posed by continued, uncontrolled drug or alcohol use
- avoiding personal accountability through denial, blame, and rationalization (2)
- assuming that if they figure out the cause of their addiction that they can return to moderate drinking or drug use
- recalling past traumatic events which can trigger a relapse.
However, recent developments in psychodynamic therapy have addressed these concerns and have developed several modalities that are now making vital contributions to the treatment of addictions. These psychodynamic modalities include (a) interpersonal psychotherapy (IPT), modified dynamic group therapy (MDGT), and supportive-expressive psychotherapy (SE).
However, an important contribution to contemporary addiction treatment has been made by psychoanalyst Edward Khantzian, considered the “father of the self-medication hypothesis of addictive disorders.” Dr. Khantzian suggests that individuals use drugs and alcohol as a way to self-medicate their suffering and regulate their lives. According to Dr. Khantzian, this suffering is a result of childhood neglect and family dysfunction where substances become a way to cope. This dysfunctional method of coping is termed by Dr. Khantzian as a “self-regulatory impairment” of which there are primarily 4 types (3):
1. Affect tolerance – is where individuals “feel too much” or not at all and have trouble verbalizing or even identifying these emotions. Thus, the individual with low affect tolerance turns to drugs and alcohol as a way to cope with the confusion that comes from roller coaster emotions.
2. Impairments in self-care – is where individuals engage in risk-taking behaviors. Dr. Khantzian has termed this personal regard (or lack of) for ones own safety as “self-care.” A second aspect of self-care is the inability of an individual with an addiction to lower their level of stress, anxiety, or anger. A final aspect of self-care impairment is the inability to reach out for help when struggling with negative thoughts and emotions.
3. Vulnerabilities in self-development and self-esteem – is a self-regulatory impairment where individuals fail to integrate the opposing, yet complementary, character traits of humility and self-worth. Thus, these individuals have grandiose or narcissistic tendencies and use substances hide deep-seated feelings of failure and worthlessness.
4. Troubled relationships – is where individuals with low self-esteem and self-worth have troubles in intimate relationships, particularly with parents. An unhealthy dependence on parents is often disguised by creating conflict, being distant, or being manipulative. Alcohol and drugs becomes a way to further foster a dependence on parental support. Furthermore, alcohol and drugs becomes an effective deterrent to participating in activities that would promote independence such as school or work.
Furthermore, Khantzian suggests that “patients experiment with various classes of drugs and discover that a specific one is compelling because it ameliorates, heightens, or relieves affect states that they find particularly problematic or painful” (4).
(1) Source: Treating Patients with Alcohol and Other Drug Problems: An Integrated Approach (2001) Robert D. Margolis, Joan E. Zweben, pg. 29-30.
(2) Source: Dangers of psychotherapy in the treatment of alcoholism. In M.H Bean & N.E. Zinberg (Eds.), Dynamic approaches to the understanding and treatment of alcoholism. George Vaillant. (pp. 36-54).
(3) Source: The self-medication hypothesis of substance use disorders: A reconsideration and recent applications (1997) Harvard Review of Psychiatry, 4, 231-244, E.J. Khantzian.
(4) Source: Treating Patients with Alcohol and Other Drug Problems: An Integrated Approach (2001) Robert D. Margolis, Joan E. Zweben, pg. 65-68.
B.2.1. PSYCHODYNAMIC MODALITIES
-Interpersonal Psychotherapy (IPT)
-Modified Dynamic Group Therapy (MDGT)
-Supportive-Expressive Psychotherapy (SE)
B.3. FAMILY THERAPY MODALITIES
The Family Systems Model
The family systems model believes that each family has a set of rules that maintain homeostasis or “balance” within the family unit. This need to maintain homeostasis can manifest itself as:
- adaptive functioning – son drinks because parents are fighting
- rigid functioning – mom tells daughter not to talk about dad’s drinking
- family boundaries – mom enables drinking son, dad detaches
- role playing – the “clown,” the “enabler,” the “overachiever,” etc.
Therefore, family systems therapy tends to focus on revealing hidden family rules, reorganizing boundaries that are more functional, and identifying the roles family members play. Importantly, family systems theory avoids pathologizing addiction as a family disease.
The Family Behavioral Model
The family behavioral model is based on the observation that addicted family members often become the focus of the family. This focus is inadvertent but serves to maintain the addiction. The family behavioral model relies on ways to help couples change the way they interact with one another such as communication skills, problem-solving skills, and behavior-change skills.
The Family Disease Model
The third model, the family disease model, is the most common form of family therapy used in treatment centers. It extends the disease model of addiction into the family unit, with the disease being “codependence.” Codependence describes the obsessive behaviour of partners and family members to change the family member with the addiction. This preoccupation leads to a gradual loss of self-esteem and identity. The solution offered by the family disease model is to “detach with love.” While family members may be encouraged to continue with family therapy, emphasis is placed on self-help groups such as Al-Anon and Nar-Anon where peer support can help develop and maintain detachment.
For more information on couples and family therapy see the Help for Families & Partners section.
(1) Source: Brief Intervention and Brief Therapies for Substance Abuse (1999) Ch. 8, Treatment Improvement Protocol (TIP) 34. DHHS Publication (SMA) 99-3353.
Source: Treating Patients with Alcohol and Other Drug Problems: An Integrated Approach (2001) Robert Margolis, Joan Zweben.
B.4. HUMANISTIC AND EXISTENTIAL
B.4.1.1. Client-Centered Therapy
-motivational enhancement therapy
B.4.1.2. Narrative Therapy
B.4.1.3. Transpersonal Therapy
B.4.1.4. Gestalt Therapy
B.5. STRATEGIC/INTERACTIONAL THERAPIES
B.5.1. Ericksonian Therapy
B.5.2. Solution-Focused Brief Therapy
B.5.3. MRI Therapeutic Model
B.5.4. Haley’s Problem-Solving Therapy
B.6. OTHER PSYCHOLOGICAL MODALITIES
B.6.1. GROUP MODALITIES
-modified dynamic group therapy
-modified interactional group process
Peer-Led Self-Help Groups (AA, NA, etc.)
B.6.2. RESIDENTIAL MODALITIES
Residential Milieu Therapy:
-12 step facilitation (TSF)
B.6.3. OTHER PSYCHOLOGICAL MODALITIES
Printed Resources – General Reading on Psychological Theories of Addiction
The Myth of Addiction (1997) examines the “why?” of addiction by examining human desire and intention rather than something that just happens to people. John Booth Davies
Psychological Theories of Drinking and Alcoholism (1999) Kenneth E. Leonard, Howard T. Blane.
Psychosocial Treatments: Key Readings in Addiction Psychiatry (2004)focuses on the most current and efficacious psychosocial therapies for substance abuse addiction. Elinore F. McCance-Katz, H. Westley Clark.
Theories on Alcoholism (1988) C. Douglas Chaudron, D. Adrian Wilkinson, Alcoholism and Drug Addiction Research Foundation.
Theories on Drug Abuse: Selected Contemporary Perspectives (March 1980) Dan J. Lettieri, Mollie Sayers, Helen Wallenstein Pearson, National Institute on Drug Abuse.
Theory of Addiction (2006) Robert West
Printed Resources – General Information on Psychological Treatment
Practical Approaches to Alcoholism Psychotherapy (1985) provides a comprehensive collection on the latest research developments in the understanding and treatment of alcohol abuse. Sheldon Zimberg, John Wallace, Sheila B. Blume.
Printed Resources – 12 Step Facilitation as Psychological Treatment
Adolescent Substance Abuse Intervention Workbook: Taking a First Step (2000) is intended for teenagers who use drugs and alcohol but for whom the amounts, frequency, and negative consequences are unrecognized. Helps teenagers become aware of the negative consequences of their alcohol and/or drug use. Corresponds to the first step of a twelve step program. Steven L. Jaffe, MD.
Note: also comes with the Staff Manual.
For more information on the 12 Steps see the 12 Step Support Groups section.
Printed Resources – Client-Centered Therapy as Psychological Treatment
Problem Drinking: A Person-Centred Dialogue uses dialogue to enable the reader to appreciate the nature of counseling a person with an alcohol problem through the application of person-centred counseling theory. Richard Bryant-Jefferies.
Substance Abuse: A Patient-centered Approach (2002) is written by primary care clinicians and is focused to meet the needs of primary care providers, demonstrating how the patient-centered clinical method can assist clinicians in learning how to diagnose this complex psychosocial disorder. Michael Floyd, J. Paul Seale.
Printed Resources- Cognitive Therapy as Psychological Treatment
Choice, Behavioral Economics and Addiction (2003)is about the choice-based model of substance use and addiction which is based on a behavioral approach. Rudolph Eugene Vuchinich, Nick Heather.
Cognitive Therapy of Substance Abuse (2003) clearly details the cognitive model of substance abuse, the specifics of case formulation, and the structure of the therapy sessions. Aaron T. Beck, Fred D. Wright, Cory F. Newman, Bruce S. Liese.
Handbook of Implicit Cognition and Addiction (2006) lays the groundwork for new approaches to the study and addictive behaviors as the first handbook to apply principles of implicit cognition to the field of addiction. Reinout Willem Henry, Jon Weirs, Alan W. Stacy.
Printed Resources – Community Reinforcement Approach as Psychological Treatment
Alcohol Treatment: The Community Reinforcement Approach (1995) is the first book to implement the Community Reinforcement Approach (CRA) for treating alcohol problems. Robert J. Meyers, Jane Ellen Smith.
Printed Resources – Community Reinforcement Approach Family Therapy (CRAFT) as Psychological Treatment
Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening (2003) is a book for those who have “tried everything” to get their loved ones sober – from scolding and nagging, to begging and bribing – all to no avail. Provides the guidance and tools you need to recognize how you and your loved one interact and to change these patterns for the better.
Printed Resources – Coping Skills Training as Psychological Treatment
Treating Alcohol Dependence: A Coping Skills Training Guide (2002) presents a multisession coping skills training program complete with client handouts, assessment instruments and therapist forms. Peter M. Monti, Ronald M. Kadden, Damaris J. Rohsenow, Ned L. Cooney, David B. Abrams.
Printed Resources – Disease Model as Psychological Treatment
For printed resources for the Disease Model see the Biopsychosocial section.
Printed Resources – Gestalt Therapy as Psychological Treatment
Getting Beyond Sobriety: Clinical Approaches to Long-Term Recovery (1997) explores treatment and recovery using Gestalt therapy and a “self-modulation” approach. Michael Craig Clemmens.
Printed Resources – Group Therapy as Psychological Treatment
The Group Therapy of Substance Abuse (2003) bridges the gap between substance abuse treatment and group psychotherapy. Includes clinical examples and specific recommendations for treatment techniques. David W. Brook, Henry I. Spitz.
Printed Resources – Minnesota Model as Psychological Treatment
The Minnesota Model (1993) takes an inside look at the Minnesota Model – how it began; how it successfully combines professional assistance, self-initiative, and a mutual care community. Jerry Spicer.
Printed Resources – Motivational Enhancement Therapy as Psychological Treatment
Group Treatment for Substance Abuse: A Stages-of-change Therapy (2001) presents a 29-session treatment program designed to engage, motivate, and stimulate change in clients at all stages of recovery. Mary Marden Velasquez, Gaylyn Gaddy Maurer, Cathy Crouch, Carlo C. DiClemente.
Motivational Interviewing: Preparing People for Change (2nd Ed.) (2002) explains to counsellors how to work through client ambivalence to facilitate change. Also presents detailed guidelines for using the motivational interviewing approach, and reflect on the process of learning the technique. William R. Miller, Stephen Rollnick.
Substance Abuse Treatment and the Stages of Change (2004) offers guidance to clinicians for tailoring interventions to clients with varying levels of motivation or readiness to change. Gerard Joseph Connors, Dennis M. Donovan, Carlo C. DiClemente.
Printed Resources – Narrative Therapy as Psychological Treatment
Narrative Means to Sober Ends: Treating Addiction and its Aftermath (2002) shows how narrative techniques can help in achieving recovery. Jonathan Diamond, David C. Treadway.
Printed Resources – Psychoanalysis as Psychological Treatment
Dynamic Approaches to the Understanding and Treatment of Alcoholism (1981) Margaret H. Bean, Margaret Bean-Bayog, Norman Earl Zinberg.
Group Psychotherapy with Addicted Populations: An Integration of Twelve-Step and Psychodynamic Theory, 2nd Edition (1997) provides proven strategies for addiction through group psychotherapy. Includes integrating a modern analytic approach with AA and Twelve-Step programs. Philip J. Flores.
The Heart of Addiction (2002) explores the “why?” question of alcoholism and other addictions. Lance M. Dowds
Printed Resources – Rational-Emotive Therapy as Psychological Treatment
Alcohol: How to Give It Up and be Glad You Did (1996) is a self-help book for people with alcohol problems. Written by a Rational Emotive Behavioral therapist. Philip Tate.
Rational-Emotive Therapy with Alcoholics and Substance Abusers (1988) Albert Ellis
Printed Resources – Spirituality as Psychological Treatment
The Psychospiritual Clinician’s Handbook: Alternative Methods for Understanding and Treating Mental Disorders (2005) provides the latest theoretical perspectives and practical applications by recognized experts in positive and integrative psychotherapy. A whole-person approach that incorporates practices such as yoga, and meditation. Sharon G. Mijares, Gurucharan Singh Khalsa.
The Soul of Recovery: Uncovering the Spiritual Dimension in the Treatment of Addictions (2002) documents that many people who recover from an addiction to drugs or alcohol do so by developing a spiritual life. Christopher D. Ringwald.
Printed Resources – Therapeutic Community as Psychological Treatment
Therapeutic Community: A Practice Guide (2003) provides an experiential flavor while attempting an easy to follow description and explanation of various aspects and methods of the Therapeutic Community. Fernando B. Perfas.
Online Resources – Cognitive Behavioral Therapy as Psychological Treatment
A Cognitive-Behavioral Approach: Treating Cocaine Addiction (April 1998) Kathleen M. Carroll, PhD, National Institute on Drug Abuse, NIH Publication 98-4308
Online Resources – Community Reinforcement Approach as Psychological Treatment
A Community Reinforcement Approach: Treating Cocaine Addiction (April 1998) Alan J. Budney, PhD, Stephen T. Higgins, PhD, et.al., National Institute on Drug Abuse, NIH Publication 98-4309
Online Resources – Group Therapy as Psychological Treatment
TIP 41. Substance Abuse Treatment: Group Therapy has a bibliography of recommended reading on group therapy.
Online Resources – Psychoanalysis as Psychological Treatment
How AA and Psychotherapy can Work Together (July 1999) Edward J. Khantzian, Psychiatric Times, Vol. XVI, Issue 7.
Online Resources – Spirituality as Psychological Treatment
Spiritual Evocation (June 2004) focuses on the integration of spiritual direction with the counseling style of motivational interviewing, which was designed specifically for working through ambivalence. Expertise in spiritual direction is assumed. William R. Miller, Center on Alcoholism, Substance Abuse, and Addictions (CASAA).
Spirituality in Addiction and Recovery (Fall 1998) has some excellent articles on addiction and spirituality written by some of today’s foremost authorities on addiction research. American Psychological Association, Division 50. Volume 6, No. 1.
Video Resources – General Information on Addiction
Roots of Addiction is a 30 minute video that explores why we use drugs, alcohol, even gambling, eating, etc. Includes patient interviews. CNS Productions and Haight-Ashbury Clinic.
Video Resources – Psychoanalysis as Psychological Treatment Modality
Psychology of Substance Abuse is a program aired on PBS with Philip Zimbardo, Ph.D. that profiles a young mother who was treated with psychotherapy for her drug addiction.