Drug Addiction Treatment

Drug Addiction Treatment: An Overview

There are many different types of facilities and programs for the treatment of drug addiction. Some are credible, while others are not. The most effective treatment programs are those that follow evidenced-based practices and treatment protocols. The best treatment facilities are staffed with professionally trained and experienced drug and alcohol counselors, doctors, nurses, therapists, and psychiatrists. 

However, the type of facility or program one enters depends a good deal on the length and manner of drug use, as well as other contributing factors. Research has demonstrated that for those people who have been using drugs very heavily or for long periods, long-term treatment programs have the best outcomes. Why? Long-term inpatient treatment programs provide patients with the time necessary to identify and change thinking and behavior. Unfortunately, many people cannot afford to take nine months out of their lives and go to long-term treatment.

The development of quality shorter-term programs has altered the treatment landscape. Scientifically based short-term, intensive inpatient treatment programs can still deliver excellent patient outcomes. When inpatient treatment is not available, quality outpatient programs, with modifiable treatment plans and close supervision and monitoring, can also be successful for patients. However, one of the weaknesses of outpatient treatment is the reliance on accurate self-reporting by the patient; an individual struggling with an active addiction may have a hard time being honest or objective while attending an outpatient program. Many patients may not gain enough structure and support with outpatient treatment to maintain abstinence.

Successful Treatment Approaches

The most successful approaches are medically based addiction programs that use a combination of therapies and an evolving treatment plan. Being able to adjust treatment rapidly is a necessity due to the constantly changing state of a patient in drug detox and treatment. Physical conditions and mental health issues can appear, disappear, or drastically alter a patient’s condition at anytime and must be addressed immediately.

Comprehensive, multidisciplinary approaches are designed to address a broad range of patient problems. Is the patient addicted to multiple drugs? Has the patient been diagnosed with a mental disorder? Is the patient involved with the criminal justice system? Does the patient have other medical conditions that need to be addressed? Does the patient have a healthy support system at home? Does the patient need work-related rehabilitation? A whole range of questions shape the direction and intensity of a patient’s treatment plan.

Treatment Plans

Treatment plans often include behavior modifications for specific patient needs or medication to stabilize a patient’s psychological or physical state. The patient must then learn about appropriate medication management. A patient’s poor physical health can be the result of long-term or intense drug abuse. Proper hygiene, nutrition, and other components of essential wellness should be taught so that a healthy physical state may be maintained. Physical conditions, such as back injuries, and the medicines prescribed to treat them, may have originally been a contributing factor of the addiction. Therefore, patients must learn how to manage pain without abusing medication.

Depending upon the patient’s history, specialized treatment programs may be advisable. For example, women sometimes respond best to gender specific treatment that can address issues of past trauma, sexual abuse, body image, and more. Those people who are part of the gay, lesbian, transgender, bi-sexual, and questioning community usually respond best to GLBTQ-focused treatment programs that address issues unique to this community. There are also speciality treatment programs for seniors, teens, religious Christians, Native Americans, and the dually diagnosed. And while they are specialized programs, they still contain fundamental and core components essential to any recovery program.

Without addressing the environmental, physical, psychological, and psychosocial factors of a patient’s life, chances of solid sobriety diminish. Long-term abstinence is possible if patients follow the treatment protocol and aftercare plan designed for them. It should be noted that medication therapy without individual and group counseling makes abstinence a far-reaching goal.

Stages of Recovery

From the moment a person recognizes that he or she has an addiction problem and takes steps to deal with the problem, there are several stages that the person will move through toward a healthy lifestyle that is balanced and productive.  Like anything, recovery does not move in one direction only. It waxes and wanes but the forward momentum can be maintained with work. Below are the stages as Terence Gorski, a leader in the development of recovery modalities, has outlined them.

Developmental Period Goals

1.  Pre-Treatment

1.  Recognition of Addiction

2.  Stabilization

2.  Withdrawal and Crisis Management

3.  Early Recovery

3.  Acceptance and Non-Chemical Coping

4.  Middle Recovery

4.  Balanced Living

5.  Late Recovery

5.  Personality Change

6.  Maintenance

6.  Growth and Development

(source: Terence T. Gorski, Merlene Miller, Staying Sober,1986, p.84)

A person can relapse at any point through the stages of recovery. Most often, a person ignores the warning signs, the stressors, and the distorted thinking. He or she may talk about being in pain but does not acknowledge the source of the pain. The slip back into active addiction is triggered. If nothing in the person’s behavior changes, the downward spiral into addiction will continue. Sometimes a person can maintain a period of abstinence and then relapse. The pattern can be repeated over and over until he or she decides to confront the source of the pain and decides that different responses to stress, anxiety, and pain are needed. Only then will the path forward continue. Gorski calls this pattern “partial recovery.” “Partial recovery is not sobriety.” (Staying Sober, pp.94-102).

Types of Treatment Centers

  • Outpatient Detox
  • Inpatient Medically Monitored Detox
  • Inpatient Treatment
  • Residential Treatment Programs
  • Partial Hospitalization or Day Treatment
  • Outpatient and Intensive Outpatient Programs
  • Opioid Treatment Programs

It should be noted that detox, whether it is outpatient of inpatient, can never be a substitute for addiction treatment. The disease of addiction is not halted or abated by going through detox alone. It is now accepted that the best course of action is to immediately follow detox with treatment.

Specific Therapeutic Processes

Psychodynamic Therapies

There are several different approaches to psychodynamic therapy. All are grounded in the concept that personal awareness can lead to behavioral change.

Psychotherapy (Freudian Analysis)

Psychotherapy relies heavily upon “talk therapy” and non-verbal communications. It requires a trusting relationship between the patient and the therapist. Therapist and patient work together typically 1-3 times a week. Identifying childhood relationships can link to the cause of the emotional disturbances. Dreams, thoughts, feelings, memories, fantasies, images, sensations are used to identify meanings.  Once these sources are identified, the patient examines how the sources of the problems have impacted his or her life, work, and relationships.

The relationship between the therapist and patient is crucial. The goal is to promote “transference” of the patient’s relationship with his or her parents or an important parental figure to the therapist making it easier to analyze the origins of problematic feelings and experiences.

Freudian theory is based upon the concept that individuals are governed by three elements the:

  • Ego- unconscious part of the personality that modulates ideas, thoughts or actions from both the Id and the Superego preventing actions based upon basic impulses and modulating responses from the Superego
  • Id- primitive part of the brain that seeks pleasure
  • Superego-the social conscience part of the brain through which moral judgments are made based upon socially acceptable norms learned in childhood

Cognitive Behavioral Therapy (CBT)

This type of therapy is based upon our thoughts, our feelings, and our behaviors and the interconnectedness of the three. The focus of this therapy is upon our ability to change our thought patterns. That in turn alters our feelings, which then shift our behavioral choices. Outside influences, such as people, places, or circumstances, do not control our thinking or determine our behavioral choices. It is considered one of the most rapid forms of

CBT relies upon the assumption that people have an internal dialogue that often pertains to negative thinking, which creates negative feelings and thus negative actions. With attention paid to the negative thoughts, a patient can address the reality/non reality behind the thoughts. These are known as dysfunctional assumptions. CBT helps the patient move outside of the thoughts to understand what is actually happening emotionally. The choice to respond differently, to alter the thought will alter the feeling and thus the ability to behave in a different way.  With CBT, patients are assigned homework, skills training, and behavioral analysis. The focus shifts to what the patient wants, what goals etc, and together the therapist and the patient set about achieving those goals.

Dialectic Behavioral Therapy (DBT)

DBT specifically targets self-destructive behaviors. Generally, these behaviors include suicide attempts, self-cutting, and suicidal urges. These intolerable feelings often drive people to substance abuse. Negative emotions such as shame, guilt, sadness, fear, and anger, are all part of normal emotional responses and are heightened in patients suffering from addiction and personality disorders. The goals are to reorient the patient to experiencing feelings within normal bounds, and to teach them to negotiate the reality of their lives without self-destructive behavior.

Dialectic Behavioral Therapy also has its roots in philosophy and fosters a state of mindfulness and being in the present. Learning to handle the contradictions in life, while maintaining a feeling of control, is also an important goal. In this therapy model, patients focus first on life-threatening behaviors, then on life-interfering behaviors, followed by quality of life interfering behaviors, and finally, skills building. Patients learn how to accept situations while making positive choices for change. They learn to balance feelings, thoughts, and actions.

There are four essential functions:

  1. Enhance and expand a patient’s repertoire of skillful behavioral patterns
  2. Improve patient motivation by reducing reinforcement of maladaptive behavior
  3. Ensure new behavioral patterns move from the therapeutic environment to the natural environment
  4. Structure environment so that effective behaviors are reinforced
    (Synopsis of Psychiatry, 10th Edition, Ch 35)

Rational Emotive Behavioral Therapy (REBT)

REBT is a comprehensive theory based upon a “bio-psycho-social” explanation for the way people feel and behave. It is a form of Cognitive Behavioral Therapy combining biological, psychological, and social factors. Similar to the other therapies mentioned thus far, the basic premise of REBT rests upon the belief that a person’s actions are dependent upon self-perception and how he or she feels about self. REBT suggests that there are three basic musts:

  • Inference (what we think is happening)
  • Evaluation ( what our inference means to us)
  • Core beliefs (the foundation upon which our inferences and evaluations are developed)

To help clients change they must understand “that emotions and behaviors are caused by beliefs and thinking….The emphasis is on both rethinking and action…”

The goal is to motivate a patient to view his or her behavior as either functional or dysfunctional.  Homework “targets” certain beliefs then through other assignments, the patient learns to modify and reduce fears based upon questionable core beliefs, and finally provides clients with strategies and techniques to build new coping skills. The end result is an alteration of the core beliefs and a new set of behaviors.
(source: Wayne Froggatt, “A Brief Introduction to Rational Emotive Behaviour Therapy, 2005, pp. 3-5, http://www.betterthinking-betterlife.com/gallery/Intro-REBT.pdf)

Eye Movement Desensitization and Reprocessing Therapy

This is a highly specialized form of therapy used to treat people suffering from Post Traumatic Stress Disorder (PTSD) and certain phobias. It is based on research that has identified a physiological-based information processing system in the body, which stores memories and experiences. However, the memory can be stored without a link to the appropriate associative thought connections. Thus, a trigger can set off the memory and leave the patient vulnerable to the sensation of reliving the original experience. Eye movements are part of the information processing system involved in this physical and psychological dynamic.

Tracking eye movements in relationship to disturbing images or thoughts about a traumatic experience can then allow a patient to retrain his or her eye movement in the midst of an anxiety-producing thought. Breaking the physical-psychological cycle allows a person to replace negative thoughts with positive thoughts. Often this treatment is followed by specific behavioral therapy based on a person’s needs.

By attending to past experiences, present triggers, dysfunctional emotions, beliefs, sensations, and positive experiences, a patient can develop adaptive behaviors and improved mental health. “Although eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation.” (EMDR Institute, Inc.)

Rapid Trauma Resolution

This is a relatively new form of therapy used to treat people suffering from PTSD and other traumas. And while not formally adopted by the army, it is consistently being used to treat veterans. The most significant element of this therapy is that it is does not require a patient to relive the pain of the trauma in order to come to a resolution. Sessions are structured so that the therapist leads the patient in a revealing conversation. Hypnosis is sometimes used. The conversation helps the patient understand how the past event no longer has control over the person in the present. The process reorders thinking, feeling, and behavior, often leaving the patient with a “clear mind” and a sense of being re-energized.

Schema Focused Cognitive Therapy

Schema therapy is used with people suffering from personality disorders, chronic depression, and other difficult personality disorders. Identifying life-long, self-defeating patterns that developed early in life (called “early maladaptive schemas”), provides a patient with a context in which to view their present behavior. Schemas such as mistrust, defectiveness, shame, social undesirability, failure to achieve, abandonment, and instability have a controlling influence on a patient’s sense of self and the behavioral choices made. The goal of this treatment is to identify the schema(s), change the dysfunctional beliefs, break down maladaptive behavioral patterns, build new coping skills, and empower patients through healthy emotional validation.

Motivational Enhancement Therapy (MET)

There are often serious disparities between a patient’s perception of self and his or her stated goal(s). This therapy is used to help a patient find his or her own motivation for change and to help the patient plan for change. The process is based upon cognitive and social psychologies, which lead a patient toward significant personal goal setting. The goal setting may be singular, such as abstinence, or it may be more encompassing, such as going back to school, dealing with work issues, and family problems.

Motivational Interviewing

Ambivalence is defined as a conflict between actions. Such ambivalence leaves a person stuck between two actions, such as “should I light up the cigarette?” or “should I take care of my health and avoid smoking?” The patient is stuck, unable to make a choice. This therapeutic model is designed to help a patient resolve his or her ambivalences. It is client-centered, focused, and goal directed. Once a patient’s ambivalence is resolved, there is an intrinsic shift within the patient’s thinking that triggers the need to change.

Behavioral Therapy

Behavioral therapy does not take the patient back to the origin of the problem. It is of no significance. Maladjusted behaviors, indeed, even negative feelings are all viewed as “learned responses.” As such, they can be replaced with positive, self-affirming behaviors and feelings. Patients generally have to agree to work on altering destructive behaviors and they are given homework, modeling, skills training and a range of other behavior modification techniques to help achieve that goal.

Twelve-Step Programs

Twelve-step programs, while not considered therapy, are in fact part of many treatment protocols. Alcoholics Anonymous (AA) is the original twelve-step program based upon a belief that “we can do together what we cannot do alone.” In regular meetings, open communities of alcoholics gather to share their experience, strength, and hope.  

The AA program is based on the realization that one must stop drinking and then thoroughly and honestly examine every aspect of his or her life. That process removes the power of old triggers and helps addicts and alcoholics avoid acting on negative thoughts that might otherwise send them “out” or back to drug or alcohol use.

To accomplish this honest inventory, members of AA use the 12 steps to explore behavior and the consequences of that behavior. There is a spiritual component to the 12-step program based on the concept of a personal “higher power.” Since AA’s inception, many 12-step programs have arisen to help people with various addictions, such as sex, gambling, and overeating. These programs are an informal support system for addicts and alcoholics and help them maintain abstinence and achieve personal growth. 12-step meetings are not a replacement for treatment or therapy, but a complimentary activity.

Supportive-Expressive Psychotherapy

This therapeutic model is used to treat substance abusers suffering from dual diagnosis, primarily depression. Patients are provided an environment in which they are comfortable talking about their problems, experiences, and interpersonal relationship issues. Special attention is given to the role drugs play in relation to feelings and negative behaviors, and on ways to handle problems without resorting to substance use. It helps patients improve insight concerning feelings, thoughts, behaviors, personality, approach to others, and constructing appropriate responses to life’s varying situations.

An Interdisciplinary Approach

“Best practices,” proven and effective protocols for substance addiction treatment, provide facilities and doctors with the latest and most successful approaches based on research. Treatment for substance abuse and dual diagnosis disorders requires a range of treatment modalities to address the breadth of medical, psychological, and social issues faced by a patient.

Not included in the above list, but part of an interdisciplinary treatment approach to addiction, are medication management, relapse prevention, occupational therapy, spirituality workshops, physical fitness, a nutrition program, aftercare planning, and family therapy.

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