Treating Substance Addiction

Treating any type of substance abuse and substance addiction is challenging because they both have so many dimensions and they both disrupt so many aspects of the individual’s life. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the condition and its consequences. Ultimately, treatments aspire to help the individual stop using substances in an abusive or addictive way which would usually entail maintenance of a drug-free lifestyle, and achieving a productive level of functioning in the family, at work, and in society.

Because addiction is a disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives. (National Institute of Drug Abuse, NIDA, 2009)

Motivational Interviewing

Motivational Interviewing is a style of person-centred counselling developed to facilitate change in health-related behaviours. The approach aims to help people explore and resolve their ambivalence about behaviour change. The approach strives to increase the client’s own motivation so that change occurs from the client rather that the therapist imposing the change (Astofi & Evans, 1997). It combines warmth and empathy from the therapist toward the client with focused reflective listening and the development of discrepancy between where the person is and where they would like to be.

A core principle is that the person’s motivation to change is enhanced if there is a gentle process of negotiation in which the client, not the counsellor, explores the benefits and costs involved in change. The theory assumes that people can change their behaviour when they can clearly see a discrepancy between their behaviour and their broader personal goals (Astofi & Evans, 1997). Another strong principle of this approach is that conflict is unhelpful and that a collaborative relationship is essential between counsellor and client, in order to tackle the problem together (Miller & Rollnick, 1991).

Motivational enhancement helps change patterns of behaviour that have become habitual. It works in small doses to produce a large effect by reducing behaviours in the person that interfere with therapy. The four central principles of motivational enhancement are outlined below.

  1. Express empathy by using reflective listening to convey understanding of the person’s point of view and underlying drives
  2. Develop the discrepancy between the person’s most deeply held values and their current behaviour (i.e. tease out ways in which current unhealthy behaviours conflict with the wish to ‘be good’ or different in the way they currently function)
  3. Roll with resistance by responding with empathy and understanding rather than confrontation
  4. Support self-efficacy by building the person’s belief that change is possible

(Miller & Rollnick, 1991)

Motivational interviewing has numerous applications because it is helpful in most settings where there is resistance to change. Therefore, once the approach is learnt and developed into a constructive level of proficiency, it can be adapted to many situations. However, while the principles are simple to understand, the practical application of it is less easy.

Counsellors might use motivational interviewing for people who are undecided about change (known as the precontemplation and contemplation stages) and later shift to a more structured treatment approach such as cognitive–behavioural techniques once the person is committed to change. There needs to be room for flexibility to adjust to individual differences in the readiness to change and an empathic counsellor will know when to switch their approach depending on the client’s current stance in their desire and motivation to change.

Motivational Interviewing highlights the importance of change by reflecting on the discrepancy between the person’s current world and their ideal world. It also aims to bolster the client’s confidence in making changes by reflecting a positive view of the person and an authentic belief in their ability to make behaviour change. The counsellor reinforces commitment to change and supports small steps towards it.

Rollnick & Miller (1995) defined key skills used by counsellors that would help lead to a stronger therapeutic alliance and a more effective therapeutic outcome. These key skills are summarised below.

The first four skills listed aim to explore the reasons the person sustains the behaviour and aim to create a shift in the balance of pros and cons towards the decision to change. The last two items in the list cover the interpersonal aspects of the relationship. The counsellor provides warmth and optimism and takes a subordinate position, putting the client in a position of power, emphasising their autonomy and right to choose.

Understand the person’s frame of reference

  1. Filter the person’s thoughts so that statements encouraging change are amplified and statements that reflect the status quo are dampened down
  2. Elicit from the person statements that encourage change, such as expressions of problem recognition, intention to change and recognition of ability to change
  3. Match the processes used in treatment to the stage of change; ensure treatment does not jump ahead of the person.

Express acceptance

  1. Affirm the person’s freedom of choice and self-direction.

(Rollnick & Miller, 1995)

Instead of trying to ‘fix’ the person’s dependence by forceful instruction, counsellors are encouraged to use warmth and respect to show the value of change to the client. Motivational counsellors need to hold back any inclination they might have to try to solve the client’s problems and instead remain flexible and able to provide an appropriate balance between acceptance and drive for change.

Studies focused on the process of change within motivational interviewing have been able to highlight key factors that help to facilitate change. For example, Miller, Benefield & Tonigan (1993) found that a low level of resistance within the counselling session predicts change. Resistance often arises in the presence of confrontation, so if the counsellor behaves in a way that minimises confrontation, and in turn resistance, then change will most likely follow. An increase in the rate of ‘self-motivational statements’ by the client that clearly express interest in and intent to change, is positively associated with behaviour change.

In motivational interviewing, any arguments for change should come from the client, not the counsellor. The natural expected outcome of a counsellor making an argument for change is that an ambivalent client will argue against it. A client will often become more committed to what they hear themselves saying, so if the counsellor causes a client to argue against the need for change, they are being encouraged not to make changes.

For example: When asking “On a scale of 0 to 10, how important is it for you to change your drug use behaviour?” (When 0 is not considered important at all and 10 is extremely important) and the client answers 5 out of 10… an appropriate follow-up question could be “Why are you at a 5 and not 0?” This is an appropriate follow-up question because the answer to this prompts the client to give a reason for change. Asking instead, “Why are you a 5 and not a 10?” is not motivational because the answer to this question encourages the client to provide reasons against change.

Expressing Empathy

This involves understanding the person’s feelings and perspectives without judging, criticising or blaming. The counsellor simply accepts the person’s ambivalence about change as a normal part of human experience whereby reluctance to give up the problem behaviour is to be expected.

Developing Discrepancy

Change is motivated by the size of the discrepancy between where a person is and where they want to be. The bigger the discrepancy, the stronger the motivation is for change. Often clients who ask to change their use of drugs and alcohol experience a discrepancy between their current behaviour and how they see themselves in the future (Astofi & Evans, 1997).

This approach often utilises what is often referred to as the “Colombo approach” where the counsellor plays detective, investigating a mystery where the clues don’t add up and therefore they engage the client in the process to help solve the mystery. This process encourages the client to recognise reasons for change. A number of strategies can be useful at this stage:

Future projection: exploring how the drug and alcohol use interferes with the client’s future goals
For example: “do you think you will be able to walk your daughter down the aisle if you continue to smoke 2 packs a day. She is 15 years old now?”

Looking back: exploring strengths in the client’s life prior to the onset of the substance abuse/dependency
For example: “you once told me how you used to run 10 km every day before you started using. You must have been very fit and healthy”

Explore extremes: loosening the client’s attachment to their substance abuse/dependency by exploring their worst fears
For example: “What is the worst thing that could happen to you if you keep using the way you have been?”

Respectfully provide information on the negative consequences of the substance abuse/dependence
For example: Have you thought about giving up your regular drinking? Drinking that much is really putting your liver at risk”

Challenging the client’s statements
For example: “You mentioned that you have concerns about your physical health, yet you continue to drink excessively every day. I’m not sure how these two go together?”

Externalise the substance abuse/dependence: This is a process of separating out the abuse/ dependence from the client and can be done through talking to or writing letters directly to the drug or alcohol behaviour
For example: Therapist: “If you could talk to the alcohol, what would you say?” Client: “You ruined my life. My wife left me and I can’t even see my children. Now you are attacking my health. What more do you want to take from me? I’ve had a gut full of you… just get out of my life and don’t come back”

Rolling With Resistance

There are four types of resistance:

  1. Arguing – the person contests the accuracy, expertise or integrity of the counsellor.
  2. Interrupting – the person interrupts the counsellor in a defensive manner.
  3.  Denying – the person expresses an unwillingness to recognise problems, or to cooperate and accept responsibility.
  4. Ignoring – the person shows signs of ignoring or not following what the counsellor is saying.

In motivational interviewing, arguments are considered counterproductive because defending breeds defensiveness. The best strategy is to respond with none resistance – or roll with resistance – by acknowledging the client’s perception.

For example: Therapist: “Have you thought about giving up smoking as you know it is unhealthy particularly for your blood pressure?” Client: “Yes. I have tried though it is very difficult and to be honest I enjoy it”.

Therapist: “But isn’t there a lot of other things that you enjoy too? If you gave up smoking then you can take up something else that you enjoy instead”. Client: “Yes. I am aware of the health risks. But it is not as easy as it sounds”

Supporting Self-Efficacy

This step involves supporting the person’s belief in their ability to succeed in changing behaviour. The counsellor encourages the person to remember any achievements they may have had in the past. They also assist the person to develop an internal locus of control whereby they are encouraged to take personal responsibility for change by seeing change happening as a direct consequence of their choices and actions, rather than attributing change to external factors outside their control that is seen as being independent of their choices and actions (an external locus of control).

Family Therapy

Addiction affects the whole family. Because of this, it is understandable why some would suggest that treatment should involve the whole family. It is often the case that addicted individuals seek treatment in response to a form of external pressure exerted by family members. Many therapists adopting family therapy to treat substance abuse today have broadened what constitutes family to include other members of the substance user’s social networks including employers, friends and concerned others in the intervention (Fals-Stewart, O’ Farrell & Birchler; 2006). The level of involvement with the family in treatment is regulated by the therapist ranging from family members offering support, to them being full partners in the treatment process with the user and the therapist.

Treatment can be provided separately or jointly with family members. However it is structured a major emphasis of treatment is to educate family members about co-dependence. Co-dependency is an unconscious addiction to another person’s abnormal behaviour (Wekesser, 1994). Specifically, co-dependent members of the family often forget about their own needs and desires as they devote their lives to control and cure the substance abuser (Parson, 2003).

Each member of the family may be affected by substance dependence/abuse differently. Parental substance abuse/dependence may have severe effects on normal children of alcoholics. Children of the substance dependent/abuser may hold themselves responsible for their parents’ dependency and may think they may have caused it. Feelings of guilt, depression, loneliness and fears of abandonment are common with children of substance dependants/abusers. Such children may also have problems is school and have their school performance affected (Parson, 2003). Crime, violence, incest and battering are common in substance abuse families. Relationship issues such as loss of intimacy have also been associated with substance dependence/abuse.

Partners of substance dependants/abusers are also affected negatively by the addiction. Feelings of self-pity, hatred, avoidance of social contacts and embarrassment have been said to be common in such relationships (Berger, 1993). The role of the therapist is to gain understanding of these functions of substance use in the broader family system in order to explain to the family the development of the behaviour and the function it serves. Problem solving skills, coping skills, positive interactions and communication skills training are some of the interventions provided (Fals-Stewart, O’ Farrell & Birchler; 2006).

Cognitive-Behaviour Therapy (CBT)

Cognitive-behaviour therapy aims to help substance-dependent people abstain from using by applying the same learning processes that developed the substance dependence initially. In treating substance dependence, the goal of cognitive behaviour therapy is to teach the person to:

  1. Recognise situations in which they are most likely to use the substance,
  2. Avoid these circumstances wherever practical and possible, and
  3. Use more effective ways of coping with the range of various problems and behaviours which may lead to their substance use/abuse in the first place.

While this approach is valuable in the treatment of most addictions, it has proven to be most effective in the treatment of behavioural addictions; for example, gambling. The cognitive aspect of CBT is based on the process of (1) Identifying a client’s irrational thinking (2) Challenge the irrational thinking identified (3) Identifying core beliefs and (4) Challenge the core beliefs identified. Cognitive behavioural approaches teach clients the skills to evaluate their own thought patterns and core beliefs. (McMullin, 2000)

Examples are illustrated below.

Example: Identifying the client’s irrational thinking

Counsellor: Now, Tom, I’d like to spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you didn’t drink alcohol?

Don: Yes. On Wednesday

Counsellor: How did you feel?

Don: I felt tense and anxious

Counsellor: What was going through your mind?

Don: That I need to drink to help me relax

Counsellor: Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop in to our mind without any effort on our part. Most of the time the thought occurs so quickly, we don’t even notice, but it has an impact on your emotions. It’s usually the emotion that we notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question them.

Example: Challenging the client’s irrational thinking

Counsellor: Ok Don, I want you to think about the automatic thought we’ve just identified, “I have to drink to help me relax”. Tell me…what’s the worst thing that could happen if you didn’t drink?

Don: Well, I guess I would end up feeling pretty damn anxious and restless

Counsellor: And, if this were to happen, could you live through it?

Don: What do you mean live through it? If I don’t drink it doesn’t stop?

Counsellor: Are you sure about that Mitch? Are you saying that if you don’t have a drink you would always be feeling anxious? And that drinking is the only way to stop feeling anxious?

Don: Well, I do get scared about never being able to stop feeling anxious… and drinking just seems to stop it pretty good.

Counsellor: Has there ever been a time when you have not felt anxious and you weren’t drinking?

Don: Well yeah, of course…

Counsellor: Ok… so you don’t necessarily always need a drink in order for you not to feel anxious?

Don: Hmmm… never thought of it like that… I suppose I can feel fine sometimes without a drink

Counsellor: Ok, so you agree then… there are times you can feel just fine without having to have a drink to make that happen.

Don: (Smiling with a sense of knowing that his logic has been caught a little short) Well yeah… true… very true… when you put it that way… I suppose I don’t always need a drink… and I can feel fine sometimes without having a drink.

Counsellor: Ok, so what’s the worst thing that could happen if you were feeling anxious and you didn’t drink?

Don: Hmm, ok… when I really think about it… I suppose I’d just get over it eventually… I’d feel anxious and spin out for a bit, but then I suppose I’d end up focusing on something else… go for a walk, watch the TV… don’t know… but I suppose I’d get over it.

Counsellor: Is that true? You really couldn’t live without alcohol?

Don: Hmmm, that’s a tough one… When I really think about it though… while I would be a bit nervous… and it’d probably result in some pretty boring parties… deep down I know I could live without it if I really had to…

Counsellor: What if you were feeling really anxious? Could you live without it if you were feeling really anxious?

Don: Well… I wouldn’t really want to but when I think about it if I really had to… yeah. Yes – of course I would be able to live without alcohol… even if I was really anxious. I don’t know what I would do… might go crazy… but yeah; if I had to live without it, I would.

Example: Identifying core beliefs

Counsellor: So you are upset that you can’t stop gambling.

Client: Yes, that’s right. I have to win

Counsellor: So, you’ve got to win because…?

Client: Because if I don’t win I will not be able to provide for my family and it would prove that I’m a worthless and useless failure…

Example: Challenging core beliefs

Counsellor: Do you feel like a worthless and useless failure now?

Client: Yes… I’m pathetic… useless…

Counsellor: You’re pathetic and useless? How pathetic and useless?

Client: Completely useless; and that’s pathetic… I can’t do anything right…

Counsellor: Do you see how extreme you are in your beliefs about yourself? You’re honestly trying to tell me that you can’t do anything right? Absolutely nothing right…If that were true though… how did you even get to this appointment? How did you end up getting married and having a family… you must have done something right there at some point along the way…

Client: Yeah, but I’m just useless .And worthless… my family would be better off without me.

Counsellor: Would your son would be better off without you, his dad?

Client: Yes…

Counsellor: If you just decided to leave home now… never to come back… how would it affect your son…?

Client: He’d get over it…

Counsellor: He’d get over what?

Client: He’d get over me not being around…

Counsellor: But if your son thought you were so useless and worthless why would he need to get over anything if you left and never came back?

Client: I don’t know… it’s because he’s a kid… I don’t know…

Counsellor: Do you think that it might be because he might value his dad? Do you think it might be because he doesn’t think you’re as useless as you do?

Client: Yeah, I know… he does look up to his old man… but he’s young he wouldn’t know would he… how useless I am…

Counsellor: Who’s his old man?

Client: Me…of course

Counsellor: So you son looks up to you?

Client: Yeah…

Counsellor: Your son looks up to you… he thinks you’re all right… he looks up to you?

Client: Yeah… he does?

Counsellor: So he doesn’t think you’re worthless and useless?

Client: No, he doesn’t.

Counsellor: Do you disagree with him…?

Client: Well, no, I… hmmm, I just don’t want to let him down. I want to do the best I can for him… but it’s so hard; bringing up a family is so hard. It’s so easy to get it wrong.

Counsellor: Ok so what you’re saying is that you love your son very much and you want to do the very best you can for him – but sometimes you feel you stuff up with that or that it’s not always that easy to make sure the best happens for your son?

Client: Yeah… that’s it…

Counsellor: So where does the “I’m useless and worthless” thing come in to it then?

Client: I don’t know… I just wish I could be a better dad…

Counsellor: Well it certainly sounds like you’ve got your heart in the right place… your goal and your desire for your son sounds like a pretty valuable goal to have… and you sound really adamant on trying to achieve it as best you can… how is all this of no value? How do you end up rating such goals and aspirations you have as useless and worthless?

Client: Well because it’s so hard sometimes…

Counsellor: Ok… so you’re saying you are pathetic, useless and worthless because you find it hard to be a parent sometimes? Isn’t that being a bit harsh on yourself?

Client: Yeah… I know… I suppose I might beat myself up a bit too much… you know that’s what my wife says… she says the kids love me and they ‘worship their dad’… I suppose sometimes I just don’t see it… I don’t know…

Counsellor: And you think you can fix it all by gambling? Now really… are you sure about that?

Client: When you put it like that. it does sound pretty stupid and desperate…

Counsellor: Well, there’s better ways of trying to do the best for your family don’t you think?

Client: Yeah… true… I don’t know what I was thinking…

Pharmacological Treatment

Addiction is often treated by a combination of pharmacological and psychological interventions. The use of medications is to manage the physiological symptoms of withdrawal during the withdrawal stage. In recent times, pharmacological treatment has been used specifically to reduce the craving of the substance thus alleviating the distress associated with it.

Medication has also been said to be effective in treating mental disorders that are co-morbid with addiction. The use of pharmacological interventions manage the physiological aspects of addiction paving the way for psychological intervention to take effect (Shand, Fawcett & Mattick, 2003; Krishnan-Sarin, O’Malley & Krystal, 2008; Martin, Weinberg & Bealer, 2007).

This article is adapted from Mental Health Academy’s “General Addiction” CPD course. Click here for more information.


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