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Key points
- Addiction psychotherapy is a highly sought-after specialty.
- These three pillars provide a helpful framework using scientifically-proven models.
- Because insight alone is not enough to heal addiction, therapists need to be action-oriented.
It seems clear that people are hungry for alternatives to traditional treatment for addiction—aka "rehab"—and that many could be well-served by individual psychotherapy. Unfortunately, many therapists are hesitant to work with active substance use disorders because of a fear that they won't know how to help.
To address this, I've developed a broad framework that can serve as a foundation for effectively working with substance use issues. The three pillars are motivational assessment and enhancement, recovery skills and action-oriented approaches, and long-term psychotherapy using the conceptual framework of your choice (more on that below). By using these models, you can join me in one of the most rewarding corners of the field of therapy: addiction psychotherapy.
Motivational Assessment and Enhancement
The first—and arguably, most important—place to start with someone wanting to address their substance use has to do with motivation. People come to addiction therapy for all kinds of reasons. Maybe their substance use is impacting their relationship and their spouse or partner is concerned. Or perhaps they got in trouble at work and need to make a change in order to hold onto their job. Whatever the situation, it is a guarantee that the person in front of you is ambivalent: on the one hand, they know what they're doing isn't working. And yet, on the other hand, they really enjoy drinking or getting high and would love to keep doing so if at all possible.
The first phase of the work involves spending time understanding how this person's substance use fits into their life and what their reasons for making a change might be. Instead of spending all of our time on the problems associated with their drug use, it's vitally important to talk about what is working for them, and why they love this substance, despite the problems.
The goal here is to explore and understand each individual's ambivalence about making a change so that we can address these specific concerns in our work together. One of the most common problems that therapists make is assuming that simply because they made their way to our office they are ready to take action and dive head-first into change. Instead, most people are way more uncertain about the best path forward and need some time to explore their options.
This might be the first time that this person has felt understood around this topic. Too many folks spend years feeling ashamed and guilty and spend their time drinking secretly because they don't think anyone will understand what they are going through.
Once we develop an understanding of the person's reasons for wanting to change, we can look for ways to help them resolve their ambivalence and begin taking some action steps. There is no specific timeline here and progress is not linear—you might need to jump back into exploring and resolving ambivalence again and again. That said, once they are ready to make a change, your approach will also need to shift.
Recovery Skills and Action Steps
The next pillar of addiction psychotherapy is recovery skills training and so-called "relapse prevention" approaches. Here, we are looking for ways to help each individual take specific actions and make changes to their substance use. Leaning on models like cognitive behavioral therapy, contingency management, or behavioral activation can be helpful.
Let's be honest, change is hard. Getting the motivation to make a change in the first place is difficult enough—now actually moving ahead and doing so opens up yet another can of worms. What's more, most people find that their drinking or drug use has been taking up a great deal of their time and has become an integral part of their lives. Finding new things to do new ways to cope, and filling up their free time are all going to be vital.
It's been said that "the opposite of addiction is connection." If that's the case with your client, then finding social outlets and ways to support others and be supported will help. There are loads of support groups and meetup groups across the U.S. and abroad that might be of interest to keep a focus on being active and social.
Other important strategies will include action steps like setting specific drinking or use goals. Setting limits and trying to stick with them is an experience that helps people decide if it's realistic to reduce to moderate their use, and may even help someone build their motivation to quit altogether. We spend a lot of time looking at the week and weekends to identify which parts of the day are going to be difficult. It's also important to plan ahead for high-risk situations like weddings, parties, holidays, etc.
One of the overarching goals here is to turn a behavior that has become unconscious and automatic back into something conscious and intentional. This is because almost no one wakes up in the morning and says, "I think I will become addicted to alcohol." Instead, it's probably a behavior that started out normal/adaptive and non-problematic, but over time increased or snuck up on the person and became problematic over months, years, or even decades. Any use from this point forward should be something they pay close attention to and, ideally, have a plan for.
Remember, change is rarely linear, so expect setbacks, challenges, and "F-it moments." Your goals must be specific, quantifiable, and achievable. Recurrences to problematic use are common and should be normalized when they happen. I like to take the approach that any setback is an opportunity to learn about what isn't working. It suggests we need to change our plan to address this as we move forward. The worst thing after a setback is not learning anything and going on to repeat that same mistake over again.
Long-Term Psychotherapy Models
Once a person is feeling good about having made a change to their substance use, they may find that this behavior was a symptom of other problems; a tool that helped them tolerate intolerable things in their life, or arose as a coping strategy of some kind. Sure, removing or treating the addiction is necessary, but not always sufficient for living a full life. Here is where you the therapist will rely on your preferred models or theories for helping your client achieve the broader goals that brought them to therapy.
For me, this involves psychodynamic or psychoanalytic psychotherapy. For others, it might be IFS, CBT and Schema therapy, somatic therapies, existential approaches, trauma therapy, etc. This might also be a good time for couples or family therapy, especially if substance use issues have caused problems at home.
I often find that substance use is a solution to some kind of problem: mental health symptoms like anxiety, things like loneliness or low self-image, or problems in relationships and communication. As these factors reveal themselves, therapists need to address them and work to identify new ways for that person to move through the world.
One area where I diverge from some of my analytic colleagues is my insistence that insight alone is not sufficient for changing a drinking or drug use pattern. By the time they make it to therapy, most people have loads of insight and watch themselves in horror as they continue using despite negative consequences.
We need to help people with specific strategies tailored to their situations. This might involve specifically targeting physiological effects like dependence and withdrawal, in collaboration with medical providers. However, once your client has achieved some distance from their use patterns, then they can develop new insights into the role their use played in their lives and use that insight to make additional changes.
Addiction Psychotherapy
It is my hope that keeping these three pillars in mind will help you become more effective with your clients who are considering a change to their substance use. If my experience is any indication, there is huge demand for this service and far too few therapists are available to meet it. Assisting people in making this change and achieving their goals—whatever they may be—is a truly enjoyable and rewarding experience. If you are interested in learning more or going more in-depth on this topic, consider signing up for the training. Either way, I hope you decide to join me in demystifying the process and supporting your clients as the first-line approach to the treatment of substance use issues.
To find a therapist, please visit the Psychology Today Therapy Directory.
