Substance Abuse Treatment Therapy Models

A History of Psychotherapy: Continuity and Change examines the historical factors of different schools of psychotherapy. The book notes that the use of “talking therapy” can be traced back to ancient Greece and perhaps even beyond; however, the actual term psychotherapy is attributed to an English psychiatrist, Dr. Walter C. Dendy. Dr. Dendy used a type of talking therapy approach to treating patients in the late 1800s that he termed psychotherpeia, which is the origin of the term psychotherapy. However, the text and the majority of other professional sources attribute the founding of psychotherapy to the Austrian neurologist Dr. Sigmund Freud.

Freud became involved in the use of hypnosis for patients who suffered from hysteria, which is better known today as conversion disorder or functional neurological disorder. These patients presented with some type of a neurological deficit, such as paralysis, blindness, mutism, etc., in the absence of any actual neurological damage. When these patients were able to discuss the experiences that led to their symptoms under hypnosis, they slowly improved. Freud eventually found that he did not need to use hypnosis but that he merely needed to get the patients to talk about what was on their mind or about certain experiences, and they would slowly improve; this was the beginning of his psychoanalysis. In this manner, Freud was able to treat patients with hysteria and other issues, and he became the founding father of what we now considered to be psychotherapy.

Freud primarily practiced individual therapy, where the therapist works with one patient in the sessions at a time. Psychotherapy can also be practiced in groups (group therapy) where one or more therapists works with two or more patients in the same session at the same time.

According to the above source, it appears that group therapy was first practiced by a physician who was instructing individuals about aspects of caring for tuberculosis, Dr. J. H. Pratt. Dr. Pratt began to notice that there were significant benefits accruing in the group sessions beyond the mere convenience of him being able to work with more than one person at a time. He found that the groups began to take on an identity of their own, and group members benefited in ways that were different than individuals who are treated singularly. Various therapists worked with individuals in groups up until World War II; however, group therapy really began to flourish following the war when returning veterans were treated in groups. Since that time, group therapy has become a mainstay of most psychotherapeutic practices along with individual therapy.

What Is Psychotherapy, Really?

The major professional organization of psychologists in the United States, the American Psychological Association (APA), has formally defined psychotherapy as the practice of a trained professional therapist applying clinical techniques that originate from the principles of psychology in order to help people adjust to situations in their lives, change how they think, change how they feel, alter certain behaviors, or bring about change in other areas of their lives.

The formal definition of therapy indicates that there are definite, but fine, lines that divide therapy and other forms of intervention. Psychotherapy is delivered by trained and professional therapists who apply interventions and principles based on psychological concepts. In addition, APA and the vast majority of other organizations that treat issues with mental health require that the therapist apply techniques derived from psychological principles that have been empirically validated to be useful in treating the specific issue. This means that the specific techniques, principles, or interventions used by the therapist must have sufficient research evidence to document their use and effectiveness or they should not be used.

Trained therapists are typically individuals who have a license to practice psychology in the state where they practice. Trained therapists may be formal clinical psychologists, social workers, counselors, marriage and family counselors, counseling psychologists, etc.

The formal definition of psychotherapy indicates that many interventions individuals considered to be therapeutic would not formally defined as psychotherapy. For instance, many individuals find participation in 12-Step groups for substance use disorders to be therapeutic for them – that is, they help them with their goals and help them to change certain behaviors and feelings – but because these groups are not run by professional, trained therapists and do not apply empirically validated techniques, they do not fall under the definition of psychotherapy. Certain types of complementary and alternative therapies, such as recreational therapy, art therapy, music therapy, etc., would also not qualify as formal psychotherapy if they are not delivered by a trained and professional therapist. That is not to say that these types of interventions cannot be effective, but they do not formally qualify as psychotherapy. Thus, an intervention that simply can be subjectively defined as having therapeutic benefits is not sufficient to be recognized as a formal form of psychotherapy.

Different Types of Psychotherapy

According to APA, numerous different types of psychotherapy exist (literally hundreds of different types/styles). However, the majority of professional sources, such as the book Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, still maintain that all of these different types of psychotherapy originate from one or more of the five major paradigms in the field of psychology. Furthermore, as a general designation, psychotherapy can be divided into two major approaches: experiential therapies (sometimes also referred to as insight-oriented therapies) and action-oriented therapies.

Individuals who practice experiential therapies focus on helping the individual change their experiences, particularly the experience of certain feelings, emotions, or insights. Experiential therapies consider the mechanism of change to be a kind of awareness or discovery that comes from experiencing thoughts, feelings, etc. Action-oriented therapies focus on actually having the individual directly change something through some form of action, most often directly changing a thought or behavior as opposed to simply experiencing one’s feelings or thoughts.

It is important to note that no form of therapy is totally experiential or action-oriented. All forms of therapy contain aspects of both of these approaches; however, different types of therapy focus on either being experiential or action-oriented and use one of these factors as their primary mechanism of change.

The five major paradigms in psychology that influence all forms of psychotherapy today are outlined below.

Psychodynamic paradigm: The psychodynamic paradigm originated from Sigmund Freud. This paradigm is primarily experiential in nature and considers the notion that all behaviors are related to unconscious motives (motives that the person is not directly aware of). Dysfunctional behaviors are often related to past experiences with relationships, child-rearing, etc., and the impetus for these dysfunctional behaviors are buried in the individual’s unconscious mind. The goal of the psychoanalytic paradigm is to bring these unconscious motivations, feelings, memories, etc., into awareness, and this process helps the individual gain insight to change.

The psychodynamic paradigm also originally conceptualized issues with certain types of defense mechanisms that people use to explain away their behavior or to avoid confrontation or issues they may find distressing. Even today, many other different types of therapy address defense mechanisms from an action-oriented or experiential approach.

The original technique of psychoanalysis developed by Sigmund Freud was lengthy, complicated, and required a long-term commitment, often consisting of years of therapy several times a week. Modern psychoanalytic approaches are much more focused, direct, and considerably shorter.

Behavioral paradigm: The behavioral paradigm grew out of experimental psychology, and it is the antithesis of the psychodynamic paradigm. The focus on the psychodynamic paradigm is on the individual’s feelings, thoughts, reactions, subjective interpretations, etc. Traditionally, the behavioral paradigm ignored feelings, cognitions, etc., in favor of observable environmental events that appear to shape an individual’s behavior. This paradigm is largely influenced by experimental animal research.

Behavioral therapists do not traditionally concentrate on thinking and feeling, but concentrate on the antecedents (the conditions that occur before a specific behavior) and the consequences (the results that occur when one performs a behavior) as the mechanisms of change. The behavioral paradigm has developed many rich and useful techniques/interventions that are primarily action-oriented and that can be used in psychotherapy; however, few therapists today strictly practice behavioral psychology. Instead, the majority of therapists today combine the techniques of behaviorism with the principles of cognitive psychology or symbols from another paradigm.

Cognitive paradigm: The cognitive paradigm of psychology developed in opposition to the principles of the behavioral paradigm. Behavioral psychology became very popular in the late 1950s, 1960s, and 1970s, and its tendency to ignore cognition (thinking) resulted in the development of the cognitive paradigm. The cognitive paradigm concentrates on the internal processes that occur in an individual’s thinking and how these processes (information processing) relate to feeling and behaving.

Cognitive therapy grew out of the experimental paradigm of cognitive psychology, and it was initially applied to the treatment of depression. Eventually, it became useful in other applications. Cognitive therapy is primarily action-oriented; however, it is most effective when it is combined with behavioral techniques (referred to as Cognitive Behavioral Therapy).

Humanistic paradigm: The humanistic school of psychology developed as a reaction to both the psychoanalytic (Freudian) and behavioral approaches that were extremely popular in psychology at the time. The humanistic paradigm is primarily an experiential paradigm when applied to psychotherapy. It considers individuals to be driven by more than instincts (psychodynamic) or environmental factors (behaviorism), and to have certain types of needs, goals, and aspirations that they reach for. These concepts were originally inspired by Abraham Maslow’s development of the Hierarchy of Needs Model, which is often considered to be the beginning of the humanistic paradigm.

Often, individuals are blocked in reaching their full potential by their impressions of how they should behave that are developed from the impressions of others. The different types of humanistic psychotherapy concentrate on the relationship between the therapist and the client as the primary mechanism of change. This relationship is the driving factor for change in all types of psychotherapy, such that positive and productive therapeutic relationships have better outcomes than more mechanistic and uninvolved relationships between the therapist and client.

This is an experiential approach where the therapist treats the client in a genuine, empathetic manner and shows them unconditional positive regard. This relationship guides other action-oriented and experiential interventions used by humanistic psychologists.

Biological paradigm: The biological paradigm grew out of experimental psychology and the understanding of brain/behavior relationships. The use of medicines and psychosurgery in the treatment of behavioral issues is a direct application of the biological paradigm in psychology. Modern psychiatry’s primary focus is on the biological aspects of behavior.

In the early days of psychiatry, most practicing psychiatrists adopted a Freudian approach to treating their patients, but with the advent of certain medications to treat psychiatric/psychological disorders, modern psychiatry developed from the biological paradigm of psychology. Today, many training programs for psychiatrists offer literal or no training in formal psychotherapy and concentrate on medical approaches to treating patients. Other action-oriented therapeutic techniques have also been attributed to the biological paradigm, such as diaphragmatic breathing for stress management, visualization, different types of meditation, etc.

Some Specific Types of Psychotherapy

Gestalt therapy is an experimental form of psychotherapy that originated from the psychodynamic paradigm and heavily incorporates aspects of the humanistic paradigm. The therapy was originated by Fritz Perls and his wife Laura Perls, and it focuses on the individual’s personal experience in the moment during the interactions that occur in therapy, the relationship between the therapist and client, the social contexts that occur in a person’s life, and the types of adjustments that people make in order to explain their actions and justify them. Gestalt therapy emphasizes responsibility and accountability for one’s behavior and being able to freely express oneself without guilt.

Cognitive Behavioral Therapy is an umbrella label for numerous different types of psychotherapies that combine the principles of the cognitive paradigm and the behavior paradigm. These therapies are primarily action-oriented, but they incorporate significant experiential aspects into their interventions. The primary goal of Cognitive Behavioral Therapy is to help the individual recognize certain types of irrational and dysfunctional beliefs or feelings, test how these irrational beliefs and feelings lead to dysfunctional behaviors, and then change both the irrational thoughts and emotions and behaviors in more realistic and productive ways.

Dialectical Behavior Therapy (DBT) is based on the principles of Cognitive Behavioral Therapy and used to treat individuals with numerous issues, most of them quite severe and difficult to treat with other forms of therapy. The approach uses individual therapy where principles are primarily based on cognitive-behavioral techniques, group therapy sessions that are primarily didactic in nature (focus on psychoeducation and the group practice of techniques for change), and the belief that clients have accessibility to therapists when they need them.

Eye Movement Desensitization and Reprocessing therapy (EMDR) combines cognitive-behavioral principles with neurobiological theory. Therapists use cognitive-behavioral principles and exposure principles from behavioral psychology while having clients follow various hand motions with their eyes. Exposure is a behavioral technique that confronts an individual with an anxiety-provoking stimulus/visualization in order to help them reduce their anxiety. It is believed that these hand motions and eye movements help to enhance the therapeutic process.

Didactic therapy is based on the principle of psychoeducation and primarily experiential, although learning is both experiential and action-oriented. Didactic therapy is most often performed in group sessions. It adopts a more classroom-like atmosphere where certain principles, techniques, and other forms of information are taught through methods of instruction based on psychological principles.

Expressive therapies (sometimes referred to as expressive arts therapy or creative arts therapy) utilize various forms of expression and creation as the therapeutic mechanism of change. These techniques are primarily experiential in nature, but also obviously incorporate an action-oriented element. Expressive therapy is an umbrella term for numerous different types of complementary and alternative therapies that can include art therapy, dance therapy, music therapy, etc.

Psychodrama is a type of expressive therapy where people attempt to explore unconscious internal conflicts by acting out their experiences on a stage with others or alone. Typically, the therapist uses a protagonist (the major player in the scene), actors (other individuals who interact in the scene), and the therapist is known as the director. Specific feelings, reactions, experiences, etc., are then acted out, and individuals get a chance to discuss these activities with the therapist and with others in either an individual or group session later. The technique is primarily experiential in nature but incorporates some action-oriented principles as well.

Hypnotherapy or hypnosis uses guided relaxation and focused concentration to achieve heightened states of awareness that allow individuals to change their feelings, behaviors, or attitudes. Hypnotherapy was originally used in the Freudian paradigm to help individuals gain insight, but today, it is primarily practiced in a more action-oriented environment. Some therapists still use hypnosis to help individuals gain insight into experiences and feelings.

Motivational therapy or Motivational Enhancement Therapy is based on the principles of Motivational Interviewing. These are primarily cognitive-behavioral techniques that help individuals improve their motivation to change and become more empowered in the process of changing issues.

Narrative therapy concentrates on the personal experiences and stories of an individual that shape their identity. The technique is primarily experiential and allows individuals to empower themselves and develop their natural abilities to help them change issues they wish to address.

Organized recreation therapy is a method that uses various activities, such as games, outings, etc., to get individuals to experience positive aspects of life, reconnect with their family, and develop relationships. It is primarily experiential in nature and can be extremely beneficial in treating younger clients.

Traumatic Incident Reduction (TIR) involves re-experiencing past stressful or traumatic events in a safer environment as a matter of dealing with the aftereffects of these events. It is heavily influenced by cognitive-behavioral principles.

Does Psychotherapy Work?

The history of the research into the effectiveness of different types of psychotherapies indicates that psychotherapies that have empirical validation regarding their use for specific types of issues, problems, conditions, disorders, etc., are effective. For instance, the book The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work notes that, based on empirical evidence, therapies derived from all of the major paradigms have sufficient evidence to indicate that they are effective for specific types of problems.

Some paradigms may be slightly more efficacious than others; for instance, the majority of sources recommend therapies that are based on cognitive-behavioral principles as being the most consistent therapies producing positive outcomes for issues with substance use disorders. However, other types of complementary and alternative interventions can enhance the effects of formal psychotherapy. Certain types of techniques or interventions may not be appropriate for specific individuals, and some individuals may prefer to be involved in more experiential-type interventions as opposed to action-oriented or vice versa.

Several important issues can help to determine the potential effectiveness of a particular type of therapy. Some of these are outlined below.

  • The working bond between the therapist and client is often referred to in clinical circles as the therapeutic alliance. This principle represents the closeness and the respect that both the therapist and the client have for one another and their commitment to work together to both understand the issues and implement a plan of change.
  • Certain aspects of the therapist are important. For instance, therapists must develop a formal plan of action as opposed to trying to “wing it” in order for the therapy to be effective. Therapists need to work with their clients to develop a list of goals and objectives that need to be met over the course of treatment; otherwise, treatment will be less likely to be efficacious. Therapists need to respect the client, demonstrate empathy, and show a high level of unconditional positive regard for the person (recognizing the person’s worth despite any issues the person has). Obviously, the therapist should be trained and competent in dealing with the type of issue that is being addressed.
  • Certain aspects of the client are also important. Clients in therapy must be willing to do the work in order to effect positive change. Therapists can help to enhance the client’s motivation, but clients who are largely uninvolved in the therapeutic process will most likely struggle. Clients who have specific issues, such as being actively psychotic, are often not appropriate for engagement in therapy.
  • The specific type of therapy should be appropriate for the problems being addressed. For example, simply enrolling an individual with a severe alcohol use disorder in a program of music therapy is very likely not going to be successful; for some clients, music therapy can be an adjunctive (additional) intervention that can enhance formal substance use disorder therapy, but music therapy alone is not a solid approach to treating a substance use disorder. The particular intervention should have empirical validation for treating the issues being addressed.

Clients interested in becoming involved in psychotherapy always have the option of asking the therapist to explain their credentials, reveal their experience in working with the particular type of issue being addressed, and ask for a referral to a more appropriate therapist if the potential therapist does not have the qualifications to deal with their issues. In addition, therapists are bound by the ethical responsibility to make sure they are competent in treating the issues the client brings to the sessions, that they approach treatment in a way that is consistent with empirical notions of effective treatment, and that they refer the client to a proper therapist if they cannot effectively treat them.

Further Reading

  • Cognitive Behavioral Therapy: A results orientated form of counseling. Effective in treating a wide range of mental health issues, from depression, to eating disorders, to substance abuse. This treatment is focused on the here and now. Clients are encouraged to question and examine recurring thoughts. Through objective, thoughtful analysis, recurring negative thoughts are proven to be false and are therefore phased out.
  • Didactic Group Therapy: This classroom-like treatment seeks to explain to clients the nature of their drug addiction or alcoholism. Understanding a problem is essential to effectively combating it, especially when it comes to the vicious cycle of substance abuse. Supportive group sessions may feature visual aides such as slideshows or videos, with clients learning the real consequences of untreated addiction. Sessions are low-key and not emotionally intense, and may focus on teaching particular skills important to a successful recovery, such as relapse prevention.
  • Motivational Interviewing: Friends and family members are quite familiar with trying to “talk sense” into the addict, but this confrontational approach rarely works. Instead, the addict may become resentful or angry instead of recognizing that he or she needs substance abuse help. Motivational interviewing is a different way of encouraging addicts to get clean — a nonjudgmental counseling method in which treatment options are discussed in a back-and-forth manner. Studies of this method have found it to consistently outperform traditional methods of giving advice. In motivational interviewing, addicts actively contribute ideas and possible solutions regarding their care.
  • Organized Recreational Therapy: Using activities such as painting, playing games and picnics, this treatment teaches clients and their families to reconnect with each other through shared, fun activities. The proven, positive effects of this therapy include decreased social anxiety, stress relief and strengthened social bonds for the client.

Recovery Process