Psychotherapeutic

Approaches
for
Addiction
Toni
Peters
MSN, RN
Disorders

Objectives
Identify

signs of substance dependence

Define relapse, recovery, and addiction
Identify the guiding principles of recovery
Identify evidence-based therapies used for
individuals with substance use disorders
Identify special populations to consider
when treating individuals with a substance
abuse

Prevalence of Substance
Use
In 2013, 4.1 million persons aged 12 or older (1.5

percent of the population) received treatment for a

problem related to the use of alcohol or illicit drugs
(SAMHSA, 2014)

According

to the National Survey on Drug Use and

Health (NSDUH), an estimated 20 million Americans
aged 12 or older used an illegal drug in the past 30
days. This estimate represents 8% percent of the
population aged 12 years old or older. (NCADD, 2014)

The

estimated cost of drug abuse exceeds $190

Billion:
$130 Billion in lost productivity
$20 Billion in healthcare costs
$40 Billion in legal costs including efforts to stem the flow of
drugs (National Counsel on Alcoholism and Drug Dependence,
2014)

At Risk Populations
History

of
physical,
emotional,
sexual abuse
Mental illness
Physical,
sensory, or
cognitive
disabilities
Chronic pain

Chronic

pain
Unemployment
Limited education
Low socioeconomic
status
Military experience

Wheeler,
2014

Associated Terms
Tolerance:

progressive need for more of the

substance to achieve the desired effect

Physical

Dependence: the individual must

receive the substance to prevent the onset
of withdrawal symptoms

Withdrawal:

physiologic signs and

symptoms when a particular drug or
substance is discontinued
NCADD, 2014

Associated Terms
Substance

Abuse: excessive use of a

substance that differs from societal norms

Addiction:

the psychosocial behaviors

related to substance dependence

Abstinence:

substance

voluntary avoidance of a

Dual

Diagnosis: co-occuring substance

abuse and psychiatric disorder
NCADD, 2014

Signs of Dependence
Spending a lot of time engaging in activities
related to substance use
Using the substance in greater quantities or for a
longer time than intended
Tolerance (i.e., needing to use the substance more
than before to get desired effects or noticing that
the same amount of substance use had less effect
than before)
Unsuccessful attempts to cut down on use
Continued substance use despite physical health or
emotional problems associated with substance use
Reducing or eliminating participation in other
activities because of substance use
Withdrawal symptoms when substance is
discontinued (Substance Abuse and Mental Health
Services Administration, 2014)

Addiction as a Disease

Addiction is a chronic disease. It is a complex disease characterized

by craving, seeking and using drugs that affects every organ system
in the body, including the brain.

Repeated use of drugs changes the brainincluding the way it looks

and functions. The changes in the brain interfere with a persons
ability to think clearly, exercise good judgment, control behavior,
and feel normal without using drugs.

There is no cure for drug addiction, but it is a treatable disease and

millions of people are living lives in long-term recovery. Recovery
from drug addiction, like other chronic diseases, is a lifelong process.

Addiction impacts every aspect of your life: physically, emotionally

and socially.

Recovery requires making major changes to the way you live, deal
with lifes problems, and relate to others.
NCADD, 2014

Relapse
Relapse:

recurrence or return to
substance use or addictive
behaviors after periods of
abstinence
It is estimated that 40-60% of addicts will
relapse at least once
Not a treatment failure
Can be drug or reward triggered, cue
triggered, or stress triggered

SAMHSA, 2014

Recovery
A

process of change through which individuals

improve their health and wellness, live a selfdirected life, and strive to reach their full
potential

lifelong process that includes four

dimensions:
Health: overcoming/managing the disease as well as
living in a physically and emotionally healthy way
Home: a stable and safe place to live
Purpose: meaningful daily activities (job, school, family,
independence, income, participation in society)
Community: relationships and social networks that
provide support, friendship, love, and hope
SAMHSA, 2014

Guiding Principles of
Recovery

Recovery emerges from hope: recovery is real and people

can and do overcome the internal/external challenges, barriers
and obstacles that confront them

Recovery is person driven: self-determination and selfdirection. Life goals and future path defined by the individual

Recovery occurs via many pathways: individuals are unique

with distinct needs, strengths, preferences, goals, culture, and
backgrounds that affect and determine their path to recovery

Recovery is holistic: includes mind, body, spirit, and

community

Recovery is supported by peers and allies: mutual

support/aid groups, sharing experiential knowledge/skills,
social learning
SAMHSA, 2014

Guiding Principles of
Recovery

Recovery is supported through relationship and social

networks: presence and involvement of people who believe in the
individuals ability to recover, offer hope, support, encouragement,
and suggest strategies and resources for change

Recovery is culturally based and influenced: cultural values,

traditions, and beliefs determines the individuals journey and unique
pathway to recovery

Recovery is supported by addressing trauma: services and

supports should be trauma informed to foster safety and trust and
promote choice, empowerment, and collaboration

Recovery involves individual, family, and community strengths

and responsibility: all have strengths and resources that serve as a
foundation for recovery

Recovery is based on respect: community, systems, and societal

acceptance and appreciation for people affected by mental health
and substance use problems are crucial in achieving recovery
Wheeler, 2014

Integrative Theoretical
Framework
It is a sensation + an associated emotion + an
Feeling-State
Therapy
associated cognition with
a behavior that causes
the urges and cravings for both substance and
behavioral addictions

Feeling

states associated with addictions develop

from intensely positive events and create positive
beliefs

These

positive feeling states can mask a defense

that serves to decrease anxiety or depression

Feeling

state examples: chilling out, being

productive, having great sex
Wheeler, 2014, p.583

Evidenced-Based
Psychotherapeutic
Interventions
Goals

of Interventions
Improving impulse control
Reducing craving
Promoting an adaptive social
environment
Wheeler,
2014

Addiction Treatment Focus

Address

the motivation to change

Provide incentives for abstinence
Build skills to resist behavioral or drug use
Replace behavior or drug using activities
with constructive and rewarding activities
Improve problem-solving skills
Facilitate improved interpersonal
relationships
Wheeler, 2014, p.
547

Evidenced-Based
Psychotherapeutic
Interventions
Motivational Interviewing (MI)
Integrated

Family Therapy (IFT)

Contingency Management (CM)
Cognitive Behavioral Coping Skills and
Relapse Prevention
Complementary and Alternative
Therapies

Wheeler, 2014

Motivational Interviewing

Motivational Interviewing (MI) is a goal-directed, client-centered counseling

style for eliciting behavioral change by helping clients to explore and resolve
ambivalence.

Assumption in MI is that ambivalent attitudes or lack of resolve is the primary

obstacle to behavioral change, so that the examination and resolution of
ambivalence becomes its key goal.

MI counseling style generally includes the following elements:

Establishing rapport with the client and listening reflectively.
Asking open-ended questions to explore the client's own motivations for
change.
Affirming the client's change-related statements and efforts.
Eliciting recognition of the gap between current behavior and desired life
goals.
Asking permission before providing information or advice.
Responding to resistance without direct confrontation. Resistance is used
as a feedback signal to the therapist to adjust the approach.
Encouraging the client's self-efficacy for change.
Developing an action plan to which the client is willing to commit.
SAMHSA, 2014

Integrated Family Therapy

Treatment

program that includes couples

and family in identifying the causes,
triggers, and destructive impact on couples,
the family and the community
Helps the family to learn how to cope more
effectively to decrease the likelihood of
relapse
Promotes assertiveness, communication,
understanding, trust, self-efficacy
Strengthen dysfunctional relationships
associated with addiction
Wheeler,
2014

Contingency Management
The

use of positive and punishing

reinforcement to give addicts incentives to
maintain desired behavior
Typically monetary based incentives such as
vouchers for retail purchases
Requires identification of desired behavior and
reinforcement
Monitor the individual for compliance
Provide tangible reward for desired behavior
Withhold reward or implementing negative
consequences when behavior continues
2011)

(Witkiewitz & Marlatt,

Cognitive Behavioral Coping

Skills and Relapse Prevention
Integrating

therapies such as CM, MI, and CBT

Help individuals increase coping skills and
develop a relapse prevention plan by focusing
on cognitive, behavioral, and lifestyle choices
Identify relapse triggers and develop coping
strategies to successfully avoid or manage
different triggers without turning to substances
Wheeler,
2014

Relapse Prevention
Therapy

Behavioral self-control program that teaches individuals with substance

addiction how to anticipate and cope with the potential for relapse.

Can be used as a stand-alone substance use treatment program or as an

aftercare program to sustain gains achieved during initial substance use
treatment.

Coping skills training is the cornerstone of RPT, teaching clients strategies to:
Understand relapse as a process
Identify and cope effectively with high-risk situations such as negative
emotional states, interpersonal conflict, and social pressure
Cope with urges and craving
Implement damage control procedures during a lapse to minimize
negative consequences
Stay engaged in treatment even after a relapse
Learn how to create a more balanced lifestyle
Coping skills training strategies include both cognitive and behavioral
techniques.
SAMHSA, 2014

More Behavioral Therapies

Complementary

and Alternative Therapies

electroaccupuncture for alcohol addiction:
acupuncture combined with electrical stimulation
(National Institute of Health,
Acupressure for opioid addiction (National Institute
of Health,
Integrated medication with ear acupressure for
cocaine addiction (Chen, Berger, Gandhi,
Weintraub, & Lejuez, 2013)

Brief

Behavioral Intervention: assessment of alcohol

use and personalized feedback . Focus on providing
options for strategies for change, goal setting,
empathy, and enhancing self-efficacy (Witkiewitz &
Marlatt, 2011)

More Behavioral Therapies

Coping Skills Training: social learning theory and skills

training to enhance individual coping skills. Includes cue
exposure with response prevention to break the association
between substance cues and substance seeking

Facilitated self-change: Assessment and feedback, motivation

information and self-help materials focused on goal-setting,
problem solving skills, and self-monitoring

Aversion Therapy: Pairing the substance (sight, taste, or

other cue) with an unpleasant experience (including nauseainducing drugs and electric shock) to modify response
Witkiewitz & Marlatt,
2011

Harm Reduction Therapy

G. Alan Marlatt research with college and university

students

Alternative to abstinence programs

Based on Buddhas teachings of seeking the middle way,

a way to seek enlightenment by pursuing a middle path
between the extremes of abstinence and gluttonous selfindulgence

Belief that controlled drinking and moderation is a viable

goal for treatment

Goal
make drinking behavior safe for students and not to try
to coerce abstinence
2012

Blume,

Harm Reduction Therapy

Development of Alcohol Skills Training Program (ASTP)

Students measured BAL when the potential negative

effects outweighed the pleasurable effects

Relapse results in negative feelings (guilt, shame)

associated with poor outcomes and slower response to
seeking help for the relapse

HRT avoids these negative feelings, improving outcomes

Blume, 2012

Also useful in certain behavior addictions such as

internet addiction when abstinence is not practical
Young, 2011

Special Populations
Older Adults

High rates of lifetime illegal drug use among the baby boom
generation, people born between 1946 and 1964, suggest that the
number of older adults using illegal drugs will increase in the next two
decades.

It has been predicted that by the year 2020, the number of persons
needing treatment for a drug abuse and addiction will double
among persons aged 50 or older.

In 2008, 4.3 million adults aged 50 or older, or 4.7% of adults in that

age range, had used an illegal drug in the past year.

Between 2000 and 2008, substance abuse treatment admissions

among those aged 50 and older increased by 70%, while the overall 50plus population grew by only 21%.

1 out of every 8 people seeking help for substance abuse, including

illegal drugs, prescription drugs and over-the-counter drugs (OTC) is
over age 50.
NCADD, 2014

Special Populations
Older Adults
Increased

risk due to OTC medications,

herbal remedies, chronic conditions,
prescribed medications
Baby boomers drink more and will
continue to drink therefore alcohol
screening is important
Diagnosis is often missed: Symptoms are
often attributed to old age or the normal
aging process

Stevenson, 2005

Special Populations
Older Adults
Brief

Interventions: 10-15 minute

sessions
Senior-tailored aftercare Interventions:
1:1 counseling instead of groups
Non-confrontational approaches
Slower paced information sessions
Medical interventions for chronic conditions
Higher level of structure
Comprehensive 12 month aftercare
SAMHSA, 2014

Special Populations
Adolescents
9.4%

of adolescents aged 12-17 use illicit substances

in 2013

Third

leading cause of death among ages 12-17

Important

to ask about substance use

Delaying

the use of alcohol until after age 14

decreases the lifelong risks of alcohol abuse and
dependence

Potential

likelihood of youths diagnosed with a mildmoderate drug abuse is high

2007

Witters, Leitten, Wagner, et.al,

Special Populations
Adolescents

Action-oriented approaches result in more engagement than

highly didactic and lecture-oriented approaches

Motivational Interviewing because it is non-confrontational

CBT utilizes cognitive behavior skill development and reframing

expectations of the social benefits of drug use

Adjust unrealistic perception that heavy drug use is normal for

their age group increases the chances of the individual
recognizing his/her problem

Family-Focused Interventions
Adolescent focus, parent focused, adolescent-parent focus

Tevyaw, 2007

Winters, Leitten, Wagner &

Special Populations
Co-Occurring Disorders
Dual

Diagnosis Disorders
Addiction occurs simultaneously with a
mental health disorder
Both disorders require treatment
Which came first?
May seek treatment for either one or
both
Always assess substance use history

Dual Diagnosis Treatment

III
Less severe mental
disorder/ more severe
substance abuse
disorder

IV
More severe mental
disorder/ more severe
substance abuse
disorder

Care provided in the

substance abuse
treatment system

Seen in state
hospitals, jails,
prisons, EDs, or
criminal justice
system on
parole/probation

I
Less severe mental
disorder/ less severe
substance abuse
disorder

II
More severe mental
disorder/ less severe
substance abuse
disorder

Care provided in primary Seen in the mental

Trauma-Informed Care
Hx

of childhood physical, emotional,

sexual abuse increases likelihood of
substance abuse disorders
Women substance abusers have higher
rates of
comorbid PTSD related to abuse
Military personnel
Treatments: SSRIs, EMDR, CBT
Wheeler, 2014

12 Step Programs
Peer

support groups
Set of 12 guiding principles
Admit you cannot control your addiction
Recognize a higher power
Examine past mistakes with sponsors help
Make amends for past mistakes
Learning to live a new life with new
behaviors
Help others who suffer from addictions

Wheeler, 2014

Examples of Self Help

Groups

Alcoholics Anonymous (AA) www.aa.org

An international fellowship of men and women who come together to share their experience, strength
and hope with the purpose of staying sober and helping other alcoholics to achieve sobriety. The only
requirement for membership is a desire to stop drinking.

Alcoholicos Anonimos (AA) www.aa.org/lang/sp/subpage.cfm

Alcoholics Anonymous outreach and support for speakers of Spanish.

Al-Anon/ALATEEN www.al-anon.alateen.org
Whether the person you are concerned about is still drinking or not, Al-Anon/Alateen offers hope and
recovery to all people affected by the alcoholism of a loved one or friend. Support for friends and families.

Adult Children of Alcoholics (ACA) www.adultchildren.org

Adult Children of Alcoholics is an anonymous Twelve-Step for people who grew up in an alcoholic or
otherwise dysfunctional home. We meet in a mutually respectful, safe environment and acknowledge our
common experiences. We discover how childhood affected us in the past and influences us in the present.

Cocaine Anonymous (CA) www.ca.org

A fellowship of men and women who share their experience, strength and hope with each other so that
they may solve their common problem and help others to recover from their addiction; the primary purpose
is to stay free from cocaine and all other mind-altering substances, and to help others achieve the same
freedom.

Examples of Self Help

Groups

Dual Recovery Anonymous www.draonline.org

An independent, twelve-step, self-help organization for people with a dual diagnosis of
chemical dependence and an emotional or psychiatric illness. Dual Recovery addresses
how both illnesses affect all areas of life.

Marijuana Anonymous (MA) www.marijuana-anonymous.org

Marijuana Anonymous is a 12-Step fellowship that addresses the common problem of
marijuana addiction. There are in-person and online meetings. The only requirement for
membership is a desire to stop using marijuana.

Narcotics Anonymous (NA) www.na.org

NA is a fellowship of men and women who come together for the purpose of sharing their
recovery from drug abuse. NA members are working together in a spirit of unity and
cooperation to carry their message of recovery. The only requirement for membership is
the desire to stop using.

Nar-Anon Family Groups (Nar-Anon) www.nar-anon.org

Nar-Anon is a twelve-step program designed to help relatives and friends of addicts
recover from the effects of living with an addicted relative or friend.

Crystal Meth Anonymous www.crystalmeth.org

Crystal Meth Anonymous is a fellowship of men and women who share their
experience, strength and hope with each other, so they may solve their common
problem and help others to recover from addiction to crystal meth. The only
requirement for membership is a desire to stop using.

Summary
There

are several evidence-based

psychotherapeutic approaches to treating
substance use disorders.
Interventions must be person-centered and
individualized with the person guiding their own
recovery
Relapse is common during treatment and
should not be seen as a failure
Identifying triggers and developing alternative
coping methods decrease the likelihood of a
relapse

Question #1
An individual with a more severe mental
disorder and a less severe substance
abuse disorder will most likely be seen
A. in the primary health care setting
with some counseling with
specialized cars
B.
in the substance abuse
treatment
system
C. in the mental health system
D. State hospitals and prisons

Question # 2
All of these are part of the
Guiding Principles of Recovery
except
A.
B.
C.
D.
E.

Supported by addressing trauma

emerges from hope
Occurs via many pathways
Based on respect
All of the above

Question # 3
Relapse during recovery
A. shows that the individual is not ready
for treatment
B. occurs at least once in approximately
50% of recovering addicts
C. means that the individual should be
terminated from the treatment
program
D. should be considered a treatment
failure

Question # 4
The evidence-based
psychotherapeutic intervention
that is based on a monetary
based reward system is called
A. Contingency Management
B. Motivational Interviewing
C. Cognitive Behavioral Coping Skills and
Relapse Prevention
D. Harm Reduction Therapy

Question # 5
Addiction
A. is a chronic disease
B. is treatable but has no cure
C. impacts the physical, emotional,
and social aspects of individuals
life
D. requires making major changes to
the way you live, deal with lifes
problems, and relate to others
E. all of the above

References

Blume, A.W. (2012). Seeking the middle way: G. Alan Marlatt and harm reduction. Addiction Research
and Theory, 20(3), 218-226. doi: 10.3109/16066359.2012.657281

Chen, W.C., Berger, C.C., Gandhi, D.,Weintraub, & Lejuez, C.W. (2013). Adding integrative meditation
with ear accupressure to outpatient treatment of cocaine addiction: A randomized controlled pilot study.
The Journal of Alternative and Complementary Medicine, 19(3), 204-210. doi: 10.1089/acm.2011.00311

Ciketic, S., Hayatbakhsh, M.R., Doran, C.M., Najman, J.M., & McKetin, R. (2012). A review of
psychological and pharmacological treatment options for methamphetamine dependence. Journal of
Substance Abuse, 17(4), 363-383. doi: 10.3109/14659891.2011.592900

National Counsel on Alcoholism and Drug Dependence, Inc. (2014). NCADD-Home. Retrieved from
http://www.nsadd.org

National Institute of Mental Health (2014). Complementary and alternative medicines. Retrieved from
http://nccam.nih.gov

Recovery.org (2014). About Alcoholics Anonymous 12-Step Recovery Programs. Retrieved from
http://www.recovery.org/topics/alcoholics-anonymous-12-step/

Stevenson, J.S. (2005). Alcohol use, misuse, abuse, and dependence in later adulthood. Annual Review
of Nursing Research, 23, 245-280.

Substance Abuse and Mental Health Services Administration. (2014) SAMHSA-home. Retrieved from
http://www.samhsa.gov

References

Young, K.S. (2011). CBT-IA: The first line treatment model for internet addiction. Journal of
Cognitive Psychotherapy: An International Quarterly, 25(4), 304-312. doi:
http://dx.doi.org/10.1891/0889-8391.25.4.304

Wheeler, K. (2014). Psychotherapy for the advanced practice nurse: A how-to guide for
evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company, LLC.

Winters, K.C., Leitten, W., Wagner, E., & Tevyaw, T.O. (2007). Use of brief interventions for
drug abusing teenagers within a middle and high school setting. Journal of School Health,
77(4), 196-206.

Witkiewitz, K., & Marlatt, A. (2011). Behavioral therapy across the spectrum. Alcohol
Research and Health, 33(4), 313-319.