Addiction Treatments | CBT, DBT, 12 Steps etc

Addiction Treatment

Recovering from an addictive disorder is a tough challenge for any patient as there are many factors that could have led to their addiction, and all of these need to be thoroughly investigated before an appropriate treatment plan can be developed.

Addiction treatment is patient specific

It is important to carry out a full assessment which includes many aspects of a patient’s life when considering the best treatment options for them.

There is a wide range of treatment options open to them and each patient’s case history will be unique and feature several biological, social, psychological and spiritual factors. (5)

Overview of treatment

All modern addiction treatment programmes adopt a biopsychosocial-spiritual approach to treating patients as interventions in all these areas will help the patient overcome different aspects of their addiction and enhance their overall health and wellbeing. (4)

All addiction treatment programmes feature the following areas of treatment:

Medical (Biological)
Psychological therapies
12-step work
Education programmes / self-development work
Relapse prevention work

Biological approach to treatment

The biological component of an addiction treatment programme tackles the patient’s physical dependence on the substance.

The primary aim of this treatment is to remove all the toxic chemicals of the substance from the patient’s body and at the same time lessen the severity of their withdrawal symptoms as they cease consumption of the substance they were dependent on.

Detoxification

This is carried out by a process known as detoxification (or detox for short) and is only used to help treat a patient’s physical dependence on a substance (drugs and alcohol) and therefore does not apply to any behavioural addiction. (10)

Pharmacological treatment

Patients who are required to enter detox treatment for alcohol, opioid drugs (e.g. heroin) and drugs from the benzodiazepine category are recommended specific pharmacological treatments.

These help them detox from the drug safely whilst also ensuring any withdrawal symptoms experienced by the patient are minimised or preferably eliminated.

Alcohol detox

Great care must be taken when organising detox treatments for patients diagnosed with alcohol use disorder as alcohol is a very dangerous substance to withdraw from.

This is because alcohol is a central nervous system depressant that acts on the brain’s GABA neurotransmitters, which are responsible for slowing down physiological activity throughout the body.

The brain adapts its internal chemistry to account for the presence of alcohol and, if after adapting to alcohol a drinker decides to stop drinking alcohol suddenly the GABA neurotransmitter in the brain can start to behave erratically.

This can potentially lead to unpleasant withdrawal symptoms including brain seizures, which can be life-threatening. (13)

Because of this threat medical professionals prescribe a benzodiazepine-based drug to help the patient withdraw from alcohol safely over a period of 7-10 days.

A common drug used in the alcohol detox process is Librium, which contains a chemical that will prevent the patient from having a seizure once they begin the detox process. (4,10)

Heroin (opioid) detox

Heroin is a drug that is highly addictive and also has a high relapse rate and can produce very challenging withdrawal symptoms that can lead to very powerful cravings that are hard for heroin users to resist.

There are several medications including methadone and buprenorphine used to help patients detox from heroin.

These are chemically similar enough to prevent withdrawal symptoms without producing addictive feelings of pleasure and euphoria in the user. (5,10)

Benzodiazepine detox

The approach for detoxing from any benzodiazepine drug usually involves slowly decreasing the dose of the benzodiazepine drug that the patient has become addicted to or switching to a slower-acting benzodiazepine over a period of 4-6 months.

This enables the patient to gradually remove the presence of the drug from their body while ensuring that they are receiving enough of the drug to keep any withdrawal symptoms away.

Using slower-acting drugs means that any withdrawal symptoms can be prevented for longer which over a period of weeks reduces the patient’s reliance on the drug. (4,17)

Cannabis and Cocaine detox

There are no medications available to help patients detox from cannabis or cocaine dependence.

The main aim of the treatment team is to ensure that any withdrawal symptoms that patients experience whilst going through the early phase of detox are managed, if not eliminated ensuring that the patients are not uncomfortable or distressed in any way.

There are many different withdrawal symptoms that patients experience when coming off cannabis and cocaine and rehab medical teams will be on hand to offer advice or appropriate medication for dealing with each symptom.

Insomnia, stress and anxiety are common symptoms patients experience so there is a range of techniques patients will be taught by medical to help them deal with these symptoms.

Monitoring patients’ mental health

Withdrawing from cocaine and cannabis can cause some patients mental health difficulties as there are psychological withdrawal symptoms associated with withdrawing from these drugs.

The first 3-4 days are always crucial as people who have used cocaine or cannabis heavily are vulnerable to crashing and experiencing an extreme low which can make them suicidal or leave them in a very low mood.

It is common practice to monitor patients’ mental health symptoms during this early stage of detox and to use the expertise of specialist psychiatric services. (10)

Specialist psychological therapies

Addiction treatment professionals have a plethora of psychological therapies at their disposal these days, each of which has a slightly different approach to enhancing the patient’s psychological and emotional well-being.

However, all of these therapies make a valuable contribution to treating addiction and all of them are backed up by a strong research base.

Some of the therapies used are:

1. Acceptance and commitment therapy

Acceptance and commitment therapy (ACT). Therapists using ACT aim to provide patients with important psychological skills to help them cope with difficult thoughts and intense emotions so that they avoid becoming overwhelmed by them and can function effectively. (11a)

2. Mindfulness meditation and addiction

Mindfulness techniques are key skills taught to patients, as possessing these skills will help patients separate themselves from, and let go of distressing thoughts and memories.

Patients will also learn how to accept feelings and tough life circumstances without losing the mental energy to fight against them.

To help them develop mindfulness skills patients are encouraged to practice being in the present moment and to connect more frequently to the physical world around them,

3. Cognitive Behavioural Therapy (CBT) and addiction

Cognitive Behavioural Therapy (CBT) involves therapists working with clients to understand their unhelpful and irrational thought processes which cause them a great deal of psychological distress and help them to establish new, more productive ways of thinking about themselves and their lives and helping them view the world from a different perspective. (7)

4. Dialectical Behavioural therapy and addiction

Dialectical Behavioural therapy teaches patients to handle strong emotions more effectively so that they are not so completely distracted by them, learning these skills in their sessions with therapists will help them become more psychologically resilient and therefore able to get on with their daily lives. (2)

5. Motivational interviewing and addiction

Motivational interviewing is used by rehab therapists to ensure that clients remain committed to their treatment plan and do not lose enthusiasm for recovery.

Any clients that do appear to lose motivation for engaging with treatment will work with the therapy team to try and establish the psychological barrier(s) they are facing and the therapists will help them work through these barriers and re-engage with treatment. (9)

6. Group therapies and addiction

Group therapies such as group therapy and family therapy also make a valuable contribution to an addiction treatment programme.

Group therapy usually occurs in groups of no more than 8 people and is facilitated by a trained therapist who will help all members understand their social processes and how they relate to other people.

Being in a group also helps members achieve a sense of belonging and to appreciate the problems and perspectives of other people in the group.

7. Family therapy and addiction

Family therapy will help family members resolve several unconscious patterns of behaviour that may have led to communication problems and unhealthy family dynamics which may have impacted the mental health and social development of some members of the family and led to them participating in substance use. (19)

8. Trauma-based therapies and addiction

There is now a substantial amount of evidence available indicating that experiencing trauma is a strong risk factor for developing an addiction.

Many people experience traumatic events every day including personal attacks, accidents, natural disasters and serious illnesses.

If people experiencing such trauma do not receive the opportunity to express their feelings or fully process the memory of the event they are vulnerable to experiencing severe mental health difficulties in the future. (3)

Thankfully the intense psychological and emotional impact it has on the victims is now acknowledged and there are well-researched treatments to help people who have experienced trauma, including:

Cognitive processing therapy.
Prolonged exposure therapy.
Trauma-focused CBT.
EMDR (Eye Movement Desensitisation and Reprocessing).

9. Contingency management (CM) and addiction treatment

Many rehab treatment centres use CM to help their clients overcome addiction and it has been proven to be a very successful technique, particularly for cocaine and cannabis addiction.

CM is based on the main ideas of behavioural psychology which involves offering clients rewards such as money, vouchers and products for making positive progress with their recovery from addiction.

Rewarding clients in rehab for their huge efforts in making progress serves as a strong motivation for them to continue their progress and work towards abstinence. (12)

Rehab centres can use drug tests to check whether clients have managed to reduce or stop their substance use as there are many biological markers in the body to indicate if the level of a substance in a client’s body has decreased or been eliminated.

10. Holistic therapies and addiction

Many rehab centres use several holistic therapies in their treatment plans, holistic therapies offer patients an alternative way to express their thoughts and feelings and often use patients’ creative talents in the way they are applied, which is in stark contrast to the more traditional talking therapies that usually feature heavily on treatment programmes.

Some of the holistic therapies commonly used by rehab centres are art and music therapy, equine therapy and adventure therapy all of which offer something different to the client and are used accordingly depending on the treatment needs of the patient. (15,18)

11. Lifestyle factors

Addiction treatment centres encourage patients in rehab to identify lifestyle factors that need attending to that are currently problematic for them but could enhance their overall well-being if they made the necessary adjustments.

This may include advising the client on improving their diet and nutrition, engaging in regular exercise and improving the quality of their sleep (sleep hygiene).

Research into the area of addiction has found that becoming involved with one’s local community, having positive relationships and finding meaningful activities can act as protective factors against relapsing back into addictive behaviour.

Fellowship (support) groups

Attending support groups has become an integral part of any addiction treatment programme, regardless of whether it is a substance addiction or a behavioural addiction.

1. Alcoholics Anonymous (AA)

Alcoholics Anonymous (AA) was the original support group for people with an addiction and all other substance-related fellowship groups such as Narcotics Anonymous and Cocaine Anonymous follow the original approach to treatment and support which was laid down by Alcoholics Anonymous.

Support groups for individuals with behavioural addictions such as gambling (gamblers anonymous) and sex addiction (sex addicts anonymous) have also adapted the main AA 12-step approach into their support programme for its members. (8)

2. Al-Anon

Al-anon was specifically set up to help relatives of individuals diagnosed with alcohol addiction, they arrange weekly meetings throughout the country which always welcome new members.

3. Main principles of support groups

The whole AA ethos is based on the principle of mutual support and fellowship and that any individual who becomes addicted has a disease that will be difficult to overcome by themselves alone, but the chances of recovery are significantly boosted by the support, encouragement and empathy from other people who have been through similar experiences.

4. 12 steps addiction treatment

The 12 steps are considered one of the central foundations of any addiction treatment programme and have been developed into a form of therapy which is based on the original 12 steps to recovery model devised by the founding members of Alcoholics Anonymous.

The 12 steps are a series of personally reflective activities that individuals in recovery are expected to tackle, the steps require them to examine themselves, their life, their relationships and their behaviour to understand the reasons for their addiction and what they need to do to recover.

Some of the challenges involved in the 12 steps require the individual to:

Identify their own character flaws
Admit their mistakes, acknowledge who has been harmed by their behaviour and try and put this right (if possible)
Admit they are powerless over their behaviour
Engage in prayer, meditation and critical reflection to explore the nature of their own personal higher power which can lead them to recovery (8,10)

5. SMART Recovery

SMART Recovery is a national charity committed to helping people who are struggling with addiction, they have developed a programme to help people improve their motivation to change and also provide a range of methods and techniques to enable people to recover.

SMART Recovery aim to:

Build and maintain the clients’ motivation
Help clients cope with urges and cravings
Enable clients to manage challenging thoughts, feelings and destructive behaviour
Guide attendees towards living a balanced life
Use group meetings to discuss progress and solutions

Dual diagnosis treatment – addiction and mental health

If a patient has been diagnosed with an addiction and a mental health condition such as depression, anxiety, schizophrenia or post-traumatic stress disorder then they are referred to as a dual diagnosis patient as they have more than one mental health condition that requires treatment.

There are many specialist dual-diagnosis treatment programmes available as dual-diagnosis patients have complex needs.

These differ from patient to patient depending on which substance or activity they are addicted to, and the co-existing mental health condition they are also diagnosed with.

Dual diagnosis practitioners possess a great deal of expertise in understanding how mental health conditions and addiction interact with each other which can vary greatly depending on the type of addiction and mental health disorder a patient has been diagnosed with. (16)

Relapse prevention/maintaining progress

All addictions have a high potential for relapse as patients diagnosed with addiction will have been behaving in a certain way for a very long time so their behaviour has become automatic, habitual and firmly entrenched in their minds and it is very challenging to change this.

Even though a client may have completed an addiction treatment programme and is making good progress external factors and life experiences can cause the patient to relapse if they do not have sufficient psychological tools to help them when they are vulnerable.

Rehab centres will therefore develop a relapse prevention programme for patients to help them gain psychological techniques that will help them avoid relapsing in the future.

Relapse prevention programmes for addiction treatment focus on:

Helping clients identify high-risk situations
Enabling clients to learn and practice cognitive skills which they can use in high-risk situations to avoid relapsing
Making patients more assertive and helping them set clear boundaries in their relationships
Teaching clients about the concept of meta-cognition so that they begin to understand their own thought processes
Improving patients’ drug and alcohol education and ensuring they understand the nature of addictive behaviour (5,10)

Treatment for Behavioural addictions

Because individuals with a behavioural addiction are not physically dependent on a substance there is no requirement for any form of detoxification treatment.

Behavioural addictions include gambling, shopping addiction and sex and love addiction.

The necessity for patients to regularly attend support group meetings such as gamblers anonymous applies to all behavioural addictions. (1)

The aims of psychological therapies for behavioural addictions

The main aim of psychological therapies such as CBT for behavioural addictions is to tackle the unhelpful, obsessive and irrational thought patterns patients possess regarding the activity they are preoccupied with.

For example, gamblers may mistakenly believe that they have found a successful system that can beat the bookmakers and win themselves a lot of money.

In reality, the likelihood is that they will lose a significant amount of money because they do not fully understand or choose not to accept that the probability and odds are not in consumers’ favour.

Many people with behavioural addiction do tend to have a high level of anxiety and a low mood which drives their behaviour and many of the therapies discussed earlier in this article will help patients work through these difficulties.

Medication for behavioural addictions

Experimental studies in the area of behavioural additions have suggested that certain individuals possess biological and genetic risk factors that may predispose them to compulsive and addictive behaviour.

Doctors and psychiatrists have tended to use anti-depressants including SSSIs to help patients stabilise their mood which makes them less likely to feel the need to seek other activities such as gambling to help them feel better.

This medication when combined with therapy increases the chances of a successful recovery.

There is also medication available that has been successful in reducing some individuals’ gambling urges by modifying any dopamine imbalance in their brains which leads to a decrease in the intensity of their gambling urges.

Opiate antagonists can also be effective as they eliminate any strong cravings to gamble as they prevent the individual from experiencing any pleasure from the activity which can also lessen the likelihood of them continuing with the activity. (1)

References

(1) Alavi, S.S. et al (2012) Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views. International Journal of Prevention Medicine. April 3(4) pp290-204 available @ Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views – PMC (nih.gov)

(2) Dimeff, L., Linehan, M. (2008) Dialectical Behaviour Therapy for Substance Abusers. Addiction Science and Clinical Practice. June 2008.

(3) Flores, P. (2004) Addiction as An Attachment Disorder. Jason Aronson. Maryland.

(4) Ghodse, H. (2002) Drugs and Addictive Behaviour: A guide to treatment Cambridge University Press.

(5) Herie, A. & Skinner, W. (ed) (2014) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada.

(6) Kahan, M. (2014) Physical Effects of Alcohol and Other Drugs. In Herie, M. & Skinner, W. (ed) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada.

(7) Kennerley, H., Kirk, J., Westbrook, D. (2015) An Introduction to CBT: Skill and Applications. SAGE Publications.

(8) Lewis, J, Dana, R., Blevins, G. (2002) Substance abuse counselling. Brooks Cole, London.

(9) Miller, W., Rose, G. (2009) Towards a theory of motivational interviewing. American Psychologist. Vol 64 No 6 p527-537.

(10) Moss, A, Dyer, K (2010) The Psychology of Addictive Behaviour. Palgrave McMillan. New York.

(11) Narcotics Anonymous (2022) Narcotics Anonymous UK. Available@Welcome to UKNA | UKNA | Narcotics Anonymous in the United Kingdom.

(11a) National Health Service (2022) Acceptance and Commitment Therapy.available@Therapies we offer – Acceptance & Commitment Therapy (ACT) — Talking Change

(12) Petry, N. (2011) Contingency Management: What it is and why psychiatrists should want to use it The Psychiatrist. May 35 (5) p161-163.

(13) Raistrick, D. (2004) Alcohol Withdrawal and Detoxification in Heather, N., & Stockwell, T. (ed) The Essential Handbook of Treatment and Prevention of Alcohol Problems by (2004). John Wiley & Sons. Chichester.

(14) Rassool, G.H. (2011) Understanding Addictive Behaviours. Palgrave MacMillan. New York.

(15) Trotter, K.S.(2011) Harnessing the Power of Equine Assisted Counselling: Adding Animal Assisted Therapy to Your Practice. Routledge. London.

(16) Tsanos, A. (2014) Concurrent Disorders in Herie, A. & Skinner, W. (ed) Fundamentals of Addiction: A Practical Guide for Counsellors. CAMH. Canada.

(17) Wills, S. (2005) Drugs of Abuse. Pharmaceutical Press. London.

(18) Wilson, M. (2003) Art Therapy in Addictions Treatment in Malchiodi, C. (ed) The Handbook of Art Therapy. The Guildford Press. London.

(19) Yalom. I. The Theory and Practice of Group Psychotherapy. Basic Books. New York.

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