____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
of intensive outpatient programs and the time commitment cause many individuals to choose traditional outpatient individual psychotherapy. Intensive outpatient treatment has become a level of care for clients whose recovery is unlikely in a less structured setting. OUTPATIENT INDIVIDUAL PSYCHODYNAMIC THERAPY Traditionally, outpatient psychodynamically oriented indi- vidual psychotherapy is not considered an evidence-based treatment for substance use and is not recommended until the person is secure in his or her abstinence from chemicals, because the anxiety aroused during treatment may lead to the resumption of alcohol or drug use (Lightdale et al., 2012). However, if a client has stopped using substances or is mak- ing serious efforts to diminish his or her drug or alcohol use, cognitive-behavioral therapy, ego-supportive counseling, or a self-psychology or harm reduction approach may be use- ful (Erickson et al., 2015; Lightdale et al., 2012). Because substance abusers’ primary relationship has been with their substance of abuse, a treatment goal for individuals who are recently abstinent from substances is establishing a nonjudg- mental relationship with a caring, consistent, and reliable provider. This relationship can help improve self-esteem and provide ego support. EVIDENCE-BASED TREATMENT APPROACHES Research studies show evidence for the effectiveness of various substance abuse treatment approaches discussed subsequently. The length of treatment is determined case by case, but most of these treatments have been tested over periods of 12 to 16 weeks; few have been tested on populations that are age, gender, sexual-orientation, or ethnoculturally diverse. Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) strategies are among the most common approaches used today. These techniques are based on the theory that learning processes play a critical role in the development of problem behaviors, such as drug abuse, and that negative thoughts and beliefs influence emotion and behavior. In general, CBT aims to reduce self-defeating behavior by modifying cognitive distortions and maladaptive beliefs and by teaching techniques of thought control (Liese, 2014). CBT changes clients’ substance use through cognitive restructuring. The therapist works with the client to identify the thoughts that are causing distress and employs cognitive and behavioral therapy techniques (e.g., recognizing behavioral chains; analyzing drug abuse situations; identifying negative emotional states, such as frustration, boredom, and depres- sion; cognitive restructuring; practicing alternatives to drug use; and preventing relapse) to alter the resulting behavior (Elison-Davies et al., 2022). A core element of CBT is teach- ing participants how to cope with stressors in their lives. For
example, individuals who live in poor urban areas may face major challenges, such as violence, physical abuse, and crime. In CBT, the client identifies and anticipates high-risk situations and applies an array of self-control skills, such as emotional regulation and anger management, practical problem solv- ing, and social skills training (e.g., effective communication and substance refusal). The focus is not on reducing stressors that are out of clients’ control, such as community violence, physical abuse, crime, and so on, but on improving their own functioning. CBTs with the strongest evidence for effectiveness include contingency management therapy (CM), the previ- ously discussed MET, and 12-step facilitation therapy (NIDA, 2021b). CM is essentially a behaviorally based treatment in which individuals are rewarded for desirable behavior and achieving specific behavioral goals (Elison-Davies et al., 2022). This modality has been shown to be one of the most efficacious behavioral treatments for a multitude of populations (Elison- Davies et al., 2022). CM approaches have been demonstrated to encourage abstinence, program participation, retention in treatment, and other desirable treatment goals, such as employment (Elison-Davies et al., 2022). Studies indicate that CM not only results in lower amounts of substance use but also reduces psychiatric symptoms (Elison-Davies et al., 2022). This behavioral treatment is relatively new in clinical settings and is implemented in various ways. For example, clients in such treatment might receive vouchers for each clean urine specimen. Such vouchers can be used toward the purchase of desirable items such as clothing or electronic devices. By rewarding clients for achieving their goals, clinicians are rein- forcing positive decision making. Another derivative of CBT that shows promise is acceptance and commitment therapy (ACT). This type of therapy focuses on increasing a client’s psychological flexibility and incorpo- rates aspects of mindfulness, while emphasizing focus and acceptance (Hayes et al., 2012). All sessions involve both didactic and experiential learning, with the aim of increasing the alignment between a client’s values and behavior. Clients learn to observe their own feelings and self-talk and become aware of how they are interpreting their experiences. As the model’s name implies, clients learn to accept, rather than avoid, difficult feelings and emotions by escaping them through the use of substances (Burckhardt et al., 2017). With successful ACT, a client’s feelings no longer provide the basis for his or her behavior (Dewane, 2008). DIALECTICAL BEHAVIOR THERAPY Dialectical behavior therapy (DBT) is a specialized form of CBT that utilizes both individual psychotherapy and group skill-building to teach four core skills: 1. Mindfulness
2. Emotion regulation 3. Distress tolerance 4. Interpersonal effectiveness
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