How to Provide Basic Addiction Treatment
by Tom Horvath, PhD., ABPP
This blog is addressed to psychotherapists who do not view themselves as capable of providing addiction treatment. Many (if not most) therapists have this perspective. However, as I have suggested for many years, individual therapy (possibly supplemented by couple’s and family therapy) is the setting of choice for most individuals with addictive problems, and therapists should learn to address these problems. Unfortunately, many therapists lack the confidence even to learn about addiction treatment. Therapists already know most of what they need to know for basic addiction treatment. They also need some basic information about addiction and recovery.
In an effort to boost the confidence of these therapists, below are the principles they would keep in mind as they provide basic addiction treatment. Perhaps by seeing these principles they will realize how much they already know about addiction treatment, and be willing to take the next step to learn more.
1) Conduct psychotherapy as you normally would
The following list is not exhaustive. Helpful therapy typically has the following guidelines: be empathic, listen to problems, screen for other problems, get history, obtain records, contact or see family or other collaterals, refer out for medical evaluation if needed, provide focused treatment or education at times, be a case manager at times, keep the treatment organized, be ethical, be sensible, etc. In addiction treatment, continue to follow these guidelines!
2) Collaborate with the client to establish treatment goals
All effective psychotherapy includes mutually established goals for the work being done together. It is not your job to confront the client and push for goals other than the goals the client proposes. The proposed goals might be examined. For instance, if the client wants to moderate alcohol use as a primary goal, you might ask about whether there is a history of such attempts and how they turned out. If there have been many unsuccessful attempts, what will be different about this one? If moderation does not work out, what is the backup plan? When or under what conditions would the backup plan be invoked?
Perhaps the scariest goal for therapists is some version of a moderating or “cutting back.” However, these goals are not fundamentally different than an abstinence goal. Both types of goals require someone to stop. Stopping is stopping. Your perspective with the client is: “You choose the limits. I’ll help you stay within them.”
3) Identify what is meaningful and helpful about the addictive behavior
Simply asking “what do you like about [it]?” is typically sufficient, and reveals an entire treatment plan if the client can provide a complete answer. If someone drinks to accomplish A, B, and C, then part of treatment involves figuring out how to get A, B, and C by other means. We assume that A, B, and C are meaningful and non-problematic goals. In my experience they almost invariably are. If the client cannot provide a full answer to this question, who better than a therapist to help the client arrive at the answer?
4) Recognize the client’s adaptive effort
Everyone is trying to lead a happier life! In the client’s case the short-term benefits of the addictive behavior keep negatively impacting longer-term goals (or the client would not be sitting in front of you). In some cases, especially when clients have had significantly distressing experiences in the past, the addictive behavior has, in the short run, some genuinely valuable aspects. It is time to help the client expand the timeframe of the decisions being made.
5) Teach coping with craving
Craving is a very common aspect of the change process. Just as with panic attacks, craving is time-limited, does not harm the individual, and does not force the individual to engage in the addictive behavior. Just as with panic attacks, simply waiting out the experience (and coping with it until it departs) is a basic and effective tactic.
6) Make building up a new life the primary focus
The new life can be building up even while the addictive problems continue. In time the new life can become so valued that addictive behavior fades away, because it is getting in the way.
7) Refer out for medical evaluation
Ideally every client with substance problems goes, at the beginning of treatment, for a physical evaluation, and a medical opinion about the likelihood of withdrawal symptoms. If significant withdrawal occurs, it will typically arise from alcohol, benzodiazepines (Xanax, Klonopin, Valium, etc.) or opiates, but the medical risks vary by dosage, substance, the client’s overall health status, and other factors, and should therefore be assessed by a medical professional. Some clients will be very knowledgeable about their substances and their impact on the body. A medical evaluation should always be recommended, but may not be followed.
8) Remember that to be effective, psychotherapy, regardless of the orientation(s) the therapist uses, involves necessary basic elements
These elements are collaborative goal setting, an empathic therapist, a treatment alliance in which both are working toward the same goals and using methods that are mutually agreeable, respect for the client by the therapist, and a therapist who is genuine and honest. No amount of technical brilliance will overcome significant shortcomings in any of these areas.
9) If the client truly seems stuck, discuss a referral out to another provider
However, if the client wants to keep working with you, consider continuing, and get some consultation with a colleague who knows more about addiction. In many cases the power of your relationship outweighs your relative inexperience.
If these principles have piqued your interest, consider learning more! Excellent places to start that learning process include taking the SMART Recovery facilitator training course, learning motivational interviewing, using Stanton Peele’s Recover! or my Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions, both of which can be used as self-help books or therapy guides. If you want more reference material the DSM5 is an excellent resource, as well as the Surgeon General’s report (in 2016) on addiction (a free download). All of these resources will point you in additional directions.