Why Traditional Addiction Treatment Might be Ineffective

By Tom Horvath, PhD

By traditional addiction treatment I mean expecting the client to agree that addiction is a disease, abstain for life, engage deeply in 12-step meetings, and attend them for life. This approach probably continues as the dominant US approach, although there may be much variation in how firmly it is applied. This approach can work well for someone who agrees to it. Or enough of it. Because we do not understand exactly how addiction treatment works, it seems likely that even variations in the approach can be effective.

This variation is a positive sign, because a strict approach would likely violate much of what we have come to know about how psychotherapy works. Although there are many forms of psychotherapy, successful psychotherapy appears to involve what are known as “common factors.” The common factors are 1) having the client and the therapist agree about the goals of the treatment and 2) agree about how to accomplish those goals. Further, if the 3) client believes the therapist understands them, if the 4) client feels that there was a strong working alliance or sense of teamwork, and if the 5) client views the therapist as a respectable and honest person, therapy is likely to be successful, regardless of the specific approach of the therapist.

There are various ways to describe these common factors. I have given one. Further research will clarify what is fundamental. From what I have seen empathy and goals are on every list of common factors.

If “addiction treatment” consisted of psychotherapy, then the therapist would work (NOT in the order of the common factors listed above) 1) to understand the client’s view of their situation (empathy). The therapist might disagree about how to understand the situation, but that disagreement could be addressed over time. The client does not need, right at the beginning, to be “confronted” about their views. 2) The client’s goals would be elicited and perhaps refined, and 3) a plan for accomplishing them would be created. What if the therapist disagrees with the goals or client’s proposed plan? This could happen, but collecting some evidence from the client’s life, or reviewing the history, or getting family or other collateral contacts involved, would be methods for addressing the conflict. With luck the client 4) experiences the therapist as “on my side” (both in the short-term and long-term sense, even if the client is only focused on short-term concerns), and that 5) the therapist seems like a respectable, honest, and genuine person.

From my perspective, addiction treatment should be considered psychotherapy, and these common factors should be the standard for that experience. We know that when these factors are minimized in psychotherapy, that psychotherapy is of limited or no benefit. I suggest that when these factors are minimized in addiction treatment, that treatment will be of limited or no benefit also.

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