Psychoanalytic approaches

Psychoanalysis, a psychotherapeutic approach to behavior change developed by Sigmund Freud and modified by his followers, has also offered an explanation of substance abuse. This orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesised specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing. Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction.

Historical approaches to substance abuse treatment

Disease model and twelve-step programs

The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displayed by addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network who can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939. These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological and legal grounds. Nonetheless, despite this criticism, outcome studies have revealed that affiliation with twelve-step programs predicts abstinence success at 1-year follow-up for alcoholism. Different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care.
Client-centered approaches

In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items in the therapeutic relationship could help an individual overcome any troublesome issue, including alcohol abuse. To this end, a 1957 study compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques per se. The authors note two-factor theory involves stark disapproval of the clients’ “irrational behavior” (p. 350); this notably negative outlook could explain the results.

A variation of Rogers' approach has been developed in which clients are directly responsible for determining the goals and objectives of the treatment. Known as Client-Directed Outcome-Informed therapy (CDOI), this approach has been utilized by several drug treatment programs, such as Arizona's Department of Health Services

Counseling

Traditional addiction treatment is based primarily on counseling. However, recent discoveries have shown those suffering from addiction often have chemical imbalances that make the recovery process more difficult.

Counselors help individuals identifying behaviors and problems related to their addiction. It can be done on an individual basis, but it's more common to find it in a group setting and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. They are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. It's very common to see them work also with family members who are affected by the addictions of the individual, or in a community in order to prevent addiction and educate the public. Counselors should be able to recognize how addiction affects the whole person and those around him or her. Counseling is also related to "Intervention"; a process in which the addict's family requests help from a professional in order to get this person into drug treatment. This process begins with one of this professionals' first goals: breaking down denial of the person with the addiction. Denial implies lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, besides of continuing the destructive behavior. Once this has been achieved, professional coordinates with the addict's family to support them on getting this family member to alcohol drug rehabilitation immediately, with concern and care for this person. Otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. An intervention can also be conducted in the workplace environment with colleagues instead of family.

Criminal justice

Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings. There are a number of ways to address an alternative sentence in a drug possession or DUI case; increasingly, American courts are willing to explore outside-the-box methods for delivering this service. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U. S. Constitution, mandating separation of church and state.

Pharmacotherapies

Certain opioid medications such as methadone and more recently buprenorphine (In America, "Subutex" and "Suboxone") are widely used to treat addiction and dependence on other opioids such as heroin, morphine or oxycodone. Methadone and buprenorphine are maintenance therapies intended to reduce cravings for opiates, thereby reducing illegal drug use, and the risks associated with it, such as disease, arrest, incarceration, and death, in line with the philosophy of harm reduction. Both drugs may be used as maintenance medications (taken for an indefinite period of time), or used as detoxification aids. All available studies collected in the 2005 Australian National Evaluation of Pharmacotherapies for Opioid Dependence suggest that maintenance treatment is preferable, with very high rates (79–100%) of relapse within three months of detoxification from LAAM, buprenorphine, and methadone.

Cognitive-behavioral therapy

Cognitive-behavioral therapy, which seeks to help patients to recognize, avoid and cope with situations in which they are most likely to relapse.

Multidimensional family therapy, which is designed to support recovery of the patient by improving family functioning.

Motivational interviewing, which is designed to increase patient motivation to change behavior and enter treatment.

Motivational incentives, which uses positive reinforcement to encourage abstinence from the addictive substance.

The Substance Abuse and Mental Health Services Administration has provided a list of programs and institutions that offer diverse treatments according to the age group, type of addiction and other aspects. Among these programs can be found: Partners for Recovery (PFR), Medication Assisted Treatment (MAT), Recovery Community Services Program (RCSP), and the National Center on Substance Abuse and Child Welfare (NCSACW).

Scientific research

Scientific research since 1970 shows that effective treatment addresses the multiple needs of the patient rather than treating addiction alone. In addition, medically assisted detoxification alone is ineffective as a treatment for addiction. The National Institute on Drug Abuse (NIDA) recommends detoxification followed by both medication (where applicable) and behavioral therapy, followed by relapse prevention. According to NIDA, effective treatment must address medical and mental health services as well as follow-up options, such as community or family based recovery support systems. Whatever the methodology, patient motivation is an important factor in treatment success.

For individuals addicted to prescription drugs, treatments tend to be similar to those who are addicted to drugs affecting the same brain systems. Medication like methadone and buprenorphine can be used to treat addiction to prescription opiates, and behavioral therapies can be used to treat addiction to prescription stimulants, benzodiazepines, and other drugs.

Types of behavioral therapy include: