Table of Contents

Overcoming Addiction: Contingency Management, Inpatient & Outpatient, More | Part 2

Welcome to the second part of the two-part series on recovery options for those suffering from substance abuse disorder. In the first article, we looked at detoxification, 12-step programs, Cognitive Behavioural Therapy, and Rational Emotive Behavioural Therapy, which are all excellent options. We will continue exploring these options here.

Contingency Management: Positive Reinforcement

Contingency Management (CM) leverages the principles of operant conditioning, where consequences drive behavior changes. The best example of operant conditioning comes from the animal world. When we train animals, we use food or treats to reward desired behavior. For those with addiction issues, this approach aims to build healthier habits and diminish reliance on substances.

CM is straightforward: rewarded behaviors are more likely to be repeated. CM involves monitoring substance use and providing rewards or incentives for drug-free urine samples, attending counseling sessions, or achieving other treatment goals. Depending on the specific program and setting, rewards can range from vouchers and prizes to cash incentives or privileges.

One of the main advantages of Contingency Management is its simplicity and immediate reinforcement, which can be particularly motivating for individuals struggling with addiction. The immediate gratification provided by CM contrasts with the often delayed and intangible benefits of sobriety, helping individuals maintain motivation during the challenging early stages of recovery.

Contingency Management programs typically follow a structured process:

Assessment and goal Setting: The process starts with assessing one’s substance use patterns. Once identified, meaningful rewards can be discussed and paired with clear, measurable goals. Common goals include maintaining abstinence, attending therapy sessions, or completing treatment-related tasks.

Monitoring and Verification: Regular monitoring, usually through urine tests or breathalyzers, verifies adherence to the established goals. The key is to have measurable goals that offer no room for misunderstanding of what it takes to achieve them. This objective monitoring ensures that providers base rewards on verifiable behaviors.

Reinforcement: When individuals meet the specified goals, they receive a reward. The type and frequency of rewards vary, but they always provide immediate positive reinforcement.
Adjustment and Maintenance: As the individual progresses, the CM program may adjust the frequency and type of rewards to sustain motivation and encourage continued adherence to treatment goals.

Contingency Management has been extensively studied and has shown effectiveness in various settings, including outpatient and inpatient programs, for a range of substance use disorders. Research indicates that CM can significantly reduce drug use, increase retention in treatment programs, and improve overall treatment outcomes. For example, studies have demonstrated that CM is particularly effective for individuals with stimulant use disorders, such as cocaine or methamphetamine addiction, where other treatments might be less effective.

When paired with other types of recovery approaches, CM can have a positive synergistic impact on recovery efforts. For example, combining CM and cognitive-behavioral therapy (CBT) can make for a more effective overall approach. Moreover, practitioners can tailor CM to different populations, including adolescents, pregnant women, and individuals with co-occurring mental health disorders.

Critics of CM argue that individuals may develop dependence on external rewards and doubt the sustainability of treatment gains once incentives are removed. However, proponents say CM fosters initial motivation and helps individuals create habits that can be sustained over time.

The goal is to reduce and then eliminate the rewards as the person begins to rely more on internal motivation and other forms of support.

In conclusion, Contingency Management offers a powerful and practical approach to treating substance abuse disorders. CM helps individuals build the motivation and habits necessary for long-term recovery by providing immediate and tangible rewards for positive behaviors.

Inpatient Treatment: Comprehensive Care

Inpatient therapy is a comprehensive and intensive approach to addressing substance abuse disorders. This treatment approach is also referred to as residential therapy, as it involves living round-the-clock in a treatment facility for some time.

Inpatient therapy is designed to provide a structured and immersive environment that fosters recovery, reduces the risk of relapse, and addresses the multifaceted nature of addiction. Due to the complexity of treating substance abuse disorders, some require a higher level of care. Inpatient therapy is particularly beneficial for individuals with severe or long-term addiction, those who have relapsed after previous treatment attempts, or those with co-occurring disorders.

Some people need to be removed from home and work environments, which hinders early recovery and allows them to focus entirely on healing without distractions. Inpatient therapy allows for an intense, dedicated period of time in a supportive and healing environment.

One primary advantage of inpatient therapy is the comprehensive nature of the treatment provided. Most facilities offer the following therapy options: individual counseling, group therapy, family therapy, and holistic approaches such as art therapy, meditation, and physical exercise.

The idea is to take a holistic view of addiction, addressing the mental, physical, and spiritual aspects of the disease. Most programs also provide family therapy, a critical support system for those seeking recovery. Addiction devastates both individuals and families, making family healing an essential part of the recovery process.

Inpatient therapy typically follows a structured daily schedule. Much of the time is spent on recovery-related activities, but there is ample time for reflection and individual healing. This structure helps individuals develop healthy routines and habits crucial for maintaining sobriety after leaving the facility.

Another key element is that people serve each other in various ways as a small community. This approach fosters a sense of camaraderie and support among residents who share similar experiences and challenges. It also gives the patients a sense of the fellowship support they will encounter if they choose to practice a 12-step program.

As noted in the previous article about the importance of seeking medical assistance during detoxification, inpatient therapy includes medical supervision when needed. Many individuals entering treatment may experience withdrawal symptoms, which can be severe and even life-threatening. Medical professionals in inpatient facilities monitor and safely manage these symptoms.

This medical oversight also allows for the management of any co-occurring mental health conditions. When depression or anxiety, for example, are diagnosed, the medical staff can help address those issues at the same time by building sessions into a tailored support plan.

Inpatient therapy is not without its challenges. This approach requires a significant time commitment. One can expect to spend 30 to 90 days or longer completing the process. This time can be a barrier for those with work, family, or financial obligations.

Additionally, as you can imagine, the cost of inpatient treatment can be substantial, as it involves the costs of housing and feeding people in the program. While many facilities accept insurance or offer payment plans to make treatment more accessible, it is still a financial commitment.

In conclusion, inpatient therapy is the most comprehensive approach to treating substance abuse disorders as it covers all aspects of early recovery in a compressed and focused manner.

Outpatient Treatment: Balancing Treatment and Daily Life

Outpatient therapy is an alternative to inpatient therapy when appropriate. Unlike inpatient therapy, outpatient therapy allows individuals to receive treatment while continuing to live at home. They can also maintain their jobs and other daily responsibilities while participating.

People with less severe addictions, who have already completed an inpatient program, or individuals who cannot commit to a residential program due to personal, professional, or financial constraints are ideal for this treatment approach.

Outpatient therapy can vary in intensity, from low-intensity programs that require a few hours per week to intensive outpatient programs (IOPs) that involve several hours of therapy multiple days a week. Outpatient therapy typically involves all of the same therapy options except medically supervised detoxification.

Both individual and group therapy are often involved. Individual counseling sessions allow for intense individualized work, while group therapy sessions offer peer support as part of the process. Family therapy helps address any family dynamics that may contribute to the addiction and works to improve communication and support within the family unit.

Outpatient treatment programs often use Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Motivational Interviewing (MI). CBT focuses on modifying negative thought patterns, DBT emphasizes emotional regulation, and MI enhances motivation by helping individuals set and achieve realistic goals. These therapeutic approaches prepare individuals to maintain sobriety through new skills and strategies.

One of the strengths of outpatient therapy is its focus on real-world application. Participants go out every day and apply what they have learned most recently in their sessions, and they can report back on their progress in future sessions to adjust their thoughts and behaviors accordingly.

The challenge with outpatient therapy is that, without a controlled environment, participants have greater access to substances and are exposed to triggers that may have fueled their addictions. Because of these factors, this type of therapy requires a significant personal commitment to the process. It also relies heavily on family involvement and peer support to be successful.

Outpatient therapy is more affordable than inpatient treatment, as it does not include the expenses associated with residential care. Many outpatient programs accept insurance, and some charge income-based fees, making them more financially manageable for many individuals.

In conclusion, outpatient therapy provides a flexible and practical approach to treating substance abuse disorders. With individuals receiving treatment and continuing to live at home, the therapy allows real-world application of learning in everyday life.

Aversion Therapy: Associating Negative Consequences

Aversion therapy is a behavioral treatment approach used to address substance abuse disorders by associating negative stimuli with addictive behavior. The goal is to create a strong aversion to the substance, making its use undesirable and uncomfortable for the individual. This therapy applies classical conditioning principles by pairing an unwanted behavior (substance use) with an unpleasant stimulus to reduce or eliminate it.

In aversion therapy, the unpleasant stimulus can be a variety of things, such as a mild electric shock, a bitter taste, or a nausea-inducing drug. For example, someone struggling with alcohol addiction might take disulfiram (Antabuse), a medication that causes severe nausea and vomiting upon alcohol consumption.

The idea is that with continued use of the medication, a person associates the unpleasant physical reactions with alcohol consumption. They choose not to drink rather than experience the negative consequences. There are multiple steps involved in the process:

Assessment: The process starts with assessing one’s substance use patterns. Once identified, the therapist can determine the best medication to trigger the appropriate aversion.

Conditioning Sessions: During these sessions, the individual is exposed to the substance while simultaneously experiencing the aversive stimulus. These are controlled sessions done multiple times to introduce one to the consequences of drinking while on the medication.

Follow-up and Reinforcement: To prevent relapse, there must be ongoing support and reinforcement as it is not always practical, and some participants choose to drink and suffer the consequences. When coupled with other treatment options, it can become more effective than using it as the only treatment the person receives.

Aversion therapy has more than its share of criticisms and limitations. This approach can be distressing and uncomfortable for the individual, and some question its long-term effectiveness. It also requires significant oversite by a trained profession to ensure the safety and effectiveness of the plan.

In conclusion, aversion therapy offers a potentially practical approach to treating substance abuse disorders by creating negative consequences with substance use. Combining Aversion Therapy with other techniques can also be effective.

Going Cold Turkey: High Risk, Low Success Rate

When someone is going to try to quit using substances “cold turkey,” they mean they are going to stop all use of addictive substances immediately. This approach ignores gradually reducing use over time or seeking any medical assistance. While willpower alone is generally insufficient to keep most substance abusers in recovery, there are exceptions.

The hardest part of cold turkey is there will be withdrawal symptoms within 24 hours, anywhere from mild discomfort to severe physical and psychological distress. The symptoms will escalate to nausea, tremors, sweating, and intense cravings. Some individuals will sign up to weather the consequences as they seek a quick solution.

The worse the active addiction was, the worse this process was going to be. Medical-assisted detoxification uses various medications to reduce the severity of withdrawal symptoms. Given the potential level of unpleasantness, it requires significant determination to take on detoxification cold turkey. The person must have a dedicated support network as they can be incapacitated for several days.

Detoxing from some substances like alcohol and opioids can have severe withdrawal symptoms that can become life-threatening. Medical professionals strongly recommend being supervised during this process.

In conclusion, the cold turkey approach can work for some; however, it is a high-risk undertaking with limited success relative to other approaches to recovery. Understanding the risks and having a solid support network is crucial for those considering this method.

Conclusion: Finding the Right Path

We have considered many options, which can be overwhelming. If you are unsure which approach might be a good fit, it is worth discussing with your family doctor. They will typically have connections with recovery professionals and can give you a referral.

Many addiction treatment options are available, and the right one is waiting to be pursued. Exploring these options is the first step towards a healthier, addiction-free life. If you need further help trying to identify your best solution, plenty of resources are below, and checking with your family physician is always a good start.

Resources

National Institute on Drug Addiction – Home Page

Alcoholics Anonymous – Home Page

Narcotics Anonymous – Home Page

Detoxification – National Library of Medicine

Cognitive Behavioral Therapy Article – Mayo Clinic

Rational Emotive Behavioral Therapy – Psychology Today

Written By Tony Harte

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Your Addiction Recovery Journey: Understanding Detox and Therapy Approaches

This article is the first of two describing programs and approaches to addressing addiction issues. In it, we will discuss the importance of safely detoxifying our bodies after prolonged and excessive substance use. Then, we will discuss the three popular approaches to achieving recovery: 12-step programs, Cognitive Behavioural Therapy, and Rational Emotive Behavioural Therapy.

We are among the lucky ones. Modern-day living offers immense options for those who have an addiction. Before the 40s and 50s, extreme measures like being institutionalized in sanitariums with poor patient treatment, electric shock therapy, and lobotomies were considered addiction treatment; we now have access to a variety of proven addiction treatment options.

Luckily, we now have many humane addiction treatment options to consider. Key factors in selecting an approach to addressing addiction include the type and severity of the addiction, one’s overall health, and personal preferences. Combining multiple methods, like a 12-step program with individual therapy, proves particularly effective.

First Step: The Importance of Detoxification

There are two main areas to address if one wants to overcome an addiction. The physical body is the first to suffer, experiencing significant impacts from heavy and prolonged substance abuse. Heavy use of substances like alcohol, heroin, or painkillers, the body itself develops a dependency in addition to the psychological factors involved in addiction. Anyone with a long history of use must seek medical help before attempting to stop the use of these substances.

Importantly, going through detoxification and experiencing withdrawal from certain chemicals can be life-threatening and requires professional medical care for a safe cessation. This is not a question of whether one should seek medical assistance or not; life is at stake. Detoxification, the process of freeing your body of chemicals, is the initial step in addressing the emotional and other underlying factors driving addictive behavior.

Physical withdrawal symptoms during detoxification can include a range of issues such as headaches, low energy, shaking, fever, nausea, diarrhea, a runny nose, abdominal cramps, and muscle and bone pain. How severe these symptoms are often depends on the length of time, frequency, and volume of substances consumed.

Additionally, psychological symptoms may encompass intense cravings, anxiety, depression, brain fog, mood shifts, irritability, confusion, and insomnia. Those with advanced symptoms may experience delirium, hallucinations, or even seizures.

Exploring Various Addiction Treatment Options

Now, let’s consider the variety of treatment options available to those suffering from substance abuse disorder. This overview provides a sense of the traditional methods studied and proven effective for a measurable portion of people. There are many other options to discover, but they are less well-known.

12-Step Programs: A Community Approach

12-step programs have developed into one of the most enduring and practical approaches. These programs, rooted in mutual support and spiritual growth, provide a structured framework for individuals seeking recovery.

Bill Wilson and Dr. Bob Smith created the 12-step model in the 1930s, first introducing it through Alcoholics Anonymous (AA). The program has its roots in one alcoholic helping another. They found that one who has alcoholism was far more likely to listen to a fellow traveler who has found a solution than to the medical or religious communities.

Their goal was to offer a reliable support system for people struggling with alcoholism, and they discovered that helping one another benefitted and supported both the helping and the helped.

The success of AA led to the development of various other 12-step programs, such as Narcotics Anonymous (NA), Cocaine Anonymous (CA), and Al-Anon, which support friends and family members of those with addiction issues. These programs have collectively helped millions of individuals around the world.

Central to the 12-step philosophy is the belief in a higher power and the concept of surrender. Typically, people do not enter a 12-step program until their lives have become unmanageable due to their substance use. The program encourages participants to acknowledge their powerlessness over addiction and seek guidance from a higher power, interpreted in various ways based on personal beliefs.

The 12 steps are developed as a guide to living without the crutch of substances that leads to personal growth and healing. They begin with admitting powerlessness over addiction and recognizing one’s life’s unmanageability. Many consider this admission the first and most critical step. Without this step, there is no foundation upon which to build.

From there, individuals progress through steps that involve taking a moral inventory, making amends for past wrongs, and continuing personal reflection. The final steps focus on maintaining spiritual growth and helping others who are struggling with substance abuse disorder. Helping others is the power that turns the wheels on the cycle of recovery and support.

Attending Meetings is a core component of 12-step programs. Meetings occur in nearly every major city and most small towns, from early morning to late night. At meetings, people in the program gather to share their experiences, strengths, and hopes, which is a foundation of the program. Passing along the gifts one receives in recovery supports newcomers and reinforces lessons learned for those longer in recovery.

A potent component of the program is sponsorship. Experienced members, known as sponsors, pair with new members to provide guidance and hold the newcomer accountable. Sponsors are like personal coaches available to the newcomer anytime between meetings. This one-on-one mentorship benefits both individuals and is a lifeline for the newcomer, who will one day become a sponsor.

Many reject 12-step programs due to their spiritual aspect; however, they are designed to be inclusive and open to people of all faiths and backgrounds. A higher power is a personal decision, so people are free to define their higher power so it resonates with them. This adaptability has contributed to the worldwide success of 12-step programs.

To summarize, 12-step programs offer a structured design for living to help people escape their reliance on substances to deal with life’s issues. For a decade, countless people have benefited from 12-step programs of all varieties, which have transformed countless lives. The 12 steps combine personal accountability, spiritual growth, and community support to achieve sobriety.

Cognitive Behavioral Therapy (CBT): Reframing Thoughts

Cognitive Behavioral Therapy (CBT) is a popular and effective therapeutic approach for addressing substance abuse disorders. Born from cognitive psychology, CBT focuses on isolating negative thought patterns and behaviors that drive addiction and then taking a structured approach to modifying the thoughts and behaviors. The aim is to develop healthier coping mechanisms and foster resilience.

CBT was developed in the 1960s by psychiatrist Aaron Beck. He observed that emotional and behavioral problems have their root in distorted thinking by the person with substance abuse issues. Beck’s pioneering work laid the foundation for CBT, which combines cognitive and behavioral techniques to modify distorted thinking.

In CBT, thoughts, feelings, and behaviors are interconnected, and a holistic approach is needed to achieve long-term change. Unaddressed, harmful, or irrational thoughts lead to unproductive behaviors and emotions that drive addiction.

For example, an individual struggling with substance abuse might have automatic thoughts such as “I can’t cope without using” or “I’m a failure.” These distorted thoughts reinforce the desire to use substances as a way to escape or numb these negative feelings.

CBT’s goal is to guide people in challenging these distorted thoughts and replacing them with more realistic and positive ones. This is referred to as the cognitive restructuring process and involves several key techniques:

Cognitive Restructuring involves identifying irrational or harmful thoughts and reframing them more positively and realistically. For example, changing the thought “I can’t handle stress without drinking” to “Drinking will not help manage my stress long term. I have better alternatives.”

Behavioral Activation: We can reduce our reliance on substances when we engage in activities that promote positive feelings. These activities include exercise, writing, meditation, hobbies, or anything we enjoy.

Exposure Therapy: Exposure therapy functions like a vaccine, gradually exposing individuals to triggers in a controlled environment to help them confront and overcome their fears. The inability to deal with conflict may drive someone to use substances to cope. A therapist may role-play with the person, introducing them to different forms of conflict. The controlled experiences reduce the power of the triggers.

Skills Training: CBT also focuses on teaching practical skills to manage cravings, cope with stress, and navigate social situations without resorting to substance use. These skills can include problem-solving, assertiveness training, and relaxation techniques.

Therapists deliver skills training over 12 to 24 weeks of the program. Someone can sign up for individual or group therapy, making it a flexible option for many individuals. This collaborative process involves the therapist and the individual to foster a sense of ownership and empowerment in the recovery process.

Many substance abuse disorders involve co-occurring mental health conditions. Depression and anxiety are common issues with those suffering from a substance abuse disorder. People can address the symptoms of various problems in the same setting using this holistic approach.

In conclusion, Cognitive Behavioral Therapy offers a straightforward and structured approach to overcoming substance abuse disorders. By directly addressing and modifying distorted thinking, a person effectively breaks the cycle of addiction. CBT is a well-researched and proven approach to treating addiction issues.

Rational Emotive Behavioral Therapy (REBT): Tackling Irrational Beliefs

Rational Emotive Behavior Therapy (REBT) is another cognitive-behavioral approach that has proven effective in addressing substance abuse disorders. Psychologist Albert Ellis developed REBT in the 1950s. This therapy proposes that our emotional and behavioral responses are driven not by events but by our beliefs about them.

This therapy involves challenging and dispelling irrational beliefs to help people develop healthier thinking patterns and behaviors. REBT posits that external circumstances do not directly lead to emotional distress and maladaptive behaviors but rather the interpretations and beliefs about these circumstances.

The ABC model of REBT encapsulates this concept where:

A Stands for Activating Event,

B represents Beliefs about the event and

C denotes the Consequences, which include emotional and behavioral responses.

For example, an individual might experience a stressful situation (A) and believe (B) that they cannot handle the stress without using substances. The irrational belief leads to the use of substances, and they experience the consequences (C). The approach identifies and disputes these irrational beliefs (B) and replaces them with more rational and constructive thoughts, resulting in healthier emotional and behavioral outcomes (C).

A person with addiction may resort to absolutist thinking. “I must be perfect,” “I should always be happy,” or “I can’t stand discomfort” are all examples of absolutist thinking. These thoughts are not rational and destructive. When the person inevitably fails to meet these expectations, they may return to substance abuse as a coping mechanism.

The goal is to challenge beliefs and reframe a person’s thinking to develop better-coping mechanisms than substance use. This process is referred to as cognitive Restructuring. We will review the different approaches involved in this method.

Disputation of Irrational Beliefs: This involves questioning the validity and utility of irrational beliefs. For example, if an individual believes “I can’t handle stress without drugs,” the therapist might ask, “What evidence do you have that you can’t manage stress in other ways?” This process helps individuals see the flaws in their thinking and develop more rational alternatives.

Cognitive Reframing: Once individuals identify irrational beliefs, they replace them with rational ones. For instance, “I can’t handle stress without drugs” can be reframed to “I can manage stress in healthier ways, and using drugs is not the only solution.”

Behavioral Techniques: Therapists often use stress management techniques, problem-solving skills, and controlled exposure to substance-use triggers to help individuals change their behavior. Developing and practicing these techniques reinforces new thinking patterns, eliminating the need to use substances to deal with situations.

Emotional Regulation: For those suffering from addiction, managing their emotions is a significant challenge. The use of mindfulness and relaxation exercises helps individuals manage their feelings. The sessions require full participation as the exercises require action and interaction to be successful.

In conclusion, Rational Emotive Behavior Therapy offers a robust and practical approach to treating substance abuse disorders. By focusing on changing irrational beliefs and developing healthier thinking patterns, taking this approach empowers individuals to break free from the cycle of addiction and build a more resilient and fulfilling life.

Its evidence-based techniques and emphasis on personal responsibility make it a valuable tool in the journey toward recovery. For those seeking a structured and empowering method to address substance abuse, REBT provides a pathway to lasting change and emotional well-being.

Conclusion

This article has laid the foundation for understanding three popular approaches to addressing addiction issues. We also covered how critical it is to take the detoxification period seriously and to seek medical advice and assistance before completely abstaining from substance use.

Part two of this series will cover the contingency management approach, inpatient treatment, outpatient treatment, and aversion therapy. We will also cover “cold turkey” as a method. While it is a dangerous and low-success rate approach, it is an important option to understand.