THERAPY FOR SUBSTANCE USE DISORDERS

Presented By: Shreya Mitra

Supervised By: Ms. Pallavi Majumder

INTRODUCTION

Overview of Substance Use Disorders (SUDs)

Disorders due to substance use include disorders that result from a single occasion or repeated
use of substances that have psychoactive properties, including certain medications. The essential
feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological
symptoms indicating that the individual continues using the substance despite significant
substance-related problems.
Of note, the consumption of substances, including prescribed medications, may depend in part on
cultural background, substance availability, and specific local drug regulations. Thus, there can
be significant local or cultural variation in exposure (e.g., countries with cultural prohibitions
against alcohol or other substance use may have a lower prevalence of substance-related
disorders).
An important characteristic of substance use disorders is an underlying change in brain circuits
that may persist beyond detoxification, particularly in individuals with severe disorders. The
behavioral effects of these brain changes may be exhibited in the repeated relapses and intense
drug craving when the individuals are exposed to drug-related stimuli. These persistent drug
effects may benefit from long-term approaches to treatment.

Epidemiology: According to the Ministry of Social Justice and Empowerment’s recently

released report on the “National Survey on Extent and Pattern of Substance Use in India” (2019),
the magnitude of substance use is:
●​ 16 crore people (14.6%) between the age of 10 and 75 years are current users of alcohol,
and out of them, 5.2% are alcohol dependents.
●​ About 3.1 crore individuals (2.8%) are cannabis users, and 72 lakh (0.66%) people suffer
from cannabis problems.
●​ Overall opioid users 2.06% and nearly 0.55% (60 lakh) require treatment services/health
●​ 1.18 crore (1.08%) are current users of sedatives (non-medical use).
●​ 1.7% of children and adolescents are inhalant users as compared to adults of 0.58%.
Nearly 18 lakh children need help for inhalant use.
●​ It is estimated that about 8.5 lakh people are injecting drugs (PWID – people who inject
drugs)

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Changes in Classification of Substance Use Disorders

1.​ DSM-5-TR vs DSM-5: The DSM-5-TR (Text Revision of DSM-5) published in 2022 did
not make major structural changes to the diagnostic criteria for Substance Use Disorders
(SUDs). However, the most important update is that there are a few notable updates:
●​ Clarification of Terminology: Some terms have been updated for greater cultural
and linguistic sensitivity, though the 11 core diagnostic criteria for SUDs remain
the same.
●​ Updated Textual Descriptions: Epidemiological data and diagnostic features for
different substances (e.g., cannabis, opioids) were revised to reflect current trends
and research.
●​ Inclusion of New Substance Examples: E.g., synthetic cannabinoids and other
emerging drugs are more thoroughly described.
Importantly, DSM-5 had already combined the previously separate categories of
"Substance Abuse" and "Substance Dependence" into a single continuum under
Substance Use Disorder, with specifiers for severity (mild, moderate, severe)—and this
classification continues in DSM-5-TR.

2.​ ICD-11 vs ICD-10: The ICD-11, adopted by the WHO in 2022, introduced more
substantial changes to the classification of SUDs compared to ICD-10:
●​ Broader Category Name: ICD-11 uses the term "Disorders due to substance use
or addictive behaviours", which reflects the inclusion of non-substance-related
disorders like Gaming Disorder (newly added).
●​ Simplified Structure: ICD-10 categorized substance disorders into acute
intoxication, harmful use, dependence syndrome, withdrawal state, etc. ICD-11
consolidates these into a core diagnosis of ‘Substance Dependence’, with
specifiers for harmful pattern of use, intoxication, withdrawal, etc., making it
more streamlined and flexible.
●​ Harm to Others: ICD-11 introduces the concept of "harm to others" (not just
self), which may be considered when diagnosing harmful substance use.
●​ Dimensional Approach: Similar to DSM-5, ICD-11 reflects a more
continuum-based model, although not as explicitly severity-tiered as DSM-5.

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 NEUROBIOLOGICAL CORRELATES

Neurocircuitry of Addiction

Conceptualization of addiction as a three-component cycle consisting of a binge/intoxication

stage, a withdrawal/negative affect stage, and a preoccupation/anticipation (craving) stage has
allowed identification of key neurocircuits (but with the recognition that brain networks interact
with one another) that underlie addiction to alcohol and many other drugs (Koob and Volkow
2010):

1.​ The binge/intoxication stage (mediated by neurocircuitry of the basal ganglia) reflects
the rewarding effects of drugs and the ways in which drugs impart motivational
significance to cues and contexts in the environment, termed incentive salience, which is
experienced as “well-being,” “high,” “euphoria,” or “relief,” depending on the degree of
tolerance to the rewarding effects of the drug. This stage begins the process of developing
pathological habits that contribute to addiction. Reinforcing effects of drugs may engage
associative mechanisms and reward neurotransmitters in the nucleus accumbens (NAc)
shell and core and then engage stimulus-response habits that depend on the dorsal
striatum (DS). Two major neurotransmitters that mediate the rewarding effects of drugs
of abuse are dopamine (DA) and opioid peptides. Drugs of abuse, despite diverse initial
actions, produce some common effects on the ventral tegmental area (VTA) and the NAc.

2.​ The withdrawal/negative affect stage (mediated by neurocircuitry of the extended

amygdala and the habenula) reflects the enhanced sensitivity and recruitment of brain
stress systems and the loss of reward and motivation, termed a negative emotional state,
which is experienced as dysphoria, anhedonia, and irritability.

3.​ The preoccupation/anticipation (“craving”) stage (mediated by neurocircuitry of the

prefrontal cortex) reflects impulsivity and the loss of control over drug taking, termed
loss of executive control, and the input from the default mode network that reflects the
enhanced interoceptive awareness of the desire for the drug, which is experienced as drug
craving.

ASSESSMENT

In the most recent Practice Guidelines for the Psychiatric Evaluation of Adults, the American
Psychiatric Association (2016) recommends that the initial psychiatric evaluation of a patient
include an assessment of the patient’s use of tobacco, alcohol, psychoactive substances,

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prescribed medications, and any other supplements. In contrast to screening, which is designed to
quickly identify risky patterns of substance use, a comprehensive assessment firmly establishes
where on the continuum of substance use the patient falls—use, misuse, excessive use, or
substance use disorder. This information will then add to the development of an appropriate and
evidence-based treatment plan that fits the proper level of care.
In general, the basic components of a substance use assessment include 1) describing current and
past patterns of substance use with an emphasis on characterizing use that may be excessive,
harmful, or hazardous; 2) diagnosing any substance-related disorder that may be present
currently; and 3) documenting the effect of substance use on an individual’s mental and physical
state. Understanding the patient’s readiness to change, determining the presence of co-occurring
psychiatric disorders, documenting medical history, performing a physical examination and
laboratory tests, exploring the presence of substance use disorder in the patient’s family, and
conducting a review of social factors are also parts of the substance use assessment (Dugosh et
al. 2017).
Various structured and semi-structured tools are available, each with distinct strengths and
constraints. Some of these are highlighted below:

Tool Target Advantages Limitations

Alcohol Use Screening for Brief and easy to Alcohol-specific; not

Disorders hazardous and administer, for other substances,
Identification Test harmful alcohol Culturally validated Self-report bias
(AUDIT) consumption globally, possible
Detects early risky
drinking

Drug Abuse Drug use excluding Quick screening for Lacks specificity for
Screening Test alcohol and tobacco various drugs, types of substances,
(DAST) Available in short and Self-report limitations
full versions

Addiction Severity Semi-structured Comprehensive Requires trained

Index (ASI) interview covering 7 multidimensional interviewers,
domains (e.g., assessment, Lengthy (up to 1
medical, Useful for treatment hour)
employment, drug planning and research
use, family)

Structured Clinical Diagnosis of SUD per Gold standard for Requires clinical
Interview for DSM-5 DSM-5 criteria diagnosis, expertise,
(SCID-5) Covers comorbid Time-intensive
psychiatric disorders

Timeline Daily substance use Detailed usage Cognitive recall bias,

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 Follow-Back (TLFB) over a specified patterns, Time-consuming for
period Flexible time frame longer intervals

CRAFFT Screening Adolescents at risk of Brief, Limited to risk

Tool (for substance-related adolescent-friendly, screening,
Adolescents) problems High sensitivity Does not provide
diagnosis

Urine Drug Screening Detect presence of Objective data, Invasive, privacy

(UDS) & Biological substances in bodily Useful for validation concerns,
Measures fluids of self-reports Limited detection
window for some
substances

Allied testing nay be done depending on the comorbidities and existing complications. These
may include Neuropsychological Assessment Tools (for example, AIIMS Battery, NIMHANS
Battery, PGIBBD), tools to assess affective disturbance (for example, BDI), and psychotic
symptoms (for example, BPRS).

THERAPY

Broad Goals of Therapy

1.​ Achieving and Maintaining Abstinence: This is often a primary goal, especially in the
early stages of recovery. For many, this means complete abstinence from the substance of
abuse, although some may be maintained on medication-assisted treatment like
methadone. The focus is on helping individuals stop using substances and developing
strategies to stay clean.
2.​ Developing Healthy Coping Mechanisms: Therapy helps individuals learn new ways to
manage cravings, triggers, and negative emotions without resorting to substance use. This
includes identifying and practicing healthy coping skills like exercise, mindfulness, or
relaxation techniques.
3.​ Preventing Relapse: Relapse is a common part of the recovery process, and therapy
aims to help individuals understand and manage the risk of relapse. This involves
identifying personal relapse triggers, developing relapse prevention plans, and practicing
strategies to avoid high-risk situations.
4.​ Improving Overall Well-being and Functioning: Therapy can help individuals improve
their physical and mental health, as well as their relationships and overall quality of life.
This includes addressing any co-occurring mental health conditions, such as depression
or anxiety, and improving social and vocational functioning.

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 5.​ Addressing Co-morbidities and Underlying Issues: Substance use often stems from
deeper issues, and therapy can help individuals explore and resolve these underlying
problems. This may involve exploring past trauma, dysfunctional family patterns,
psychiatric comorbidities that emerge from SUDs or negative thought patterns that
contribute to substance use.
6.​ Family Involvement: In some cases, family therapy or support groups may be
incorporated to address the impact of substance use on the family system and to help
family members develop healthy coping strategies.
7.​ Developing a Support System: Therapy helps individuals build a strong support system
of peers, mentors, or sponsors who can provide ongoing support and encouragement in
recovery.

Psychodynamic Psychotherapy

From this perspective, addiction can be considered a special adaptation by which, in the short
term, individuals prone to substance use disorders attempt to alleviate or compensate for their
dysregulation disturbances, a solution that ultimately fails. More often than not, psychodynamic
treatment is not provided as a stand-alone treatment. Combining psychodynamic treatment with
group treatments and medication-assisted treatments has been essential to establishing control
over addictive behavior. Some of the common areas of focus include:

Affect Regulation: Depending on what feelings or affects cause their difficulty, individuals who
begin using substances discover what drug suits them best through experimentation. For
example, for individuals who are anhedonic or feel empty, the activating, enlivening, and
stimulating properties of cocaine or amphetamines are experienced as welcome, whereas for
individuals who are unsettled or overwhelmed by intense or threatening feelings, opioids or
obliterating doses of alcohol act as correctives (Khantzian 1997).
Therapists can help these patients to access their feelings by using approaches that are more
interactive, such as labeling feeling states, drawing out patients’ experiences of their feelings,
and so on. By asking patients, “What did this drug do for you when you first used it?” therapists
can help patients to identify the troubling and/or painful affects that determine their drug of
choice (Khantzian 2012). Patients with substance use disorders make it amply clear that
short-term substances of abuse produce relief from confusing and threatening feelings, but it
readily becomes apparent that addictive drugs perpetuate and heighten their suffering and
distress. Although patients seem to passively endure these consequences as a trade-off for the
relief addictive drugs provide, formulations by Gedo (1986), Lichtenberg (1983), and Khantzian
and Wilson (1993) suggest that this repetitious aspect of addictive behavior represents attempts
to work out early childhood pain and suffering for which there are no words, memories, or
mental representation. Thus, the operative changes from relieving suffering to controlling it
(Khantzian 1997).

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Self-Esteem Regulation: Kohut’s (1971, 1977) development of self psychology was
groundbreaking in that it provided an understanding of the troubled sense of self and damaged
self-esteem that result from faulty parenting and empathic failure in early phases of childhood
development. Kohut emphasized how such empathic failures resulted in a disrupted sense of
inner harmony, poor self-cohesion, and unending feelings of disease. Although Kohut did not
systematically study and treat substance use disorders, he appreciated how individuals with these
disorders suffer in this respect and how they adopt defensive postures of counterdependency,
bravado, and invincibility to mask feelings of emptiness and inadequacy. Subsequent
investigators have pursued how such disturbance plays out with substance use disorders,
emphasizing feelings of powerlessness and unimportance as well as compensatory reactions of
narcissistic rage and grandiosity (Director 2005; Dodes 1996, 2002).
These dynamics suggest the need for clinicians to see through the defensive posturing as they
engage with patients who struggle with substance use disorders and who endure the fragile sense
of self that they defend against, and to be prepared to employ individual and group
psychotherapies to understand and work on the patients’ defenses and underlying vulnerabilities.

Interpersonal Regulation: The troubled and troubling sense of self and self-esteem play out
powerfully in the interpersonal relationships of individuals with substance use disorders. In
contrast to early psychoanalytic formulations that focused on pathological dependency,
contemporary psychodynamic views have focused on problems of isolation and
counterdependence (Khantzian, 1995). Early life experiences with traumatic abuse and neglect
have an impact on self structures and play out later in life in an inability to allow or express
wishes for connection, affection, and comfort from others, which these individuals so desperately
need but cannot accept or dare. As a result, relational cutoff and loneliness become a tragic way
of life, leading some individuals to substitute addictive solutions in place of human ones.
Explorations of these early attachment issues help patients and clinicians to understand how such
adaptations cause addiction-prone individuals to develop a substance use disorder to deal with
the distress and the pain-perpetuating defenses of spurious self-sufficiency, disavowal of need,
and counterdependence (Flores 2004; Khantzian 2012; Walant 2002; Weegmann and Cohen
2002).

Self-Care Regulation: Early psychoanalytic theorists attributed human self-destructiveness,

including dependency on substances, to impaired survival instincts and self-destructive drives
(Menninger 1938). Later theorists suggested that this behavior may be more the result of a
developmental failure in protective ego and self functions than of impaired survival instincts
(Khantzian and Mack 1983). The development of the ego capacity for self care is crucial for
ensuring safety, control of impulses, and a sense of well-being (Khantzian and Mack 1983).
Deficits in this function may cause addiction-prone individuals to succumb to the dangers of
behaviors leading to substance use disorders and the hazards of experimentation with and
continuous use of addictive substances. In comparison with people without substance use

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problems, individuals with substance use disorders think and feel differently about potential risks
and harms (Khantzian 2012), especially those associated with addictive behavior. For example,
these individuals may be or are indifferent to their first experience of inserting a needle into their
own veins; they may experience little thought or emotion during injections. Tactfully, the
therapist can share with patients his or her own recoil from the idea of self-injection. The
clinician initially might consider that these failures and lapses were the function of regression
secondary to addictive processes. However, after working long term with patients who misuse
drugs, the clinician more often will better appreciate that such patients are constantly remiss or
neglectful in attending to daily requirements for medical or dental hygiene, attending to
necessary details of license renewals, paying insurance premiums, and performing other
important self-care tasks. These underdeveloped self-care capacities remain apparent in
long-term treatment even with abstinent patients who are in remission. These deficits in self-care
functions malignantly interact with painful affects and suffering associated with troubled self
states and interpersonal relationships to make addictive behavior more likely (Khantzian 1997,
2012).

Treatment Implications: The most important treatment advice for psychodynamic therapists and
psychoanalysts is that they are misguided and put themselves and their patients at risk if they
think that establishing control of or abstinence from unbridled use of alcohol or drugs can wait
on working out the dynamics of these disorders. The symptoms of substance use disorders can be
life-threatening, and in such cases, an initial focus on establishing control can be critical and
essential. Important interventions to help patients achieve control of or abstain from substance
use before commencing exploration of underlying dynamics include 12-step programs,
moderation management, relapse prevention strategies, group therapy, and rehabilitation
confinement. In fact, ongoing patient involvement in 12-step programs and psychodynamically
oriented group therapy can work in a complementary and beneficial way with individual
psychodynamic psychotherapy to support long-term control of or abstinence from substance use
(Khantzian 2014). Additionally, medication-assisted treatments such as methadone,
buprenorphine, and naltrexone can be invaluable in reducing or stopping uncontrolled use and
regulating the daunting problems of craving and the instability associated with the ravages of
chronic drug use (Khantzian 2018). These agents provide biological and emotional stabilization
that allow for psychotherapeutic treatment.

Behavioral Therapies

Aversion Therapy:
A widely used behavioral treatment for substance use disorders is aversion ­therapy, an approach
based on the principles of classical conditioning. Its objective is not to undo fear or revulsion but
to induce such feelings, specifically in relation to stimuli that trigger unwanted behavior. For

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example, alcoholics may be given a drug that causes prolonged and severe nausea and vomiting
or a drug that produces feelings of suffocation and terror. They are then told to smell and sip their
favorite drink. The idea is to condition the alcoholic to feel nausea or panic when exposed to the
sight, smell, or taste of the most tempting forms of alcohol. Aversion therapy has been used to
treat alcoholism more than it has to treat other substance use disorders.
Aversion therapy should not be confused with punishment. In punishment, the noxious event is
contingent on the individual's performing a certain response. In aversion therapy, the aim is to
condition unpleasant feelings in response to a stimulus. This distinction is made clear by two
kinds of drug treatment for alcoholism. As we noted above, in aversion therapy a sickness- or
fear-producing drug is paired with the sight, smell, and taste of alcohol. Just being around
alcohol makes the person feel ill or frightened; thus he or she avoids drinking. A punishment
(instrumental, or operant) approach involves giving people a drug that makes them sick only
after they have actually taken a drink; sickness is thus contingent on drinking. This kind of
therapy works in some cases because the punishment of being sick suppresses the drinking
behavior.
Another version of aversion therapy requires people with alcoholism to imagine extremely
upsetting, repulsive, or frightening scenes while they are drinking. The pairing of the imagined
scenes with alcohol is expected to produce negative responses to alcohol itself.

Implementation Considerations: A major problem with aversion therapy is that the conditioned
aversion responses extinguish unless conditioning sessions are repeated frequently. Theoretically,
we could achieve conditioning that would resist extinction, but the conditioning sessions would
have to be so extreme and so unpleasant that they would be ethically unacceptable. Those who
have seen the movie A Clockwork Orange will recall an example of the extremes to which
aversion therapy could be taken. In real life, though, aversion therapy is actually most useful in
conjunction with other therapies. It helps people avoid unwanted behaviors while other
therapeutic techniques are teaching them new, more adaptive responses. To "kick the smoking
habit," for example, some form of aversion therapy may help during the first brief period when
the going is toughest; then other approaches must be used to help people learn to live their daily
lives without cigarettes.

Contingency Management:
An operant behavioral perspective has been very useful in formulating effective strategies to treat
individuals with substance use disorders. In this view, drug seeking and drug taking are operant
behaviors reinforced by the immediate effects following from drug use, such as euphoria and
relief from withdrawal. Therefore, behavioral treatment strategies have focused on emphasizing
the positive outcomes following from drug abstinence, such as improved health and
relationships, which in the natural environment may be remote and uncertain. Contingency
management (CM) interventions make positive consequences for drug abstinence or other
desired behaviors more immediate, salient, and predictable. CM developers have turned to

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monetary-based reinforcers (including goods) because money is a universal reinforcer that can
successfully compete with drug reinforcers.
CM interventions are efficacious when applied to a variety of clinical populations and highly
relevant target behaviors. These target behaviors have included entry and engagement in
substance use disorder treatment, abstinence from drugs and alcohol, engagement with needed
health care, and adherence to prescribed medication. It is important to utilize effective
implementation methods when applying CM to promote positive behavior change.
Stimulant use has been a logical target of CM interventions in the absence of an efficacious
medication. Higgins et al. (1994) developed the first CM intervention to promote abstinence
from stimulants using drug-negative urine tests as an objective marker of recent drug use.
Reinforcers were vouchers (points exchangeable for retail goods) awarded for each
stimulant-negative urine sample obtained over a 12 week period of thrice-weekly urine testing.
The number of points awarded increased under an escalating schedule for each consecutive
negative urine sample and reset to the original low value when a urine result was missing or
positive. The total amount available—about $1,000 over a 12-week intervention— was designed
to be attractive to patients and to motivate behavior change. The voucher program was combined
with an intensive cognitive-behavioral counseling intervention based on the Community
Reinforcement Approach (Budney and Higgins 1998).
An alternative efficacious method for delivering CM relies on principles of intermittent
reinforcement and was developed with the intent of lowering implementation costs. The
prize-draw intermittent reinforcement approach is also called the “fishbowl method” because,
operationally, patients who meet criteria for incentive delivery (e.g., submission of a
stimulant-negative urine sample) earn draws from a bowl filled with chips or tickets. As in the
voucher program, the amount earned (in this case, the number of draws) escalates over
successive instances of the target behavior in order to promote sustained behavior change. In the
standard application, about half of the chips in the bowl indicate a prize win and the other half
indicate no win (“Good job”). Furthermore, there are three different prize levels: small (worth
about $1), large (worth about $20), and jumbo (worth about $100). The number of chips present
in the bowl is inversely related to prize value so that there is a much higher chance of winning
small than large prizes and only a very small chance of winning the jumbo prize. Cost of the
intervention depends on the value of prizes and the probabilities of winning; however, total prize
values of $240 or more over an 8-week intervention are needed for efficacy (Petry et al. 2004).

Implementation Considerations: An effective CM intervention requires contingent reinforcers

of sufficient magnitude and immediacy to affect behavior. Several studies (see, e.g., Lussier et al.
2006; Petry et al. 2012a) have demonstrated that a larger magnitude (i.e., the total amount
available) of reinforcement is associated with a higher likelihood of behavior change relative to
smaller magnitudes. In general, the largest feasible magnitude of reinforcer should be offered.
When the value of available reinforcers for reducing drug use drops too low (e.g., below an

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average of $30 per patient per week over the intervention duration), efficacy may be
compromised (Petry 2012; Petry et al. 2004).
It is also important that positive reinforcers be delivered as closely as possible to the time at
which the desired behavior is observed, which in the case of drug abstinence is immediately after
results of a negative drug test are obtained. One way to achieve such timely delivery is through
use of on-site urine testing, because results can be obtained in minutes rather than days. To
adequately detect recent drug use, especially in the case of short-acting drugs, testing should be
conducted at frequent (e.g., 2–3 times weekly) or unpredictable intervals. Furthermore, although
the simplest way to deliver CM is with a fixed value reinforcer given each time the behavior is
observed, it may be ideal to use an escalating schedule in which the reinforcer amount increases
as the duration of continuous abstinence increases over time (Budney and Higgins 1998; Higgins
et al. 1994). This strategy promotes sustained behavioral change because the value of remaining
abstinent increases with consecutive submissions of negative samples, while relapse is prevented
because earnings are reset to a lower value if a sample tests positive for the target drug(s).
As a general rule, it is advisable for CM interventions to be kept in place for as long as feasible,
because longer-duration interventions (e.g., 6 months or longer) are associated with better
outcomes (e.g., Kirby et al. 2013). Abrupt discontinuation at the end of a specified intervention
period has been associated with relapse, as would be the case in any chronic relapsing disorder.
Thus, gradual withdrawal schedules implementing low-value reinforcers may be advantageous to
reduce rates of subsequent relapse (Budney and Higgins 1998; Higgins et al. 1994). Given the
strong association between in- and post-treatment abstinence durations (e.g., Higgins et al.
2000), a novel but as yet untested strategy would be to keep incentives in place until the
individual has achieved a specified duration of abstinence (e.g., 6 months).

Cognitive-Behavioral Therapy

Cognitive-behavioral therapies conceptualize substance use disorders as complex,

multidetermined problems, with a number of influences playing a role in the development or
perpetuation of the disorder (Marlatt and Donovan 2005). These influences may include family
history and genetic factors; the presence of comorbid psychopathology; personality traits such as
sensation seeking or impulsivity; and a host of environmental factors, including substance/drug
availability and lack of countervailing influences and rewards. Although cognitive-behavioral
therapies primarily emphasize the reinforcing properties of substances as central to the
acquisition and maintenance of substance abuse and dependence, these etiological influences are
seen as heightening risk or vulnerability to the development of substance use problems. For
example, some individuals may find substances unusually highly rewarding secondary to genetic
vulnerability, comorbid depression, high sensation seeking, and modeling of family and friends
who use substances or environments devoid of alternative reinforcers.
Specific techniques vary widely depending on the type of cognitive-behavioral treatment used,
and there are a variety of manuals, protocols, and training programs available that describe the

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techniques associated with each approach (Carroll 1998; Monti et al. 1989). Very simply put,
however, most CBT approaches attempt to help patients to recognize the situations in which they
are most likely to use drugs or alcohol, to avoid those situations when appropriate, and to cope
more effectively with a range of problems and problematic behaviors associated with substance
use by implementing a range of cognitive and behavioral coping strategies.

Defining Features of CBT: Two key defining features of most cognitive-behavioral approaches
to substance use disorders are 1) emphasis on functional analysis of drug use (i.e., attempting to
understand drug use with respect to its antecedents and consequences), and 2) emphasis on
teaching and implementation of cognitive and behavioral control skills. Cognitive-behavioral
approaches include a range of skills for fostering or maintaining abstinence. These typically
include strategies for the following:
1.​ Understanding the patterns that maintain drug use and developing strategies for changing
these patterns. This often involves self-monitoring of thoughts and behaviors that take
place before, during, and after high-risk situations or episodes of drug use.
2.​ Fostering the resolution to stop substance use through exploring positive and negative
consequences of continued use (also known as the decisional balance technique).
3.​ Understanding craving and craving cues and developing skills for coping with craving
when it occurs These include a variety of affect regulation strategies (distraction, talking
through a craving, “urge surfing,” and so on).
4.​ Recognizing and challenging the cognitions that accompany and maintain patterns of
substance use.
5.​ Increasing self-awareness of the consequences of even small decisions (e.g., which route
to take home from work) and identifying “seemingly irrelevant” decisions that can
culminate in high-risk situations.
6.​ Developing problem-solving skills and practicing application of those skills to
substance-related and more general problems.
7.​ Planning for emergencies and unexpected problems and situations that can lead to
high-risk situations.
8.​ Developing skills for assertively refusing offers of drugs as well as for reducing exposure
to drugs and drug-related cues.

These basic skills are useful in their application to helping patients control and stop substance
use, but it is essential that therapists also point out how these same skills can be applied to a
range of other problems. Examples of acquired skills that can be generalized include the
following:

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When therapists are teaching coping skills, it is essential that they emphasize and demonstrate
that these skills not only can be immediately applied to control substance use, but also can be
extended into general strategies that can be applied to a wide range of situations and problems
the patient may encounter in the future.
Broad-spectrum cognitive-behavioral approaches, such as those described by Monti et al. (1989),
expand to include interventions targeted toward other problems in the individual’s life that are
seen as functionally related to substance use. These interventions may include general
problem-solving skills, assertiveness training, strategies for coping with negative affects,
awareness of anger and anger management, coping with criticism, increasing pleasant activities,
enhancing social support networks, and job-seeking skills, among others. In comparison with
many other behavioral approaches, CBT is typically highly structured—that is, CBT sessions are
generally brief and organized closely around well-specified treatment goals. Each session usually
has an articulated agenda, and the clinical discussion remains focused around issues directly
related to substance use. Progress toward treatment goals is monitored closely and frequently,
with frequent monitoring of substance use through urine toxicology screens, and the therapist
takes an active stance throughout treatment. Sessions generally take place within a weekly
scheduled therapy “hour.” In broad-spectrum cognitive-behavioral approaches, sessions are often
organized roughly into thirds (the 20/20/20 rule), with the first third of the session devoted to
assessment of the patient’s substance use and general functioning in the past week and reporting
of current concerns and problems, the second third being more didactic and focusing on skills
training and practice; and the final third allowing time for the therapist and the patient to plan for
the week ahead and to discuss how the new skills will be implemented (Carroll 1998). The
therapeutic relationship is seen as principally collaborative; thus, the role of the therapist is that
of consultant, educator, and guide who leads the patient through a functional analysis of his or
her substance use, assists in identifying and prioritizing target behaviors, and provides advice and
counsel in selecting and implementing strategies to foster the desired behavioral changes.
Although CBT is structured and didactic, it is a highly individualized and flexible treatment.
That is, rather than viewing CBT treatment as a cookbook “psychoeducation,” the therapist

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carefully matches the content, timing, and nature of the presentation of the material to the
individual patient. The therapist attempts to provide skills training at the moments the patient is
most in need of them. That is, the therapist does not belabor topics such as breaking ties with
drug suppliers with a patient who is highly motivated and has been abstinent for several weeks.
Similarly, the therapist does not race through material in an attempt to “cover” all of it in a few
weeks; for some patients, it may take several weeks to master a basic skill.

Empirical Support and Treatment Implications: CBT has been combined with other
empirically supported treatments for alcohol and drug use disorders, such as motivational
interviewing (MI) and contingency management (CM), as a strategy to bolster early treatment
engagement and adherence. Several studies have investigated the combination of CBT and MI
for various drugs of abuse, including amphetamines (Baker et al. 2005), cocaine (McKee et al.
2007; Rohsenow et al. 2004), methamphetamine (Bux and Irwin 2006), and marijuana (Babor
and Marijuana Treatment Project Research Group 2004; Dennis et al. 2004). Although the
findings have been mixed with respect to CBT’s additive effects on drug use outcomes, there is
some evidence to suggest that adding motivational enhancement therapy (MET) to the early
stages of CBT can be effective in increasing motivation and improving retention in treatment.
Also, given that CM has strong immediate effects on substance use that tend to weaken after the
contingencies are terminated (Prendergast et al. 2006), while CBT tends to have more modest
effects initially but is comparatively durable, there have been several investigations evaluating
various combinations of CBT and CM. Results have largely indicated that CM is associated with
better outcomes during the treatment period, but the combination of CM plus CBT may produce
greater rates of abstinence during the follow-up period (e.g., Budney et al. 2006; Epstein et al.
2003; Kadden et al. 2007; Petitjean et al. 2014; Rawson et al. 2006).

Motivational Interviewing and Motivational Enhancement Therapy

Introduction: Motivation is a key construct in behavioral medicine and is a particularly salient

issue in the treatment of SUDs (e.g., Higgins and Silverman 1999). Prochaska and Di-Clemente’s
(1983) transtheoretical Stages of Change model is a useful heuristic for understanding the
different cognitive-motivational-behavioral states that individuals demonstrate as they move
through the change process. Briefly, the model proposes five stages of change:
1.​ Individuals may not believe there is a problem with their behavior and may not see a need
to change (precontemplation stage).
2.​ As awareness of a problem increases, individuals may begin to weigh the pros and cons
of engaging in a specific behavior, a state often described as “ambivalence”
(contemplation stage).
3.​ When a state of ambivalence is resolved in the direction of making a change, individuals
may then begin to develop a change plan (preparation stage).
4.​ Individuals then embark on successive efforts to change the behavior (action stage).

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 5.​ The maintenance stage characterizes the ongoing efforts to keep momentum and reduce
the likelihood of reengaging in previous behavioral patterns (e.g., relapse).

Importantly, this model conceptualizes change as a nonlinear process, characterized by a

dynamic back and forth of motivational states as individuals move toward long-term shifts in
their behavior. This view differs from change being characterized as a unidirectional shift from
being “unmotivated” to being “motivated” and suggests that helping strategies should be
sensitive to an individual’s position in the change process.

Motivational Interviewing - The Clinical Approach:

MI has been defined as “a collaborative conversation style for strengthening a person’s own
motivation and commitment to change” (Miller and Rollnick 2013, p. 12). Clinicians focus on
increasing client “change talk”—verbal utterances focused on the client’s desire, ability, reasons,
or need to make changes, with the goal of increasing commitment statements toward the end of a
clinical interaction (remembered by the acronym DARN-C; Amrhein 2004). For providers, MI
can be conceptualized as a conversation about change that incorporates four key processes (i.e.
engaging, focusing, evoking, and planning). While guiding these processes, clinicians adopt a
therapeutic stance (i.e., the spirit of MI) to help clients feel comfortable and empowered to
explore their ambivalence about making changes. Additionally, a specific set of core therapist
skills is used to guide these processes throughout collaborative discussions that aim to bring forth
an understanding of the client’s perspective and to elicit and strengthen the client’s talk about
change (Miller and Rollnick 2013).

Relational Components of Motivational Interviewing: MI Spirit is the name given to the stance
taken by clinicians to convey an open attitude that will encourage clients to explore reasons for
change. It encompasses the relational components of MI and includes four dimensions:
●​ Partnership: The clinician takes a stance of active collaboration with the client that is in
the service of the client’s own goals. This stance includes conveying that clinician and
client are equals with different arenas of expertise that they are collaborating around. This
collaboration has been described as a dance with two partners working together and in
sync, rather than a wrestling match in which the clinician tries to force the client into
change (Miller and Rollnick, 2013).
●​ Acceptance: Acceptance in MI is based in Rogerian therapy concepts (Rogers, 1961) and
differs from the notion of approval. The clinician’s stance should convey a belief in the
client’s absolute worth, including future potential. It also includes support for the client’s
autonomy: the client’s power in making his or her own choices and the client’s
independence of thought. This stance is in opposition to a therapeutic stance in which the
clinician confronts the client and spells out why the client “must” change. Clinicians
strive for accurate empathy in interactions with each client, or try to understand each
client’s own unique reasons for change rather than imposing what they feel should be the

15
 client’s primary motivators for change. Finally, the clinician’s acceptance of the client is
demonstrated by the clinician’s affirmation of the client’s actual strengths and positive
efforts (Miller and Rollnick 2013).
●​ Compassion: The clinician displays ongoing compassion for the client, the client’s
welfare, and the priority of the client’s needs as a driving force and motivator of
therapeutic change (Miller and Rollnick 2013).
●​ Evocation: Throughout MI guided discussions, the clinician works to pull from the client
his or her own motivations and reasons for moving forward. This includes exploring the
client’s ambivalence about change and highlighting the client’s reasons for making
changes. It is important that clinicians avoid pushing their own reasons why clients
should change, because doing so is likely to undermine the MI process (Miller and
Rollnick 2013).

Core Skills of Motivational Interviewing: In the context of MI Spirit (i.e., a nonjudgmental and
accepting stance), clinicians utilize a set of core skills, which are captured by the acronym
OARS: open-ended questions, affirmations, reflections, and summary statements (Miller and
Rollnick 2013). These components make up the “technical skills” of MI work.
●​ Open-Ended Questions: Within an MI framework, the goal is to rely most heavily on
open-ended questions. Open-ended questions cannot be answered with a simple “yes” or
“no” and are designed to elicit from the client additional information, context, and room
for further exploration of ambivalence (Miller and Rollnick 2013). For example, the
closed-ended question “Have you been taking your medications?” can be rephrased as the
open-ended question “What has your experience been with medications since we last
met?”
●​ Affirmations: With the information gleaned through open-ended questions and
reflections, the clinician highlights the client’s strengths, efforts, abilities, and what has
been going well. This approach is meant to linguistically reinforce desires or efforts to
change that are consistent with the client’s goals. For example, the therapist might say,
“You’ve worked hard to take several days off from drinking in the last month and felt
really proud when you accomplished that” (Miller and Rollnick 2013).
●​ Reflections: Reflections in MI are strategic efforts by the clinician to guess at the client’s
meaning in a way that further focuses the conversation toward change. Clinicians choose
which components of a client’s utterances they want to reflect, and these choices provide
topics for further evocation and focusing of the session (Miller and Rollnick 2013).
Reflections can be either simple (e.g., the clinician provides a paraphrase of the client’s
words) or complex (e.g., the clinician guesses at the client’s additional meanings). As an
example, if the client says, “I went out with my friends and had a blast. I don’t remember
the entire night, though, and one of my friends hasn’t spoken to me since—I’m not sure
why.” A simple reflection from the therapist could be “You don’t remember the entire
evening.” This sticks fairly closely to what the client said, and directs the conversation

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 toward what the client might want to change about substance use. A complex reflection
from the same material could be “Substance use contributed to conflict with your friend.”
In this case, the clinician guesses the meaning and adds it to the reflection, in the hope of
moving the conversation forward toward exploring ambivalence and reasons for change.
Complex reflections are particularly associated with increased change talk by the client
(Magill et al. 2018).
●​ Summary Statements: Summary statements by the clinician allow further focusing of
the session (Miller and Rollnick 2013). The clinician can choose client utterances that
will highlight the prospect of change and that are most likely to move the conversation
toward the client’s committing to change. As an example, the clinician might say, “We’ve
discussed a number of items in the past 20 minutes. You at times black out when you
drink, and that can lead to your saying or doing things that bother others. You also don’t
like waking up feeling groggy after drinking.” The clinician in this instance may have
chosen to omit information about what the client enjoyed about drinking in the past week.

The Four Processes of Motivational Interviewing: From an MI perspective, a helpful

conversation about change encompasses four processes during which the clinician continuously
sets the tone by using the MI Spirit and employing the OARS skills. The clinician’s use of the
technical skills to facilitate each of the processes can be placed alongside the Stages of Change
model (Prochaska and DiClemente 1983; see chapter introduction) to provide a broad heuristic
for conceptualizing the arch of MI-informed conversation(s) for both clinician and client.
1.​ Engaging: Building a Working Relationship - Engaging underpins any possibility of
helping a client move toward change, because a collaborative, autonomy-reinforcing
relationship helps clients build awareness of potential areas of change and open up about
ways they may be contemplating changes. Clients in precontemplation and contemplation
stages can be particularly helped by a clinician’s engaging stance, which encourages
openness, discussion of the issues surrounding their behaviors, and reasons for seeking a
talk with the counselor. This allows individuals to move toward greater readiness to
change by discussing the issues surrounding their behavior and their reasons for seeking
treatment (Prochaska and DiClemente 1983).
2.​ Focusing: Identifying a Specific Set of Changes to Address - Focusing encompasses
the clinician’s process of strategically narrowing the conversation and helping the client
to target an area for potential movement. This process may align with the contemplation
stage of change, because clients may require focused thought and discussion before being
more actively ready to change. Focusing may also align with earlier or later stages of
change. Clients in the precontemplation stage can benefit from conversations eliciting
discussion of ways that particular behaviors are or are not serving their needs or values.
Clients in the preparation or action stage can benefit from focused discussions on ways
they might move toward the changes they have committed themselves to making.

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 3.​ Evoking: Inviting Clients to State Their Own Reasons for Change - During the
evoking process, the clinician strategically “invites in” a client’s change talk and
differentially responds to it. The evoking process links with client change talk around a
specific behavior such that the clinician can elicit additional reasons for change and invite
the client to commit to a plan. This process thus tends to align with the preparation stage
of change—the stage in which most of the clinician’s directional effort occurs.
4.​ Planning: Developing an Action Plan - In the planning process, the clinician offers
guidance, with the client’s permission, on how a plan might be put in place for making
changes (Miller and Rollnick 2013). The giving of advice by the clinician is always
subject to the client’s permission, honoring the client’s autonomy and choice. The
clinician’s request for permission before providing advice ensures that the action stage of
change aligns with the client’s own values; it also encourages future discussion of what
did or did not work in action implementation, thereby providing a helpful feedback loop
leading to continued movement toward healthier behaviors and a continued positive
working relationship with the clinician.

Motivational Enhancement Therapy:

Motivational enhancement therapy (MET) is a specific, short-term manualized application of MI
relational and technical components. MET was originally developed for the National Institute on
Alcohol Abuse and Alcoholism–funded Project MATCH (Matching Alcoholism Treatment to
Client Heterogeneity), a 5-year multisite study of alcohol treatments that investigated whether
the relative efficacy of different treatments was linked to the characteristics of clients (Miller et
al. 1999b). A detailed overview of MET as used in Project MATCH—including client handouts,
assessments, and tips for applying MET to other settings—has been provided by Miller et al.
(1999b) and is available online free of charge.
The therapy begins with a comprehensive 7- to 8-hour assessment. Following this session, clients
receive four individual treatment sessions with a clinician, spread over a period of 12 weeks. Of
the four sessions, the first two occur over 2 consecutive weeks and ideally include a significant
other as part of the process. These early sessions are meant to provide personalized feedback
from the initial assessment, strengthen the client’s own commitment to change, elicit feedback
and support from the significant other, and make a change plan. The remaining two sessions
occur at the midpoint and end point of the treatment period (roughly 6 and 12 weeks after
assessment). These sessions help monitor and encourage progress (Miller et al. 1999b). In
addition to the MI Spirit and the core skills already discussed, MET explicitly tethers sessions to
personalized feedback based on the comprehensive assessment and provides a menu of choices
for how the client might move forward with change. MET can be of benefit to clinicians with
limited time or opportunity to elicit change discussions, because it was developed specifically to
be a brief intervention with a spread of time in between sessions (Miller et al. 1999b). Brief
interventions have been found to have a particularly beneficial impact on alcohol, tobacco, and

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marijuana use, and when targeting the use of other substances, brief interventions are
significantly more effective than a waitlist or no-treatment condition (DiClemente et al. 2017).

Dialectical Behaviour Therapy for Substance Use Disorders (DBT-SUD):

DBT is an evidence-based psychotherapy originally developed by Marsha Linehan to treat

Borderline Personality Disorder, blending cognitive-behavioral strategies with concepts of
acceptance, distress tolerance, and mindfulness. It typifies the synthesis of change and
acceptance, enabling clients to regulate emotions, tolerate distress, and foster effective
interpersonal skills. Because many such patients have substance use disorders (SUDs), Dimeff &
Linehan (2008) developed DBT for Substance Abusers, which incorporates concepts and
modalities designed to promote abstinence and to reduce the length and adverse impact of
relapses. Among these are dialectical abstinence, "clear mind," and attachment strategies that
include off-site counseling as well as active attempts to find patients who miss sessions. Several
randomized clinical trials have found that DBT for Substance Abusers decreased substance abuse
in patients with borderline personality disorder. The treatment also may be helpful for patients
who have other severe disorders co-occurring with SUDs or who have not responded to other
evidence-based SUD therapies (Dimeff & Linehan, 2008).
The DBT model specifically adapted to address SUDs, is known as DBT-SUD. This approach
retains core DBT elements—weekly individual and group skills sessions plus phone
coaching—and integrates substance-specific techniques such as “cope ahead” for relapse
planning, dialectical abstinence, and harm-reduction strategies.

Treatment Components & Therapeutic Techniques:

1.​ Skills Training Group: Clients learn key skills such as mindfulness, emotion regulation,
distress tolerance, and interpersonal effectiveness—all vital to manage triggers, cravings,
and relationship dynamics.
2.​ Individual Therapy: Weekly therapy focuses on behavior chain analysis, motivation
enhancement, and reinforcing commitment to abstinence, while balancing acceptance and
change.
3.​ Phone Coaching: Provides real-time support to apply DBT skills during high-risk
moments, enhancing generalization of skills to everyday life.
4.​ Tools & Worksheets: Utilizes chain-analysis worksheets, diary cards, emotion regulation
tools, and mindfulness practice assignments to foster self-awareness and skill application
between sessions.
5.​ Consultation team for therapists: For therapists to be effective and the most helpful to
an individual, they need to feel supported and validated. For this reason, a therapist
consultation team meets weekly to help fellow therapists problem-solve and implement
effective treatment in challenging situations—a suicidal individual or one who frequently
misses sessions, for instance.

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DBT skills programs adapted for those with dual diagnoses (e.g., emotional dysregulation and
substance misuse) showed reductions in binge drinking and drug use, as well as improved coping
and emotion regulation, up to 6-month follow-up (Flynn et al., 2019).

Neurospychological Rehabilitation & Cognitive Retraining:

Substance use disorders commonly produce deficits in attention, working memory, processing
speed, and higher-order executive functions (planning, cognitive flexibility, response inhibition).
These deficits hinder treatment engagement, increase relapse risk, and reduce functional
recovery, so addressing cognition is a treatment-relevant target. Cognitive rehabilitation is a
therapy programme designed as an intervention to help people with cognitive deficits. Cognitive
rehabilitation operates on the principle that functions or deficits as a result of substance use can
be restored through the brains ability to transform, heal, learn and adapt. The degree to which the
improvement in neuropsychological functions is due to spontaneous recovery, abstinence of the
substance use or due to the neuropsychological rehabilitation techniques used is still unclear.
Cognitive rehabilitation is a continuous process and should be designed for each person based on
the clinical, cognitive and other psychosocial factors impacting the individual’s activities of daily
living. The process of rehabilitation should be complete and intensive in order to help patients
return to a premorbid level of functioning and gainful employment. Follow‑up of the patients are
vital.
Among individuals with alcohol dependence alone, approximately 50‑80% are reported to have
alterations in cognition which affect their prognosis and treatment. The presence of cognitive
deficits in substance dependent patients have also been found to be associated with a higher
drop‑out rate of established treatment programmes. Thus, the importance of cognitive
rehabilitation in a psycho‑social rehabilitation programme for individuals with addictions cannot
be over‑emphasized. In a fast paced world that depends so much on using one’s mental faculties
to get ahead, cognitive deterioration can leave the already floundering addict in a seemingly
hopeless situation.

Core components of neuropsychological rehabilitation for SUD:

1.​ Comprehensive baseline assessment - brief cognitive screens (for example,
domain-specific measures or brief screens developed for AUD) plus formal
neuropsychological tests where available, and functional assessment of daily living,
vocational and interpersonal skills. Assessment guides individualized goal-setting (Gupta
et al., 2018).
2.​ Restorative interventions (cognitive remediation / cognitive training) - repeated
practice on tasks that target attention, working memory, and executive control
(computerized drills, therapist-led exercises), aiming to strengthen impaired networks and
spill over to real-world functioning. Evidence is promising but heterogeneous; modest

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 gains in executive function and attentional control have been reported, and some studies
link cognitive gains to better treatment engagement (Pazoki et al., 2024).
3.​ Compensatory strategies and functional rehabilitation - teaching external aids
(planners, checklists), environmental modifications, routine structuring, and
error-reduction strategies to improve daily functioning even when cognitive deficits
persist (Rajeswaran, 2018).
4.​ Integrated behavioral targets - pairing cognitive work with substance-focused therapies
(motivational interviewing, CBT/DBT, relapse-prevention), because cognition improves
the capacity to use these psychotherapeutic skills. Combining cognitive remediation with
vocational or work therapy has shown feasible and sometimes superior functional
outcomes (Bell et al., 2017).
5.​ Adjunctive approaches - physical exercise, mindfulness training, and sensory-based
interventions (where available) may support neuroplasticity and cognitive recovery;
neurofeedback and pharmacologic strategies are experimental and require specialist
oversight (Caetano, 2021).

Application in India: In the National Institute of Mental Health and Neurosciences

(NIMHANS), India, cognitive rehabilitation is carried out in the form of Cognitive retraining and
EEG Neurofeedback.
Cognitive retraining is a programme that helps augment and improve cognitive functions such as
attention, mental speed, planning, memory etc. Zangwill in 1947, described three processes of
rehabilitation. Restitution of a function involves restoration of the lost or impaired function. The
Substitution training focuses on the replacement of impaired functions by other strategies that
substitute the impaired function and is found to be functional. The third, which is described as
compensation involves compensatory mechanisms when the first two approaches cannot be
carried out. Cognitive retraining involves the use of specific programmes used in retraining the
brain to recover its lost functions. Some of the retraining programmes used at NIMHANS
include letter cancellation, grain sorting, shading, spatial and temporal encoding and working
memory tasks such as mental arithmetic. Both home based as well as hospital based tasks have
been developed for patients. This training has been found to be useful in improving the deficits
of attention, information processing, memory and executive functions. Results of the use of this
programme revealed reduction in symptoms, enhancement of cognitive functions and well‑being
in patients with brain injury.

Group Therapy Approaches: Alcoholics Anonymous and Twelve-Step Facilitation

“Twelve-step programs” refers to Alcoholics Anonymous (AA) and its spin-offs—Narcotics

Anonymous (NA), Cocaine Anonymous (CA), and others that are based on the 12 steps to
recovery elucidated in the original Alcoholics Anonymous meetings and “Big Book,” developed
in the 1930s in the eastern United States. Currently, there are more than 100,000 different AA

21
meetings a week in the United States, and lesser numbers of NA, CA, and other “Anonymous”
meetings. Meetings can be found in almost all countries of the world, are led by their own
members, do not involve cross-talk, and generally follow the 12 steps and 12 traditions of AA.
Meetings can occur throughout the day, but most are in the evenings and last 60–90 minutes.
The 12 Steps of AA are elaborated hereunder:
1.​ We admitted we were powerless over alcohol—that our lives had become unmanageable.
2.​ Came to believe that a Power greater than ourselves could restore us to sanity.
3.​ Made a decision to turn our will and our lives over to the care of God as we understood
Him.
4.​ Made a searching and fearless moral inventory of ourselves.
5.​ Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.
6.​ Were entirely ready to have God remove all these defects of character.
7.​ Humbly asked Him to remove our shortcomings.
8.​ Made a list of all persons we had harmed, and became willing to make amends to them
all.
9.​ Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10.​Continued to take personal inventory and when we were wrong promptly admitted it.
11.​Sought through prayer and meditation to improve our conscious contact with God as we
understood Him, praying only for knowledge of His will for us and the power to carry
that out.
12.​Having had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.

Twelve-step facilitation (TSF) is an evidence-based intervention program with a large research

base; a therapy manual (Nowinski et al. 1992, 1999); a web-based training site (Sholomskas and
Carroll 2006); and an adaptation, with a manual, for group work with stimulant users (Daley et
al. 2011). TSF is a valuable therapeutic program that is easily accessible to practicing
psychiatrists and other mental health professionals, and both research and practice reveal that
active referral makes a difference (Donovan and Floyd 2008; Manning et al. 2012). In Project
MATCH (Matching Alcoholism Treatments to Client Heterogeneity), TSF was designed to be
implemented in 12 sequential sessions over about 3 months. However, for the practicing
psychiatric clinician, it is more likely that real-world TSF will occur off and on over the course
of patients’ treatment, which for some may be weeks or months and for others may be years.
For patients who have developed a severe SUD, have lost control, and are at serious risk for
adverse consequences, referral to a specialized inpatient or outpatient program may be the best
choice. However, many patients may have a less severe SUD or may not want addiction
treatment to show up on their insurance or health records. Furthermore, participating in
concurrent, outside professional treatment may present other problems, including problems with

22
cost, location, transportation, time, and potentially conflicting treatment messages. Even if
outside referral is made but the patient returns when stable, there is a good chance that 12-step
programs will be part of the patient’s ongoing treatment plan.

Role of the Therapist: The primary role of the TSF therapist is as a facilitator of the patient’s
acceptance of his or her SUD and of the patient’s commitment to the fellowship of a 12-step
program as the preferred path of recovery. However, when the facilitator is also a psychiatric
practitioner (and often a prescriber as well), explaining the nature of co-occurring psychiatric
illnesses, medications, and other therapies is also important (this becomes TSF-COD
[Co-Occurring Disorders]).
The psychiatric practitioner can productively use the patient’s attendance and participation at
12-step meetings and the patient’s understanding of the meeting discussions as therapeutic
material for both addiction and other psychiatric disorders. With such discussion, the psychiatrist
is both demonstrating support for the patient’s attending meetings and helping the patient to
integrate the material. The clinician should keep in mind that first-time attendees or patients with
social anxiety may be reluctant to speak or meet with other members. Basic
meeting-involvement coaching might include asking questions such as the following: What
meetings did you attend since the last session? Did you arrive early, on time, or late for
meetings? Where exactly were the meetings? Where did you sit? Did you stay for the whole
meeting? Were you able to pay attention the whole time? Discussion of the patient’s answers to
these questions may uncover resistance and nonattendance as well as psychiatric problems that
might be interfering with attendance, such as paranoia or social phobia. Dealing with the causes
of nonattendance and resistance then becomes part of the therapeutic work, which can include
use of medications, motivational interviewing, cognitive-behavioral techniques, or other specific
cognitive approaches.

Role of Sponsors: Sponsors are more senior AA members who help newer members to
understand and “work” the 12-step program. Sponsors are a key part of 12-step recovery;
experienced members sometimes volunteer to be sponsors to new members, or new members
may ask a more senior member to be their “temporary” sponsor. Some clinicians choose to meet
the patient’s sponsor so that the sponsor and clinician can be sure that they are on the same side
and are providing consistent information to the individual seeking treatment. Such a meeting
would occur only with the patient’s approval and only during a session with the patient present.
Other clinicians prefer not to meet the patient’s sponsor, but it is still important to encourage a
constructive relationship between patient and sponsor. A patient may not feel comfortable with
the original choice of sponsor and may discuss this in therapy. If such a discussion takes place,
the therapist can explore the patient’s concerns; this discussion may help the patient to relate
more comfortably to his or her sponsor or to decide to find a new sponsor. Some patients are
resistant to the idea of getting a sponsor, and this can be a problem. For those with more serious
psychiatric disorders, it is best, but not absolutely necessary, that their sponsors also have

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co-occurring disorders. If the sponsor has personal experience with co-occurring disorders, then
problems relating to psychiatric diagnosis, symptoms, and treatments, especially medications, are
usually avoided, and psychiatric treatments will be reinforced rather than resisted by the sponsor.

In the Indian context: The first AA group in India was established in Mumbai in 1957,
introduced by expatriates and local members returning from abroad. AA now operates in most
major Indian cities and many smaller towns, including Delhi, Mumbai, Kolkata, Chennai,
Bengaluru, Hyderabad, Pune, and Goa. Meetings are held in-person (in community halls,
hospitals, churches, temples) and increasingly online via Zoom and phone conferencing,
especially after COVID-19. The meetings are conducted in English, Hindi, and regional
languages (such as Tamil, Bengali, Marathi, Malayalam, Kannada, Punjabi), improving
accessibility. While daily meetings are common In metropolitan areas; in smaller towns, they
may be weekly or fortnightly. Contact details and meeting schedules are maintained on AA
India’s official website (www.aagsoindia.org) and through regional helplines. Many Indian
de-addiction centres, psychiatrists, and NGOs refer patients to AA as a continuing care or
relapse-prevention support.

Family Therapy Approaches

All family counseling approaches for SUD treatment reflect the principles of systems theory.
Systems theory views the client as an embedded part of multiple systems—family, community,
culture, and society. Family counseling approaches specific to SUD treatment require SUD
treatment providers to understand and manage complex family dynamics and communication
patterns. They must also be familiar with the ways family systems organize themselves around
the substance use behaviors of the person with an SUD. Substance misuse is often linked with
other difficult life problems— for example, co-occurring mental disorders, criminal justice
involvement, health concerns including sexually transmitted diseases, cognitive impairment, and
socioeconomic constraints (e.g., lack of a job or home). The addiction treatment field has
adapted family systems approaches to address the unique circumstances of families in which
substance misuse and SUDs occur.
Family systems models, while utilizing many behavioral techniques as part of their clinical
approach, pay particular attention to patterns of behavior used by families to control the
challenges associated with chronic substance misuse. Comparable attention is paid to the choices
families make over time that result in substance use becoming an issue around which much of
family life is now organized. Three additional components are viewed as critical to the family
systems approach: 1) a therapeutic stance that emphasizes therapist neutrality, the use of non
pathologizing language with patients and families, and family–therapist collaboration (rather
than a hierarchical approach in which the therapist takes the position of “expert” and unilaterally
defines the treatment goals for the family); 2) a belief that central to the success of treatment is
the ability to ascertain both individual- and family-level beliefs about the role of alcohol use in

24
family life; and 3) a conviction that therapy, to be effective, must include a credible action plan
for addressing the drinking behavior itself that is embraced by the entire family.
Examples of treatment approaches that have relied heavily on family systems concepts include
those of Treadway (1989), those of Steinglass et al. (1987), and the Systemic-Motivational
Therapy model proposed by Steinglass (2009), an approach that integrates family systems ideas
with those of motivational interviewing (Miller and Rollnick 2013) and harm reduction (Marlatt
et al. 2011). Both the Treadway model and those proposed by Steinglass and colleagues focus
primarily on adult AUD. Two other models, Functional Family Therapy (FFT) (Alexander et al.
2013) and Multidimensional Family Therapy (MDFT) (Liddle et al. 2001, 2018), have emerged
as promising approaches for treating adolescent drug problems. Although eclectic in their
designs, both models draw substantially on family systems concepts, are evidence based and
manual driven, and have been successfully used in treating complex clinical situations (e.g., dual
diagnosis, antisocial behavior) affecting adolescents within a family context. Furthermore, both
approaches have been successfully used with families representing a wide range of ethnic and
cultural groups, as well as in diverse treatment settings. The overlap between the FFT and MDFT
models is considerable in that both approaches can be thought of as short-term, highly structured,
strengths-based family intervention models that focus on risk and protective factors at both the
individual and the family level. Of the two models, MDFT deserves particular attention, not only
because its impact on reducing adolescent alcohol and cannabis drug use has been shown to be
long-standing (Liddle 2016) but also because it has been identified as one of the more promising
approaches to the treatment of adolescent OUD when used in conjunction with medications for
OUD (Waldron and Turner 2008).
In the MDFT approach, therapy is conceptualized as occurring in four different treatment
domains: the adolescent alone, the parent alone, the family together, and the adolescent’s
community. Therefore, an MDFT therapist might at one point be having individual sessions with
the adolescent patient, but at other points be seeing the adolescent in conjoint sessions with his or
her family, teachers, employers, and so forth. In each of these “domains,” the focus is on 1)
establishing a nonjudgmental treatment environment; 2) promoting change in emotions,
thoughts, and behaviors (of both adolescents and other family members); and 3) using techniques
to enhance motivation for change.

Relapse Prevention Techniques

RP is a cognitive-behavioral therapeutic approach with the goal of aiding individuals in

anticipating and coping with setbacks during both the treatment and the after-care process, and
therefore seeks to reduce both lapses (a one-time or short-term episode) and relapses (longer
term, back to high level substance use; Hendershot et al., 2011; Marlatt & Gordon, 1985). This
approach was initially developed to reduce relapse for those with an alcohol SUD. However, RP
techniques are now also used for drug use disorders and are now one of the more common

25
behavioral interventions for SUD. The conceptual framework underlying RP is described in the
model by Marlatt & Gordon (1985).

Specific RP techniques involve:

1.​ Identifying, through the therapeutic process, situations, thoughts, feelings, and behaviors
(i.e., “triggers”) that increases the risk of a person re-engaging in substance use.
2.​ Identifying methods (techniques) for managing these high-risk situations which may
include cognitive distortions, problems related to immediate gratification, abstinence
violation, and lifestyle imbalances.
3.​ Learning, practicing, and implementing these techniques throughout a lifetime, including
learning and accepting that lapses and relapses are not moral failures but mistakes than
can be overcome.
4.​ Developing an evolving relapse prevention plan to support the generalizability of these
efforts over time. That is, triggers can change over time and if we accept SUD as a
chronic relapsing condition, new relapse prevention techniques and therapeutic support
and aid in the development of new techniques need to take place over time.

Implications: A strength of RP is the movement away from moralizing relapse as individual

failure. However, it is important to understand the client’s moral, religious, family, and
community context when working with the client, so he or she can cognitively understand lapses
and relapses as mistakes, or part of a chronic condition, where there are medication, behavioral
interventions, cognitive techniques, and other methods that can provide a positive response to the
relapse. Hence, understanding relapse and causes for relapse—and that it is not the individual’s
moral failure—is of key importance to individuals with SUD, their families, and the surrounding
community, including treatment staff, health care staff, police, and so on.

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Biological Treatments

Biological treatments may be used to help people withdraw from substances, abstain from them,
or simply maintain their level of use without increasing it further. As with the other forms of
treatment, biological approaches alone rarely bring long term improvement, but they can be
helpful when combined with other approaches.

Detoxification:
Detoxification is systematic and medically supervised withdrawal from a drug. Some
detoxification programs are offered on an outpatient basis. Others are located in hospitals and
clinics and may also include individual and group therapy, a “full-service” institutional approach
that has become popular. One detoxification approach is to have clients withdraw gradually from
the substance, taking smaller and smaller doses until they are off the drug completely. A
second— often medically preferred—detoxification strategy is to give clients other drugs that
reduce the symptoms of withdrawal (Day & Strang, 2011). Antianxiety drugs, for example, are
sometimes used to reduce severe alcohol withdrawal reactions such as delirium tremens and
seizures. Detoxification programs seem to help motivated people withdraw from drugs (Müller et
al., 2010). However, relapse rates tend to be high for those who do not receive a follow-up form
of treatment—psychological, biological, or sociocultural—after successfully detoxifying
(Blodgett et al., 2014; Day & Strang, 2011).

Antagonist Drugs:
After successfully stopping a drug, people must avoid falling back into a pattern of chronic use.
As an aid to resisting temptation, some people with substance use disorders are given antagonist
drugs, which block or change the effects of the addictive drug (Chung et al., 2012; O’Brien &
Kampman, 2008). Disulfiram (Antabuse), for example, is often given to people who are trying to
stay away from alcohol. By itself, a low dose of disulfiram seems to have few negative effects,
but a person who drinks alcohol while taking it will have intense nausea, vomiting, blushing, a
faster heart rate, dizziness, and perhaps fainting. People taking disulfiram are less likely to drink
alcohol because they know the terrible reaction that awaits them should they have even one
drink. Disulfiram has proved helpful, but again only with people who are motivated to take it as
prescribed (Diclemente et al., 2008). In addition to disulfiram, several other antagonist drugs are
now being tested. For substance use disorders centered on opioids, several narcotic antagonists,
such as naloxone, are used (Alter, 2014; Harrison & Petrakis, 2011). These antagonists attach to
endorphin receptor sites throughout the brain and make it impossible for the opioids to have their
usual effect. Without the rush or high, continued drug use becomes pointless. Although narcotic
antagonists have been helpful—particularly in emergencies, to rescue people from an overdose
of opioids—they can in fact be dangerous for people who are addicted to opioids. The
antagonists must be given very carefully because of their ability to throw such persons into
severe withdrawal. So-called partial antagonists, narcotic antagonists that produce less severe

27
withdrawal symptoms, have also been developed (Hart & Ksir, 2014; Dijkstra et al., 2010).
Many clinicians now prefer partial antagonists over full antagonists to help people withdraw
from opioid use. The use of antagonists to help people withdraw is often called rapid
detoxification because the antagonists speed things along. The full antagonists remain the
treatment of choice in emergency cases of overdose. Research indicates that narcotic antagonists
may also be useful in the treatment
of substance use disorders involving alcohol or cocaine (Harrison & Petrakis, 2011; Bishop,
2008). In some studies, for example, the narcotic antagonist naltrexone has helped reduce
cravings for alcohol (O’Malley et al., 2000, 1996, 1992). Why should narcotic antagonists,
which operate at the brain’s endorphin receptors, help with alcoholism, which has been tied
largely to activity at GABA sites? The answer may lie in the reward center of the brain. If
various drugs eventually stimulate the same pleasure pathway, it seems reasonable that
antagonists for one drug may, in a roundabout way, affect the impact of other drugs as well.

Drug Maintenance Therapy:

A drug-related lifestyle may be a bigger problem than the drug’s direct effects. Much of the
damage caused by heroin addiction, for example, comes from overdoses, unsterilized needles,
and an accompanying life of crime. Thus clinicians were very enthusiastic when methadone
maintenance programs were developed in the 1960s to treat heroin addiction (Dole &
Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory
opioid methadone as a substitute, or agonist, for heroin. Although they then become dependent
on methadone, their new addiction is maintained under safe medical supervision. Unlike heroin,
methadone produces a moderate high, can be taken by mouth (thus eliminating the dangers of
needles), and needs to be taken only once a day.
At first, methadone programs seemed very effective, and many of them were set up throughout
the United States, Canada, and England. These programs became less popular during the 1980s,
however, because of the dangers of methadone itself. Many clinicians came to believe that
substituting one addiction for another is not an acceptable “solution” for a substance use
disorder, and many people with an addiction complained that methadone addiction was creating
an additional drug problem that simply complicated their original one (W instock, ­Lintzeris, &
Lea, 2011; McCance-Katz & Kosten, 2005). Methadone is sometimes harder to withdraw from
than heroin because the withdrawal symptoms can last longer (Hart & Ksir, 2014; Day & Strang,
2011). Moreover, pregnant women maintained on methadone have the added concern of the
drug’s effect on their fetus.
Despite such concerns, maintenance treatment with methadone—or with other opioid substitute
drugs—has again sparked interest among clinicians in recent years, partly because of new
research support (Balhara, 2014; Fareed et al., 2011) and partly because of the rapid spread of the
HIV and hepatitis C viruses among intravenous drug abusers and their sex partners and children
(Lambdin et al., 2014; Galanter & Kleber, 2008). Not only is methadone treatment safer than
street opioid use, but many methadone programs now include AIDS education and other health

28
instructions in their services. Research suggests that methadone maintenance programs are most
effective when they are combined with education, psychotherapy, family therapy, and
employment counseling (Jhanjee, 2014; Kouimtsidis & Drummond, 2010).

TREATMENT OF SUD IN INDIA

Community-based treatment of substance use disorders in India

A variety of approaches have been utilized in India for providing community-based treatment of
SUD. The drug de-addiction and treatment center (DDTC) of PGIMER, Chandigarh, has been
running a community outreach clinic at Kharar Civil Hospital, Kharar, Mohali, Punjab, wherein
services are provided once a week. Special Outreach Outpatient Clinics are also operated by the
institute which are organized at different locations in premises provided by the village
panchayats. A team of psychiatrists, social workers, and nursing staff holds the clinic on a given
date to provide free consultations and medications for acute withdrawal management. The clients
are then advised to follow-up at the DDTC located in the main hospital for continuing their
treatment.

Another approach which has been used in some states of India is a camp approach. In this
approach, a village or a locality is chosen to provide treatment for acute withdrawal symptoms in
a camp for a period of 7–10 days, along with psychosocial interventions. This approach too is
less resource intensive in terms of human resources and utilizes facilities provided by the local
community to conduct camps. This approach has been used for treating acute withdrawal
symptoms of various substances, including alcohol and opioids, and has met with fair amount of
success. This approach, however, caters to the immediate needs of the patient in terms of
withdrawal management and does not provide long-term treatment of SUD in the community.
The National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi, has been
providing community‑based treatment for SUD since the 1990s. These treatment facilities are
aimed at providing substance use treatment services to the locals as well as at developing a
low‑cost model of SUD treatment for India. Currently, NDDTC provides community‑based
treatment through its three CDTCs located in different parts of Delhi.

CHALLENGES IN THE TREATMENT OF SUDs

Therapy for substance use disorders (SUDs) presents several significant challenges, including
poor medication adherence, difficulty integrating family counseling, and the complexities of
treating co-occurring mental health conditions. Additionally, issues like patient ambivalence,

29
severe symptomatology, and the need for specialized training in family therapy also pose
hurdles. Specific challenges include:

1.​ Medication Adherence: Patients may struggle to consistently follow prescribed

medication regimens due to fluctuating motivation, lack of belief in treatment, or
difficulty resisting cravings.
2.​ Integrating Family Counseling: Family therapy, though beneficial, can be complex,
requiring specialized training, funding, and addressing potential resistance from both
patients and providers.
3.​ Comorbid Mental Health Conditions: Many individuals with SUDs also experience
mental health disorders like depression, anxiety, or PTSD, making diagnosis and
treatment more challenging and requiring a comprehensive, integrated approach.
4.​ Patient Ambivalence and Resistance: Early in treatment, patients may be emotionally
fragile, ambivalent about stopping substance use, and resistant to treatment approaches.
5.​ Severe Symptoms and Self-Destructive Behaviors: Patients with severe SUDs may
present with self-destructive behaviors and intense symptomatology, requiring
specialized care and potentially posing risks to themselves and others.
6.​ Lack of Trained Professionals: There is a shortage of qualified staff in some settings,
and some clinicians lack specific training in treating patients with SUDs and co-occurring
disorders.
7.​ Infrastructure and Systemic Barriers: Challenges can also arise from the treatment
setting itself, including issues with staffing, transportation, paperwork, and the
availability of aftercare support.
8.​ Relapse: A significant challenge is preventing relapse, as SUDs are chronic conditions
requiring ongoing support and management.
9.​ Cultural and Socioeconomic Factors: Treatment approaches may need to be tailored to
address cultural and socioeconomic factors that can impact treatment engagement and
outcomes.

EMERGING TRENDS: DIGITALLY DELIVERED THERAPIES

There is strong and growing evidence for digital therapeutic approaches targeting SUDs and
related conditions across the care continuum (Marsch et al. 2014b; Sugarman et al. 2017). These
digital behavioral health approaches have demonstrated efficacy in identifying symptoms (Butler
et al. 2001; Lord et al. 2011; McNeely et al. 2016), evoking positive behavioral change
(Campbell et al. 2014; Carroll et al. 2008, 2009, 2014; Marsch et al. 2014a), and facilitating
recovery support (Gonzales et al. 2014; Gustafson et al. 2014). The empirical literature includes
studies of digital therapeutic approaches evaluated in a variety of ways, including as stand-alone
treatment approaches, as adjuncts to cliniciandelivered treatment, or as replacements for certain

30
aspects of care, across a range of patient or client populations and in diverse settings. There is
consistent evidence demonstrating that when digital interventions are developed well, and are in
concert with the needs of target end-users, they can produce outcomes comparable to, and in
some cases better than, the effects of interventions delivered by trained clinicians (Marsch et al.
2014b). In the following sections we describe the state of the science with regard to empirically
tested digital approaches for SUD treatment across the care continuum.

Screening and Assessment:

The majority of research on digital approaches to screening and assessment has focused on
translation of existing validated instruments to digital forms, primarily web-based programs and
mobile applications. For example, the Addiction Severity Index–Multimedia Version (ASI-MV;
Butler et al. 2001) is a translation of the widely used Addiction Severity Index (McLellan et al.
1992) to an interactive, multimedia web-based format that includes video-guided delivery of
assessment content to promote client self-report and engagement. The ASI-MV program
demonstrated strong psychometric properties when compared with non digital assessment
approaches (Butler et al. 2001), and it has been widely used in SUD treatment settings.
The Comprehensive Health Assessment for Teens (CHAT; Lord et al. 2011) is a web-based,
self-report comprehensive substance use assessment for adolescents that has demonstrated good
to excellent psychometric properties when compared with other validated self-report instruments
in studies with clinical and nonclinical adolescent populations.
The Screener and Opioid Assessment for Patients with Pain—Revised (SOAPP-R) is a brief
computerized self-report tool to facilitate assessment and planning for patients with chronic pain
who are being considered for long-term opioid treatment (Butler et al. 2009a; Weiner et al.
2015). The tool has been studied extensively in pain populations, with established psychometric
properties and good predictive accuracy for identifying which patients will engage in aberrant
medication-related behavior (Finkelman et al. 2017, 2019).
The Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool (TAPS; McNeely
et al. 2016) is a two-part web-based substance use screening and brief assessment tool adapted
from validated instruments and specifically developed for use in primary care settings. The
TAPS tool can be administered by a clinician interviewer or completed by patients on a computer
or tablet at a clinic or through a patient portal. In psychometric studies with adult patients in
primary care, TAPS demonstrated high sensitivity for detecting problematic tobacco and
marijuana use; moderate sensitivity for detecting tobacco, marijuana, and alcohol SUDs; and
good validity when compared with similar non digital instruments (McNeely et al. 2016;
Schwartz et al. 2017).
The examples described above are just a few of the many empirically supported and
psychometrically sound digital screening tools available for use in a range of practice settings
(e.g., primary care, specialty care, community care) as a frontline strategy to identify SUDs and
related risks among diverse patient populations. Digital screening and assessment approaches
allow for standardization of assessment processes for identification of treatment needs. There is

31
also solid evidence indicating that individuals are more likely to be honest about sensitive risk
behaviors when reporting on a digital device relative to in-person interviews (Butler et al.
2009b). Use of digital screening and assessment tools in primary care or emergency department
waiting rooms has resulted in increased rates of both screening and identification of patients with
substance use problems (Harris et al. 2016; Spirito et al. 2016). Screening results can be
automatically imported into electronic health records, and clinical protocols built into electronic
health records can prompt delivery of an appropriate intervention (Tai and McLellan 2012).

Digital Treatment Interventions:

A number of self-guided digital treatment interventions for SUDs, each derived from existing
empirically supported clinician-delivered treatment approaches, have been evaluated in
randomized clinical trials. Reduce Your Use is a self-guided web-based treatment for cannabis
use and related problems based on cognitive-behavioral therapy (CBT) and motivational
interviewing. In a randomized trial of the program with adults motivated to reduce their cannabis
use, individuals in the treatment group showed significantly greater reductions in cannabis use
compared with those in a web-based cannabis education control condition (Rooke et al. 2013).
Can Reduce is an eight-module CBT-based intervention that has been evaluated as a stand-alone
treatment and in combination with online chat counseling. This self-guided program produced
significant short-term reductions in cannabis use, particularly when augmented by chat
counseling sessions (Schaub et al. 2015).
Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT) is a self-guided
web-based CBT intervention for SUDs that has been extensively evaluated in controlled trials
and has consistently demonstrated positive effects on substance use behaviors (Carroll et al.
2008). Over six sessions, CBT4CBT assists users in identifying patterns of substance use and
developing coping skills. Video and other multimedia content are used to promote engagement
and learning. CBT4CBT has been evaluated as an adjunct to clinician-delivered treatment and as
a stand-alone treatment.
The Therapeutic Education System (TES) (Bickel et al. 2008) is a self-guided intervention,
available on web and mobile platforms, that is based on the Community Reinforcement
Approach (CRA) and CBT for treating SUDs. TES includes more than 65 modules targeting
coping skills related to SUDs and psychosocial functioning as well as HIV prevention. Modules
include video and other multimedia features and interactive exercises to reinforce skill
acquisition and learning. Knowledge consolidation is facilitated through fluency learning
techniques. TES has been evaluated in numerous randomized controlled trials and has
demonstrated positive treatment outcomes for opioid, cannabis, and methamphetamine use
disorders, as well as reductions in HIV risk behaviors, with results comparable to those produced
by clinician-delivered evidence-based treatment. The intervention has most often been evaluated
as an adjunct to or a replacement for a component of clinician-delivered treatment. In an initial
trial, TES as an adjunct to standard drug counseling produced superior opioid and cocaine

32
abstinence outcomes compared with standard counseling only, and it performed just as well as a
completely therapist-delivered CRA/CBT treatment condition (Bickel et al. 2008).

Recovery Support:
There is also growing evidence for the utility of digital relapse prevention and recovery support
interventions following intensive treatment. The Addiction Comprehensive Health Enhancement
Support System (A-CHESS) is a smartphone application created to help clients develop and
maintain motivation for abstinence, and it connects clients with resources to cope with cravings,
withdrawal symptoms, and high-risk situations to avoid relapse (Gustafson et al. 2014). In a
randomized controlled trial among clients with alcohol use disorder discharged from residential
treatment, participants who received ACHESS had higher odds of reported abstinence from
alcohol over the 8-month intervention period and fewer reported risky drinking days at 4-month
follow-up relative to participants who received TAU (Gustafson et al. 2014). The impact of
A-CHESS on reduction in risky drinking days was mediated by involvement in outpatient
addiction treatment (Glass et al. 2017). Educating and Supporting Inquisitive Youth in Recovery
(ESQYIR; Gonzales et al. 2014) is a program that harnesses the ubiquity of mobile phones and
text messaging as a popular mode of communication among young people to support addiction
recovery. This 12-week mobile text messaging aftercare intervention targets youth (ages 12–24)
transitioning out of community-based substance use treatment programs. Participants receive
daily texts related to self-monitoring of risks and wellness recovery support tips, as well as
education and social support resource information.

CONCLUSION

In conclusion, the treatment of Substance Use Disorders is a complex, multifaceted process that
demands a compassionate, evidence-based, and person-centered approach. From
pharmacological interventions to psychosocial therapies like Cognitive Behaviour Therapy,
Motivational Enhancement Therapy, and family-based modalities, each component plays a
crucial role in supporting recovery.
It is essential to remember that SUDs are chronic and relapsing conditions, and recovery is not a
linear journey—it requires persistence, patience, and a supportive environment. As mental health
professionals, caregivers, or members of the community, our role is not only to treat but to
empower individuals to reclaim their lives with dignity and hope.

33
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