Behavioral therapy is one of the most widely used methodologies in addiction treatment.1 It is highly effective and can be used in individual, group, and family settings.1 Approaches focus on various aspects of addiction, including motivation toward recovery, developing relapse prevention skills, substituting negative and destructive behaviors with healthy and productive ones, offering incentives for desirable behaviors, and improving relationships with others.1
Types of behavioral therapies for addiction treatment include cognitive-behavioral therapy, dialectical behavioral therapy, motivational interviewing, contingency management, 12-step facilitation, and family behavior therapy.
Cognitive Behavioral Therapy (CBT)
Cognitive-behavioral therapy (CBT) was first developed as a clinical approach to managing mood disorders, but later adapted to treat alcohol use disorder (AUD) other forms of addiction as well.1,2,3 CBT works on the theory that certain patterns of thought can contribute to maladaptive behaviors (such as continued substance use), but a decrease in such behaviors can be achieved through identifying and changing the negative thoughts and emotions.1,2,3 Many studies have shown that this type of treatment has benefits that continue even after treatment has concluded.1
A variety of CBT techniques can help reduce substance use, manage cravings, and avoid relapse.1 During cognitive restructuring, you are guided to examine your thoughts, discuss them with a therapist, understand any unhelpful patterns that appear, and substitute more helpful thoughts whenever possible.1,2,3 You learn to identify situations involving people, places, or things that are likely to tempt you to drink or use substances.
Another aim of CBT is to develop coping skills that can help you manage cravings and better navigate circumstances that can’t be avoided so that you become comfortable saying no.1,2 You are encouraged to participate in positive and constructive activities to fill the time that would be otherwise spent drinking or engaging in other non-constructive behaviors.2
Finally, an important aspect of CBT is building or strengthening various skills—family or other social relationships, managing emotions, occupational, or problem-solving skills—that may need some work.2 Tailored to your individual needs, this approach is achieved through a combination of education, role-playing, individual and group counseling, and at-home practice.2
Dialectical Behavioral Therapy (DBT)
Dialectical behavioral therapy (DBT) was initially developed to treat people with long-term suicidal behaviors, but it has become most well-known for treating borderline personality disorder, a mental health issue commonly associated with concurrent substance abuse.4,5 The technique has since been effectively applied to treating substance abuse itself.4,5,6 DBT ultimately aims to help patients improve their lives by synthesizing a balance between the urge to avoid painful experiences and the need to accept some of the unavoidable pain associated with life.4 DBT technique works through the promotion of two opposing goals—change and acceptance.4
DBT is typically conducted with a therapist through a combination of individual counseling sessions, group therapy focused on skill-building, and telephone sessions.4,5 Treatment focuses on reducing substance use, reducing discomfort due to withdrawal or sobriety, managing cravings, avoiding triggers that lead to substance use, cutting back or eliminating behaviors associated with substance use, increasing social support, and encouraging positive and healthy activities.4
In parallel with the aims of CBT, a key tenet of DBT is identifying triggers and either avoiding them when possible or developing effective coping skills.4 Sobriety is encouraged, but if a relapse does occur, it is addressed with acceptance rather than judgment. Problem-solving skills are used to identify ways to prevent the same thing from happening in the future.4
Emotional regulation, which teaches how to manage negative emotions without resorting to substances, is an essential part of the DBT program.5 Mindfulness training is another important tool in learning how to cope with emotions, stressors, and cravings.5 DBT also involves learning how to communicate more effectively, which helps to build a network of social support, and distress tolerance, which involves managing stressors and increasing acceptance of things that cannot be changed.5
Motivational interviewing was developed to increase an individual’s engagement with recovery efforts and is effective at reducing substance use.2,7,8 It builds on the stages of change, helping people move from thinking about making a change to actively working toward it.2,7,8 This technique can be used alone or in conjunction with other therapeutic practices. Motivational interviewing is a short-term therapy that can be offered in individual and group settings.2, 8
A therapist will encourage you to examine the negative consequences of alcohol use. The focus is on why you want to make a change and the positive and negative aspects of that change.7,8,9 You explore any discrepancies that arise between where you are, where you want to be, and how substance use holds you back.9 Resistance to change is addressed in an effort to resolve any ambivalence toward recovery.9
Contingency management (CM) uses rewards to reinforce behavioral changes.2 Small prizes or vouchers for items are offered in return for positive behaviors such as negative drug or breathalyzer results.2 Reward values may stay the same or increase with ongoing abstinence. The rewards stop in the event of negative behavior, such as relapse.2,10
Studies have shown this technique to be effective at encouraging abstinence.2, 10 Contingency management works within a framework of operant conditioning—the practice of altering voluntary behaviors through negative or positive reinforcement for those behaviors. Just as alcohol and drug use themselves have reinforcing qualities, CM can be used to offset the likelihood of these behaviors by instead reinforcing abstinence through token rewards.10
Abstinence itself isn’t the only behavior that can be targeted; for example, contingency management can also encourage you to stay in counseling or continue using medications that promote abstinence.10 This technique is generally used in conjunction with other forms of therapy.10
Contingency management operates around four main principles:10
- Consistent substance testing must be conducted to ensure that abstinence is being maintained.10
- The rewards for sobriety should be agreed on and offered by the treatment provider for specific treatment goals.10,11
- If substance use occurs, the reward will not be provided.10
- You and the therapist work together to identify positive goals and activities. Examples include strengthening relationships with family and friends, a promotion at work, or healthy hobbies.10
Twelve-step facilitation therapy involves 12-step help groups such as Alcoholics Anonymous. As therapeutic approach, 12-step facilitation encourages attendance and active participation in 12-step meetings as a goal of promoting abstinence.1,12,13 Most sessions are individual, although some may include family members if desired.13
Recognized as an effective treatment strategy, this therapy adheres to the basic 12-step principles including acceptance, surrender, and abstinence.1,12,13 The therapist works with you to guide you through the 12 steps within each session.12,13 You will generally focus on the first 3 steps:1,13,14
- Accepting that you are powerless over alcohol, which has made life unmanageable.
- Accepting that willpower cannot fix this problem and that a higher power can help.
- Surrendering to a higher power to overcome the disease of addiction.
The therapist will help you explore how alcoholism has affected your thoughts and emotions works to have you understand the negative consequences of your drinking.13 The goal is for you to learn how to manage emotions in a healthy way, develop a sober support network, change how you interact with people who have enabled you, and establish or strengthen a sense of spirituality.13 You may be asked to keep a journal of meeting attendance, reactions to meetings and reading material, cravings, and any relapses so that these issues can be discussed in sessions.13
Family Behavior Therapy
Addiction affects everyone within a family, and family behavior therapy has been shown to be effective in treating addiction.1,16 This technique addresses the addiction as well as the relationships within the family, employment, parenting issues, and behavioral concerns.1,15
In family behavior therapy, you will learn how to create goals, learn new behavioral techniques, develop the skills needed to make your home life better, and strengthen communication skills. You and your family will be encouraged to practice these behaviors outside of your sessions.1,15
Elements of contingency management—the rewards system—are often incorporated into family behavior therapy as a way of increasing motivation.15 Treatment goals are set and discussed in sessions and family members follow through with rewards.1,15 This type of therapy is designed to help families work together and support each other as they achieve goals individually and as a whole.15,16
. National Institute on Drug Abuse. (2020). Principles of drug addiction treatment: A research-based guide (Third edition).
. McHugh, R.K., Hearon, B.A., & Otto, M.W. (2010). Cognitive behavioral therapy for substance use disorders. The Psychiatric Clinics of North America, 33(3), 511-525.
. Hodge, D.R. (2011). Alcohol treatment and cognitive-behavioral therapy: Enhancing effectiveness by incorporating spirituality and religion. Social Work, 56(1), 21-31.
. Dimeff, L.A., & Linehan, M.M. (2008). Dialectical behavior therapy for substance abusers. Addiction Science and Clinical Practice, 4(2), 39-47.
. Maffei, C., Cavicchioli, M., Movalli, M., Cavallaro, R., & Fossati, A. (2018). Dialectical behavioral therapy skills training in alcohol dependence treatment: Findings based on an open trial. Substance Use and Misuse, 1-18.
. Park, J.-H., Ju, S.-J., & Kang, G.-Y. (2020). The effects of dialectical behavior therapy (DBT) skill training on depression and alcohol abstinence self-efficacy of patients with alcohol use disorder. Medico-legal Update, 20(1), 1497-1503.
. DiClemente, C.C., Bellino, L.E., & Neavins, T.M. (1999). Motivation for change and alcoholism treatment. Alcohol Research and Health, 23(2), 86-92.
. Nyamathi, A., Shoptaw, S., Cohen, A., Greengold, B., Nyamathi, K., Marfisee, M., … & Leake, B. (2010). Effect of motivational interviewing on reduction of alcohol use. Drug and Alcohol Dependence, 107(1), 23-30.
. UpToDate. (2019). Motivational interviewing for substance use disorders.
. Higgins, S.T., & Petry, N.M. (1999). Contingency management: Incentives for sobriety. Alcohol Research and Health, 23(2), 122-127.
. Dougherty, D.M., Lake, S.L., Hill-Kapturczak, N., Liang, Y., Kans, T.E., Mullen, J., & Roache, J.D. (2015). Using contingency management procedures to reduce at-risk drinking in heavy drinkers. Alcoholism, Clinical and Experimental Research, 39(4), 743-751.
. Connecticut State Department of Mental Health and Addiction Services. (2020). Twelve-step facilitation.
. Nowinski, J., Baker, S., & Carroll, K. (1999). Twelve step facilitation therapy manual. National Institute on Alcohol Abuse and Alcoholism.
. Alcoholics Anonymous. (2016). The 12 steps of Alcoholics Anonymous.
. Center for Substance Abuse Treatment. (2004). Substance abuse treatment and family therapy. Treatment Improvement Protocol (TIP) Series, No. 39. DHHS Publication No. (SMA) 05-4006.
. Lam, W.K.K., O’Farrell, T.J., & Birchler, G.R. (2012). Family therapy techniques for substance abuse treatment. Treating Substance Abuse: Theory and Technique (p. 256-280).