Behavioral Therapy Models
Behavioral therapies focus on changing an individual's behaviors concerning substance misuse, in part by teaching life skills that help them to better cope with situations that may lead to substance misuse and relapse. Several behavioral therapies have shown effectiveness in treating substance use disorders, with some types of therapy being better suited for a particular type of substance. Behavioral therapy can be provided in an outpatient setting or as part of an intensive inpatient or residential treatment setting. Residential treatment settings vary in structure, length of program, and whether or not they contain detoxification services. Treatment programs tend to begin with intensive services, then transition to outpatient settings in order to maintain recovery.
- Cognitive-Behavioral Therapy: Cognitive behavioral therapy (CBT), originally designed for the treatment of depression, is effective in treating multiple types of substance use disorders. CBT teaches people how to identify problem behaviors and triggers for substance misuse and to develop coping strategies. Research has shown that the effects of CBT continue after therapy sessions are complete and there is a benefit to cost ratio of $22.31 (in benefits for every dollar spent). The National Institute on Drug Abuse (NIDA) considers CBT an evidence-based approach for the treatment of a variety of substance use disorders.
- Contingency Management Interventions: Contingency management interventions encourage behavior modification through the provision of tangible rewards for a target behavior (for example, abstaining from substance use or attending a meeting). When a patient tests negative for drugs, a reward is given. Rewards may include money, vouchers, gift certificates, clinic privileges, or other tokens. Research suggests that contingency management interventions may be effective in the increase of treatment retention and abstinence from drugs. There is a benefit to cost ratio ranging from $10.15 for lower cost programs to $35.41 for higher cost programs (in benefits for every dollar spent). NIDA considers contingency management interventions an evidence-based approach for the treatment of a variety of substance use disorders.
- Community Reinforcement Approach (CRA) Plus Vouchers: CRA Plus Vouchers is an outpatient therapy using a variety of treatment strategies including building motivation, analyzing substance use patterns, positive reinforcement, and the involvement of family members in order to engage participants. There is a benefit to cost ratio of $5.22 (in benefits for every dollar spent on CRA). The Substance Abuse and Mental Health Services Administration (SAMHSA) and NIDA consider CRA an evidence-based approach for the treatment of a variety of substance use disorders.
- Motivational Interviewing (MI): MI is a counseling style that is especially beneficial at addressing ambivalence toward unhealthy behaviors. This evidence-based treatment builds an individuals' confidence in their ability to successful make a change (self-efficacy), and it helps people with substance use disorders explore their own desire for change and begin the process of making a change. MI is meant to be a brief intervention and could therefore be beneficial in rural primary care settings where access to specialists may not be possible. There is a benefit to cost ratio of $22.07 (in benefits for every dollar spent on MI). NIDA considers MI an evidence-based approach for the treatment of substance use disorders.
- Motivational Enhancement Therapy: Motivational enhancement therapy (MET) uses motivational interviewing approaches to strengthen motivation for behavioral change. This approach can be used for addressing behaviors from healthy eating to physical activity and behaviors associated with chronic disease. There is a benefit to cost ratio of $17.49 (in benefits for every dollar spent on MET). SAMHSA and NIDA consider MET an evidence-based approach for the treatment of a variety of substance use disorders.
- The Matrix Model: The Matrix Model is an intensive outpatient treatment intervention that has demonstrated particular effectiveness in the treatment of stimulant use disorder. This model is a multi-component intervention, using counseling, recovery skills development, relapse prevention techniques, and social supports to help maintain abstinence. The Matrix Model includes education for friends and family members of the individual with substance use disorder. There is a benefit to cost ratio of $2.08 (in benefits for every dollar spent). SAMHSA and NIDA consider the Matrix Model an evidence-based approach for the treatment of substance use disorders.
- Twelve Step Facilitation Therapy: Twelve step facilitation therapy is a brief, structured program that has behavioral, spiritual, and cognitive components. This intervention is based on the principles of 12 step peer support programs like Alcoholics Anonymous and Narcotics Anonymous, but is different in that it is a therapeutic intervention with a counselor. Twelve step facilitation therapy can be conducted either in individual or group sessions. SAMHSA and NIDA consider twelve-step facilitation therapy an evidence-based approach for the treatment of a variety of substance use disorders.
- Family Therapy: Family therapy is used to treat substance use disorders and focuses on using the strength and assets of the family to address the substance misuse and reduce the impact of the misuse on the individual and family. There are several common family therapy models used to treat substance use disorders.
- Family Behavior Therapy: Family behavior therapy (FBT) is unique from other therapies in that it involves not only the patient, but a family member or significant other. FBT involves vocational skills training, communication skills training, and training on resisting urges, among other interventions. This intervention has shown positive results in both adults and in adolescents. In addition to treating substance use problems, FBT also addresses co-occurring issues like child mistreatment, depression, conduct disorders, and family conflict. The benefit to cost ratio for family therapy is $4.93 in benefits for every dollar spent. SAMHSA and NIDA consider FBT an evidence-based approach for the treatment of substance use disorders.
- Functional Family Therapy (FFT): In functional family therapy (FFT), therapists work with adolescents and their families to identify an individual's strengths along with protective and risk factors. FFT consists of 12 sessions on average. During this time, therapists work to establish credibility with the family while exploring the dynamics that may affect and change an individual's behavior while motivating them and also provide the family with resources such as relapse plans. In addition to treating substance use disorders, FFT also addresses delinquency and violence. SAMHSA and NIDA consider FFT an evidence-based approach for the treatment of substance use disorders in adolescents.
- Multisystemic Therapy (MST): MST is an intensive family and community based treatment program targeting adolescents aged 12 to 17 who already have a history of arrests related to substance misuse. MST focuses on behavior change among criminal youth and the parenting skills of their caregivers. MST therapists meet with adolescents at home, school, or other places convenient to the adolescent and family. NIDA considers MST an evidence-based approach for the treatment of substance use disorders in adolescents.
- Multidimensional Family Therapy (MDFT): MDFT is a family-based outpatient treatment program for adolescents with substance use disorders and co-occurring disorders. MDFT can be offered in a variety of settings. The program is delivered in 12 to 16 weekly or multi-weekly sessions, focusing on interpersonal relationships with parents and peers, parenting practices, parent-adolescent interaction, and improved family communication. The benefit to cost ratio for MDFT is $0.29 in benefits for every dollar spent. NIDA and the National Institute of Justice consider MDFT an evidence-based approach for the treatment of substance use disorders in adolescents.
- Brief Strategic Family Therapy: Brief strategic family therapy (BSFT) was designed to prevent, reduce, and/or treat behavioral issues among adolescents, including substance misuse. Sessions can be conducted in the home or at other locations convenient to the family and are generally delivered in 12 to 16 family sessions. Research indicates that BSFT reduces substance use among adolescents as well as decreases alcohol abuse among parents. NIDA considers BSFT an evidence-based approach for the treatment of substance use disorders in adolescents.
- Behavioral Couples Therapy: In behavioral couples therapy (BCT), therapists work with the individual who has a substance use disorder as well as their spouse or partner. Spouses and partners are included in substance use disorder treatment to provide support with abstinence and help to prevent relapse. Couples attend therapy sessions together, developing a recovery contract, completing homework assignments, and learning effective communication skills. Research shows that BCT leads to increased abstinence and improved relationships when compared to individual-based treatments. BCT is listed in The Surgeon General's Report on Alcohol, Drugs, and Health as an evidence-based treatment for substance use disorders.
Examples of Behavioral Therapy Models
- The Southwest Montana Community Health Center in Butte, Montana, has provided training in motivational interviewing for all staff and provides cognitive behavioral therapy as part of its substance use disorder screening and treatment program.
- Great Lakes Recovery Centers, serving the counties located in Michigan's Upper Peninsula, offers a variety of outpatient services for alcohol use disorder and other substance use disorders. The centers provide substance use disorder assessment and counseling, as well as individual and group counseling.
- The Na'nizhoozhi Center, Inc., in Gallup, New Mexico, has adapted the community-reinforcement approach to serve Navajo Native Americans with alcohol use disorder in a residential program.
- Appalachian State University has conducted a study in rural western North Carolina on implementing the Matrix Model in rural communities. Preliminary findings have shown that the Matrix Model resulted in high percentages of clients demonstrating continuous abstinence from stimulants.
Considerations for Implementation
To be effectively implemented, many behavioral therapies require training. Trainings may be either in person or via web-based training. Travel, certification fees, and other training expenses may be a barrier for rural providers.
Some of these behavioral therapy models have tested computerized or web-based versions with promising results. Examples of effective electronic-based therapies include:
- Addiction-Comprehensive Health Enhancement Support System (A-CHESS) is a smartphone-based application designed to provide continuing care in order to prevent relapse for patients with alcohol use disorder.
- CBT4CBT is a computer-based version of cognitive behavioral therapy.
- Reduce Your Use is a web-based, self-guided program that uses cognitive, motivational, and behavioral methods for the treatment of cannabis use disorder.
- Self-Help for Alcohol and other Drug Use and Depression (SHADE) is a computer-delivered intensive motivational treatment available on DVD for people with co-occurring substance use disorders and depression.
- Therapeutic Education System (TES) is a web-based version of community reinforcement approach therapy.
A computer-assisted or web-based version of behavioral therapy could have significant benefits on the expansion of behavioral therapy interventions to rural communities where transportation and access to care are barriers to treatment.
Implementing contingency management interventions does not necessarily require a counselor or other staff who have been formally trained in behavioral therapy. This can be beneficial in rural communities where there are limited mental health providers. Even in communities with access to providers, one 2012 study showed that contingency management was an evidence-based practice with which clinicians were least familiar and least likely to adopt. A drawback to this model is the cost of implementation, as funding is needed for the provision of incentive items.
A benefit of the community reinforcement approach (CRA) is that it is a highly flexible treatment approach and is easily adaptable for special populations, including populations with special needs and cultural minorities. CRA has been integrated into a family therapy approach (community reinforcement and family training, or CRAFT) where concerned family members or significant others receive assistance addressing resistance to treatment from the person with the substance use disorder. Additionally, CRA Plus Vouchers has been effectively adapted for adolescents aged 13 to 25.
While motivational interviewing (MI) is typically used as a brief intervention for facilitating patients' entry into treatment, MI can be used effectively as a stand-alone treatment in rural communities where patients may experience challenges accessing treatment programs. MI can be integrated into a variety of treatment settings, making it beneficial to rural communities that may lack intensive inpatient treatment programs.
Program Clearinghouse Example
Resources to Learn More
Cognitive-Behavioral Therapy for Substance Use
Provides background information on the use of cognitive behavioral therapy for substance use disorders, covering treatment elements and common challenges.
Author(s): McHugh., R., Hearon, B., & Otto, M.
Citation: The Psychiatric Clinics of North America; 33(3), 511-525
Motivation for Change in Substance Abuse Treatment
A manual, part of the Substance Abuse and Mental Health Services Administration's Treatment Improvement Protocol series, created to give treatment providers a thorough background on motivational interviewing and tips on its implementation.
Organization(s): Substance Abuse and Mental Health Services Administration
Family Therapy (FFT)
A program description that provides background information on functional family therapy as well as information on evidence ratings.
Organization(s): County Health Rankings & Roadmaps
Provides a two-day training on delivering the matrix model and has adapted a training for American Indians/Alaskan Natives. Although it is based in California, they offer on-site trainings at other locations.
of Adolescent Substance Use Disorder Treatment: A Research-Based Guide
This guide covers basic principles of substance use disorder treatment among adolescents, FAQs and lists evidence-based approaches for treatment adolescent SUD.
Organization(s): National Institute on Drug Abuse
Program Profile: Adolescent
Community Reinforcement Approach
Profile which provides a background on the Adolescent Community Reinforcement Approach (A-CRA), along with links to studies and costs of implementation.
Organization(s): National Institute of Justice