Behavioral Therapy Models for SUD Programs

Behavioral therapies focus on changing behaviors concerning substance misuse, in part by teaching life skills that help people to better cope with situations that may lead to substance misuse and relapse. Several behavioral therapies have shown effectiveness in treating substance use disorders (SUD). Some therapies are better suited for a particular type of substance.

Individual counseling consists of one-on-one sessions with a counselor, psychologist, or therapist. It focuses on goal setting, overcoming setbacks, and tracking progress and may involve the use of various evidence-based approaches to support recovery.
Family-based counseling involves working with individuals and their family members to address the impact of SUD on family relationships and overall well-being.

Examples of individual and family-based behavioral therapy models are outlined below. The National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Evidence-Based Practices Resource Center provides additional information about the evidence base for behavioral therapy models.

Evidence-Based Behavioral Therapy Models that Focus on the Individual

Cognitive Behavioral Therapy (CBT) – Originally designed for depression treatment, research shows that CBT is a strong treatment option for multiple types of SUD. CBT teaches people how to identify problem behaviors and triggers for substance misuse and to develop coping strategies. Goals of CBT for SUD treatment include:
- Coping with substance use urges
- Improving communication
- Managing mood
- Increasing social support
CBT can help manage co-occurring issues with SUD, such as chronic pain or depression. CBT is frequently used as an individual therapy approach, and it can also be used in group therapy.
Contingency Management Interventions – Contingency management interventions use rewards to help people make positive changes in behavior, such as abstaining from substance use or attending a meeting. People in treatment receive a prize or reward for staying away from drugs (shown through a negative drug test). Rewards may be money, vouchers, gift certificates, clinic privileges, or other tokens. Research suggests that contingency management interventions may be effective in increasing treatment retention and abstinence from drugs. NIDA considers contingency management interventions an evidence-based approach for treating a range of SUDs.
Motivational Interviewing (MI) – MI is a counseling style that helps address ambivalence toward unhealthy behaviors. This evidence-based treatment helps individuals build confidence in their ability to make a change (self-efficacy), explore their own desire for change, and begin the process of creating a change. MI is designed as a brief intervention and could be beneficial in rural primary care settings where access to specialists may not be possible. NIDA considers MI an evidence-based approach for treating SUD.
Motivational Enhancement Therapy (MET) – MET uses MI approaches to strengthen motivation for behavior change. MET can be used to address behaviors associated with SUD, healthy eating, physical activity, and chronic disease. SAMHSA and NIDA consider MET an evidence-based approach for treating a range of SUDs.
The Matrix Model – The Matrix Model is an intensive outpatient treatment intervention with demonstrated effectiveness in treating stimulant use disorder. This multi-component intervention uses counseling, recovery skills development, relapse prevention techniques, and social supports to help maintain abstinence. The Matrix Model also includes education for friends and family members of the individual with stimulant use disorder. SAMHSA and NIDA consider the Matrix Model an evidence-based approach for treating stimulant use disorder.
Twelve-Step Facilitation Therapy – Twelve-step facilitation therapy is a brief, structured program with 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 structured as a therapeutic intervention with a counselor. The therapy can be conducted in individual or group sessions. SAMHSA and NIDA consider twelve-step facilitation therapy an evidence-based approach for the treatment of SUD.

Evidence-Based Behavioral Therapy Models that Focus on the Family

Family therapy focuses on using a family's strengths and assets to address substance misuse and reduce the impact of the misuse on the individual and family. Several common family therapy models are used in SUD treatment.

Family Behavior Therapy (FBT) – FBT is unique from other therapies in that it involves the patient and a family member or significant other attending sessions. In FBT, the patient and family member learn practical skills including vocational, communication, and handling strong urges. This intervention has shown positive results in both adults and in adolescents. While FBT treats SUD, it also addresses co-occurring issues like child mistreatment, depression, conduct disorders, and family conflict. SAMHSA and NIDA consider FBT an evidence-based approach for the treatment of SUD.
Functional Family Therapy (FFT) – FFT is a therapy designed for adolescents and their families. Over an average 12 sessions, a therapist works with the family to establish credibility, identify the adolescent's strengths, explore how family dynamics may be affecting behavior, help motivate positive change, and provide resources such as relapse plans. In addition to treating SUD, FFT addresses delinquency and violence. SAMHSA and NIDA consider FFT an evidence-based approach for the treatment of SUD in adolescents.
Community Reinforcement and Family Training (CRAFT) – CRAFT is a type of behavioral therapy designed to support the family members and friends of someone struggling with SUD. CRAFT does not directly involve the individual with SUD; instead, it focuses on improving the well-being of family members and friends and teaching them strategies for supporting their loved one to seek treatment. CRAFT is often used in group settings, intensive outpatient treatment programs, or as a telemedicine intervention in rural areas.
Multisystemic Therapy (MST) – MST is an intensive family and community-based treatment program designed for adolescents aged 12 to 17 who have had arrests related to substance misuse. MST focuses on behavior change among 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 SUD in adolescents.
Multidimensional Family Therapy (MDFT) – MDFT is a family-based outpatient treatment program for adolescents with SUD 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 and addresses interpersonal relationships with parents and peers, parenting practices, parent-adolescent interaction, and improved family communication. NIDA and the National Institute of Justice consider MDFT an evidence-based approach for the treatment of SUD in adolescents.
Behavioral Couples Therapy (BCT) – BCT is a type of therapy in which a person with SUD attends sessions with their spouse or partner. The intent of including spouses and partners is to build their support with abstinence and help prevent relapse. During sessions, couples work with a therapist, developing a recovery contract, completing homework assignments, and learning effective communication skills. Research shows that BCT has contributed to better substance use and relationship outcomes in comparison to individual treatment.

Examples of Rural Behavioral Therapy Programs

Great Lakes Recovery Centers, serving the counties located in Michigan's Upper Peninsula, offers outpatient services for alcohol use disorder and other SUDs. The centers provide SUD assessment and counseling, as well as individual and group counseling.
CRAFT therapy is currently offered through a partnership with the Aleutian Pribilof Islands Association (APIA) in Alaska where clients can receive therapy in rural towns including Unalaska, St. George, Atka, or Nikolski. CRAFT services are open to individuals 18 years and older, and tribal health beneficiaries can also receive them virtually.

Considerations for Implementation

Effectively implementing behavioral therapies for SUD in rural communities involves addressing several factors. Many behavioral therapies require training, which can be in-person or online. Expenses and logistics related to travel, certification fees, and other training costs may be a barrier for rural providers.

Leveraging technology may help rural communities increase access to SUD treatment. Some behavioral therapy models have tested computerized or web-based versions with promising results, Examples of effective electronic-based therapies include:

Comprehensive Health Enhancement Support System (CHESS Health), a smartphone-based application designed to provide continuing care to prevent relapse for patients with alcohol use disorder.
CBT4CBT, a computer-based version of cognitive behavioral therapy to improve substance use outcomes.

A computer-assisted or web-based version of behavioral therapy could have significant benefits in the expansion of behavioral therapy interventions to rural communities where transportation and access to care are often barriers to treatment.

Rural communities should consider therapies that offer flexibility in implementation. For example, contingency management interventions use rewards or incentives to encourage positive behaviors, such as staying drug-free or attending therapy. Contingency management intervention does not always require a formally trained counselor or other staff, allowing implementation by other healthcare providers, which can benefit rural communities with limited mental health providers. Limitations to using contingency management include costs for incentive items and lack of familiarity with the intervention.

Motivational interviewing is another intervention that offers adaptable implementation. While often a brief intervention to facilitate patients' entry into treatment, it can also be effective as a stand-alone treatment in rural areas where access is a challenge. Motivational interviewing can also be incorporated into trainings for community health workers to improve their ability to support patients in making positive health choices.

Program Clearinghouse Examples

Resources to Learn More

CLARE|MATRIX
Website
Provides two-day training for organizations and individuals in the Matrix Model, an evidence-based outpatient SUD treatment and behavioral health program that can be customized for different needs and settings. Offers onsite trainings in multiple locations.

Enhancing Motivation for Change in Substance Use Disorder Treatment
Document
Offers SUD treatment providers background information on motivational interviewing and tips on its implementation.
Organization(s): Substance Abuse and Mental Health Services Administration
Date: 10/2019