and for addiction therapists or students in addiction counseling programs, these are a primary focus of treatment. This is what we refer to as “talk therapy.” Talk therapy can take a variety of forms and orientations, including, but not limited to individual and group counseling, family therapy, educational lectures, cognitive-behavioral therapy (where the specific focus is on helping people to identify and change their thought processes and problematic behaviors), and psychotherapy.
A point of clarification: Most of the time, counseling and therapy essentially refer to the same thing. However, there are some distinctions between counseling and “psychotherapy,” with which it is helpful to be familiar. In the context of behavioral health (which includes addiction), “counseling” generally means a relatively brief treatment process that focuses on specific behavior. It often targets a particular symptom or problematic situation and offers suggestions and advice for dealing with it. Psychotherapy is typically (though not necessarily) a longer-term treatment that is oriented more toward gaining insight into mental and emotional challenges by focusing on the person’s thought processes and way of being in the world rather than on specific problems.
In clinical practice there is frequent overlap between counseling and psychotherapy. A therapist may provide counseling for specific situations and a counselor may function in a psychotherapeutic manner. As a generalization however, psychotherapy requires more skill than simple counseling, and is conducted by professionals trained to practice psychotherapy, such as psychiatrists, trained counselors, social workers, and psychologists. While a psychotherapist is qualified to provide counseling, a counselor may or may not possess the necessary training and skills to provide psychotherapy. These differences notwithstanding, for simplicity, I will use the terms “counseling” and “therapy” interchangeably.
Addiction treatment can involve the following levels of care: medical detoxification, inpatient rehabilitation, non-intensive outpatient treatment, intensive outpatient treatment, short-term residential treatment, and long-term residential treatment. All of these levels of care include various forms of talk therapy/counseling, addiction- and recovery-specific education, drug screening/testing to verify abstinence, and medication. Medications in addiction treatment can be those prescribed for detoxification and co-occurring psychiatric conditions, as well as agonist maintenance therapy and antagonist maintenance therapy.
An agonist is a molecule that combines with a receptor on a cell to trigger a physiological reaction. I liken the process to turning on an appliance through electricity. When you plug a blender into an electrical outlet, the plug is the agonist and the outlet is the receptor. The brain contains receptors. When certain drugs and medications fill those receptors, they trigger specific reactions. Agonist therapy includes medications like methadone and Suboxone (though technically, Suboxone is a partial opioid agonist—more about that later) that are designed to substitute for opiates/opioids, whether illicit or legally prescribed, on which people have become dependent (this will be discussed at length in Chapter Five). This notwithstanding, these medications have their own addictive potential and their use should be carefully structured and supervised.
There is also antagonist treatment. An antagonist is the opposite of an agonist. It is a medication that acts against and blocks the mind- and mood-altering effects of specific substances. Agonists and antagonists are key players in the chemistry of the nervous system. An example of a medication antagonist is naltrexone. This is used to block the effects of opiates and alcohol. I will also discuss these medications at length in Chapter Five.
In addiction treatment we see a lot of people who have psychiatric issues along with their addiction. There is a lot of depression and no small amount of bipolar symptomology among people with addiction. Addiction treatment providers also see a lot of anxiety disorders. Sometimes alcohol and other drugs are the primary cause of these psychiatric symptoms. In many others, the addiction contributes to and exacerbates co-occurring mental health problems that began prior to the initiation of substance use. Moreover, the existence of psychiatric issues also commonly complicates and exacerbates one’s active addiction.
When the field of addiction treatment was young, “sequential treatment” was typical. Unfortunately, what used to happen was that psychiatrists, psychologists, and therapists often refused to work with patients who were actively using alcohol or other drugs. At the same time, a lot of people in addiction treatment were uncomfortable working with addicts who also had psychiatric issues. As a result, nobody wanted to work with these patients with co-occurring addiction and psychiatric issues and they often fell between the cracks of the treatment and service delivery system. We have since learned that integrated and concurrent treatment in which patients’ addiction, mental health, and medical needs are addressed simultaneously is the most effective approach.
Behavioral therapies offer strategies for dealing with cravings, teach patients ways to enhance their coping capacity and prevent relapse, and help them deal with relapse should it occur. Addicts often suffer severe cravings. And unless they receive some form of treatment to help them learn how to manage cravings and withstand them, many addicts feel as though they have no option but to use. In treatment they learn and can practice other options. The desire to use is normal and may pop up from time to time, but there are a range of behavioral strategies that addicts in recovery can draw on instead of using.
Perhaps the most fundamental of these is instilling and reinforcing in patients the knowledge that cravings will pass because they come in bursts and spurts. Even though, for the person experiencing an intense desire to use, cravings can feel like they will last forever, they are always temporary. It is critical to teach this information because addicted people are not aware of it. The solution to cravings is to develop ways to ride them out. This often involves distraction, such as listening to music, going for a walk, going to a movie, or calling friends. This is one of the many areas where participation in mutual-aid/support programs, twelve-step programs in particular, can be extremely valuable. When people in twelve-step recovery are struggling, they can call their sponsor. They can go to a meeting; they can talk with members of their support group who have been through very similar experiences.
Why can’t addicts quit on their own? In the beginning, many addicts believe they can and from time to time they try to stop. For most addicts, discontinuing using means going through detoxification, the process of substances leaving the body and brain. Depending upon the substance and how long and how much someone used, the withdrawal symptoms people experience during detox can be agonizingly painful to potentially lethal. For example, opiate withdrawal from opiates/opioids like heroin, Vicodin, and OxyContin causes a withdrawal syndrome that is horribly painful, but it’s not dangerous (opioid overdose is dangerous but opioid withdrawal usually is not). However, withdrawal from sedative-hypnotics such as Xanax and Valium, and from alcohol, is extremely dangerous because people can die from DTs (delirium tremens) and seizures.
It’s important to not confuse how addicting specific substances are with the severity of the withdrawal syndrome associated with them. These are entirely different areas. For example, stimulants like cocaine and crystal meth are very addictive, but their withdrawal syndrome is minimal compared to opiates, sedative-hypnotics, and alcohol. To give you an idea of why, think of the neurons in your brain as little springs—alcohol and the sedatives keep the springs down, because they’re depressants. If you let a spring up really quickly, it bounces all over the room, but if you let it up slowly, you can control it. When people suddenly stop drinking, their neurons are firing like crazy (the springs are bouncing uncontrollably), and that can result in physiological instability, up to and including seizures.
But even when addicts are able to stop using—whether they detox on their own or through a medically supervised detoxification regime where medications are administered to make them safe and somewhat less uncomfortable—without treatment and/or working a program of recovery, the vast majority fail to achieve long-term abstinence. Detox is merely ridding the body of the physical presence of substances.
