Healing Addiction: One Size Does Not Fit All

September 3, 2019

Young woman visiting therapist counselor, feeling depressed, unhappy and hopeless, needs treatment and rehab for addiction to drugs.

Note: we’d like to thank Seasons in Malibu, a CARF-accredited, licensed substance abuse and mental health treatment center in Malibu, California, for their sponsorship of this post. The views below are those of HealthyPsych.com.

Introduction

Addiction is a multifaceted, common and potentially devastating malady, experienced by over 20 million Americans each year.[1] Because of its complexity, multiple theories abound with regards to both the causes of and remedies for addiction, taking into account the type of substance (or addictive behavior); degree of severity; and relevant biological, psychological and social factors. Like any disease[2] process, it’s important to evaluate and treat the whole, unique person who harbors the illness, rather than offering a one-size-fits-all approach. With that said, this article will provide a brief overview of treatment options designed to heal addiction, drawing on the latest research whenever possible.

“The question is not: why the addiction?
The question is: why the pain?” – Gabor Mate, MD

Theories of Addiction

At its most basic level, addiction is about trying to feel or not feel something. The National Institute on Drug Abuse defines addiction more specifically and clinically as “a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain.”[3] In addition to substances like alcohol, prescription and non-prescription drugs, addiction can apply to virtually anything, including food, gambling, sex, internet use and even work, with the key attributes being: compulsive and harm causing.

The initial, erroneous view of addiction was that it was a failure of morals and willpower. This couldn’t be further from the truth and unfortunately this misguided perspective has been harmful to individuals struggling with addiction. The two most current, compelling theories about the causes of addiction, supported by both research studies and clinical practice, are the brain disease and self-medication model.

The brain disease model of addiction posits that repeated exposure to a substance desensitizes our neural reward circuits, resulting in decreased ability to experience pleasure; increased reactivity to stress; and poorer executive functioning.[4] All of which form a vicious circle of decreasing coping skills, along with increasing cravings for the substance (or behavior). The brain disease model of addiction recognizes the role of environmental influences, such as stressful life events, but the emphasis is more on the biological mechanisms, including genetic predisposition[5].

Young businessman at workplace appearing stressed perhaps because struggling with addiction.

The self-medication hypothesis, first articulated by Harvard Medical School Professor of Psychiatry, Dr. Edward Khantzian and colleagues, believes the addiction process is an attempt at self-regulation, a means of coping with emotional distress. Ample evidence, as noted in the large Adverse Childhood Experiences (ACE) Study, shows that early life trauma, whether in the form of abuse, neglect, loss or other adversity, increases risk factors for the development of a multitude of health problems, including addiction. As Gabor Mate, MD, author of In the Realm of Hungry Ghosts: Close Encounters with Addiction writes, “The question is not: why the addiction? The question is: why the pain?”[6]

There is wisdom in both theories: addiction is a means of coping with pain AND repeated exposure to a substance or behavior does change the brain. Whether nature, nurture, or both, the good news is that there are many paths toward healing that can rewire the mind and body back to health.

Paths Toward Healing

Despite the prevalence of addiction problems, only 10% of people in the US receive any type of treatment.[7] To call this unfortunate is a vast understatement, as the costs in the form of premature deaths (nearly 150,000 per year in the US related to alcohol and drug overdoses[8]), relationship problems, and other forms of dysfunction are grave ($400+ billion dollars in lost productivity in the workplace, health care costs, and money spent on criminal justice[9]). As clinicians, researchers and society as a whole, we must do a better job of engaging those who need assistance, eliminating stigma, and doing everything possible to prevent abuse in the first place.

Each person contending with addiction requires a personalized and dignified approach to healing that starts with an honest assessment of the problem – discerning the impacts on one’s body, mind, relationships, occupation and other key areas of functioning. The next step is to define one’s goals.

Do you want to abstain from substance use entirely, or want more of a harm reduction approach? Has your problem become so severe that you require detoxification in a hospital? Could you benefit from the intensive support and structure of a residential program? Are your goals more related to improving your relationships, becoming a better father, mother, husband, wife, friend or co-worker? Maybe you’re most concerned about how to manage your mood or anxiety. Or, perhaps you’re unsure if you have a “problem” at all; if so, you can start by completing a short questionnaire known as the CAGE or speak with your primary care physician to learn more.

It’s safe to assume that most people around the world have struggled with some type of addiction, whether they meet the criteria for a formal diagnosis or not. As the Buddha said 2,500 years ago, life is replete with “10,000 joys and 10,000 sorrows.” It’s both hard and beautiful at the same time. And, whether due to early life experiences, current stressors, biological characteristics like temperament, or all of the above, life may be arguably harder for some.

“The opposite of addiction isn’t sobriety. It’s connection.”
– Johann Hari, Journalist

There are many pathways to addiction recovery, all of which involve developing the skills of emotional literacy – the ability to understand oneself deeply, regulate emotions, and perhaps most importantly, connect with others in an empowered, authentic, mutually respectful way. The type and severity of addiction, along with the inner and outer resources available, help guide one toward the best course of action for healing.

The following broad categories of intervention[10] have been shown to be helpful in treating addiction:

Behavioral counseling
Medical services including medication and detoxification
Concurrent treatment of co-occurring disorders
Ongoing follow-up via community and other recovery support systems

We will go into a more detailed discussion of these, including self-help strategies that may be of benefit, referencing evidence for their efficacy whenever possible.

Note: the following list is to be used for informational purposes only and does not replace the personalized assessment of a healthcare professional. Please keep in mind that treatment varies depending on the type of substance or behavior involved and individual characteristics. The more “severe” the addictive process (e.g., harm causing), the greater likelihood that more intensive interventions will be required.

“Studies have shown that just getting help is one of the most important factors in treating alcohol addiction; the precise type of treatment received is not as important.”
– National Institute on Drug Abuse

People who overcame addiction by supporting each other through rehab, holding each other by hands.

Self-Help

There are many self-help strategies targeting addiction that take into account a variety of theories of behavioral change. These are likely to be most beneficial when used in conjunction with more formal, professional supports,[11] but may be helpful as a standalone option when there exists resistance or inadequate access to more formal means.

1.) Basic Self-care: in the demanding, busy world in which we live, it’s common to forgo basic care needs, like healthy eating, exercise, sleep and quality social If you’re unsure where to begin with your recovery process, start by paying attention to just one or two of these. It will make a difference as you build a foundation toward healing.

2.) Bibliotherapy: a first and easy step for many when realizing they (or a loved one) have a problem is to learn more by reading (or listening to audio). As Janet Barlow, LCSW notes, bibliotherapy is about “finding solace and support through the written word”[12] by exploring reading materials that provide information, insight and/or skill development. She notes how personal stories from individuals facing addiction can be particularly helpful with self-acceptance and compassion, as the reader identifies with the author.[13] Bibliotherapy also encompasses writing exercises like journaling and using workbooks, both of which have been shown to be therapeutic, in particular when emphasizing both emotional expression and cognitive processing.[14]

3.) Digital Tools Like Apps: there are several online apps targeting substance use disorders and addictive behaviors, including: reSET (prescribed in conjunction with outpatient treatment, approved by the FDA); Sober Grid (networking app that connects users with other sober people; backed by the NIH); and WEConnect (focuses on building routines, accountability and positive reinforcement; users report improvement in abstinence and treatment plan adherence).

4.) Peer-Led Support Groups: studies show that a connection to a group is a key component of habit change. The 12-Step program is the most famous model of peer-led support for addiction recovery, with a multitude of free groups targeting specific addictions. Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Overeaters Anonymous (OA) are the most known; a full list can be found here. Studies indicate strong evidence for AA’s effectiveness using a number of measures.[15]

As noted in Facing Addiction in America: “Research studying 12-step mutual aid groups, specifically those focused on alcohol, has shown that participation in the groups promotes an individual’s recovery by strengthening recovery-supportive social networks; increasing members’ ability to cope with risky social contexts and negative emotions; augmenting motivation to recover; reducing depression, craving, and impulsivity; and enhancing psychological and spiritual well-being.”[16]

AA’s program book can be read here for free. The less traditional may connect better with Recovery: Freedom From Our Addictions, the comedic actor, Russell Brand’s humor-infused version of the 12 steps and how he used them to recover from addiction. Participants in peer support groups like AA often say it can take time to find the “right” group, where you feel substantial kinship with the members that will inevitably vary in terms of background. So, don’t quit if the first (or second) group you attend doesn’t feel like the right fit.

5.) Al-Anon Groups: peer-led groups, like Al-Anon, have also been a tremendous source of support and education for family members with loved ones struggling with addiction. The US surgeon general’s report states: “studies of Al-Anon show that participating family members experience reduced depression, anger, and relationship unhappiness, at rates and levels comparable to those of individuals receiving psychological therapies.”[17]

6.) Spirituality: a 2013 review of studies found “evidence suggesting at least some support for a beneficial relationship between spirituality or religion and recovery from substance use disorders.”[18] Spirituality plays a prominent role in 12-step programs and ample evidence supports the general mental health benefits of spiritual practices like mindfulness and yoga, with some promising data [19][20][21] related to addiction recovery specifically.

As noted in JAMA Psychiatry, “Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes.” A 2018 meta review found that evidence in support of yoga for depression, anxiety, and trauma to be “encouraging but preliminary.”[22]

SAMHSA supports several faith-based initiatives involved in addiction treatment as well. If you’re part of a (healthy) religious community, consider speaking with your priest, pastor, rabbi, imam, or other spiritual teacher about your concerns.

“Studies show that people must believe in their capacity to change and that things will get better to achieve more permanent habit change. Groups can have a powerful effect on belief by providing shared experiences and opportunities for people to publicly commit to change.”
–Charles Duhigg, Author of The Power of Habit

Group therapy session for healing addiction. Psychologist and several clients sitting in circle supporting each other in addiction treatment and rehab group.

Formal/Professional

Effective professional intervention does not focus solely on the addiction, but treats the whole person, addressing the relevant biological, psychological, social and spiritual factors in their life (where ‘social’ is a catchall term that encompasses quality of relationships, cultural factors, financial/vocational status, and legal matters and more).

Culturally sensitive care that addresses the unique needs of the individual is important. For example, studies show that the treatment needs of women are often different from men, as are those of racial/ethnic minorities, in contrast to whites. Each person will present with distinct challenges and strengths to be drawn upon.

1.) Outpatient Care: individuals and families contending with addiction often work with psychiatric professionals in an outpatient setting. These services can be paid for through insurance or by self-pay, depending on the professional or clinic offering the service.

Psychiatry is a division of medicine dedicated to the study and treatment of people with mental, emotional, and behavioral disorders, including addiction. Psychiatrists and psychiatric nurse practitioners are able to prescribe medications as part of a treatment plan, if warranted. For example, if one is trying to cope with depression or anxiety by using drugs, the psychiatrist may offer a safer medication on a temporary or long-term basis, depending on the needs and goals of the patient. Psychiatrists and other medical doctors also oversee detoxification services, which typically take place in a 24-hour setting (see Residential Treatment and Detox/Hospital sections for more info).

Psychotherapy/Counseling involves regular meetings with a trained professional with expertise in treating addiction. The therapist works with individuals, families, and groups to build motivation and teach them about their mood, feelings, thoughts and behaviors in order to impart personal awareness and healthier coping skills. Counselors can assist in building social support and may also offer referrals to other healthcare and social service agencies, when there are medical, housing, financial stressors, and other tangible matters that require attention.

The National Institute on Drug Abuse [24] identifies the following behavior-oriented therapies as having the strongest evidence base for addiction treatment:

Other forms of therapy may also be effective, depending on client characteristics and motivation for change, including counseling that’s geared toward developing stress management skills. Proponents of the self-medication model of addiction also advocate for any form of therapy that heals unresolved trauma and teaches self-regulation, such as somatic experiencing, EMDR, DBT, and ACT, recognizing that these modalities alone may not be sufficient for healing the totality of addiction.

For many facing addiction, engagement in a group is necessary for recovery. Healthy group membership, whether of a therapeutic or other nature, can provide the invaluable benefits of support, insight, stabilization and sense of belonging. It’s quite possible that, while perhaps eliciting more vulnerability than 1:1 interventions, participating in a therapeutic group may actually be more impactful than individual work.[25]

Medical Care: addressing relevant medical needs is an integral part of addiction treatment, as physical ailments may contribute to or exacerbate substance abuse. For many, addiction to painkillers starts with a prescription, so it’s important for both individuals and healthcare professionals to assess for history of substance abuse as well as risk factors, relying on pain management specialists when possible.

Complementary and Alternative Medicine (CAM): there are a variety of less traditional interventions that may be helpful adjuncts in the treatment of addiction, offered in both outpatient and residential treatment settings, depending on the program.

Studies [26][27] show that nutrition therapy plays an important role in treatment addiction. Acupuncture has been shown to be an effective pain management tool[28] and may also offer other benefits in the treatment of addiction, including during detoxification.[29][30]

Clinicians and patients alike also endorse the value of art therapy, bodywork, music therapy and animal-assisted therapy in the treatment of addiction.

2.) Intensive Outpatient Programs (IOPs): an IOP is a program used to treat a variety of psychiatric problems, including eating disorders, depression, self-harm, and chemical dependency without detoxification. IOPs are considered when a person doing individual therapy requires a higher level of support and also as a step-down or transition from an inpatient or residential program. IOPs typically last about 4-6 weeks, with clients attending multiple weekly individual and group counseling sessions. People attending IOPs can typically still maintain their daily responsibilities, like going to work, because the services are offered in the evening and/or on weekends.

3.) Residential Treatment: residential treatment, sometimes referred to as ‘inpatient rehab’ or simply ‘rehab’ is helpful when an individual requires a high level of support and structure around-the-clock, due to the severity and/or complexity of their addiction. These voluntary programs are staffed by licensed professionals and serve to provide the stability, accountability and positive reinforcement that may be missing in an individual’s home life. Experts recognize that sometimes one must change their environment completely, in order to “reboot one’s system” through an immersive experience that ushers in new, healthier routines; removes triggers; and allows for the rapid development of coping skills.

Length of stay in residential treatment is typically 30-60 days, but can be long-term as well. Healing modalities consist of regular individual and group therapy sessions focused on recovery and relapse prevention; medication evaluation and monitoring; family counseling; and a variety of other interdisciplinary methods, depending on the program and client needs. Detoxification services are also offered in some residential rehab centers.

Residential treatment for addiction may be covered by insurance or paid for privately, depending on the program. Different programs may offer specialties like dual-diagnosis treatment for those contending with both addiction and at least one other diagnosable mental health condition, including mood, anxiety and personality disorders.[31] Concurrent treatment of all maladies leads to the best outcomes.

Our sponsor, Seasons in Malibu, offers a free insurance check to try to open the doors to as many people as possible. They also focus on the treatment of co-occurring disorders.

Research [32] supports the potential benefits of residential treatment, emphasizing the need to match patient characteristics with service offerings. Many residential rehab centers strive to provide a comfortable and peaceful setting to increase engagement in the hard work necessary in addiction recovery.

4.) Detoxification/Hospitalization: eliminating toxins from the body is often the first step in recovery for those with a dependence on alcohol or drugs. Detoxification may be provided in a hospital, residential rehab, or outpatient basis, depending on patient needs. The withdrawal process can be both highly uncomfortable and sometimes pose life-threatening risks; the skilled services of physicians, nurses and other professionals help stabilize the patient until they’re ready for discharge to a less structured form of care.

A short-term stay in a hospital may be required when medical and psychiatric acuity is severe. Inpatient services in a hospital are covered by insurance in part or in full, depending on your insurance plan and hospitals are required to provide care to the uninsured when there’s a severe and/or life-threatening emergency.

There are a variety of medications that may be prescribed to aid in the detoxification process and prevent relapse when an individual has developed dependency on a substance. For example:

Opiate Dependence [33]:

Methadone, Buprenorphine (Suboxone) and Naltrexone (Vivitrol) help reduce withdrawal symptoms, cravings and the euphoric effects of heroin and other opiate containing drugs like prescription meds.
Use of these are most effective when combined with behavioral treatments like 1:1 and group counseling.

Alcohol Addiction [34]

Naltrexone: blocks pleasurable effects of alcohol and reduces cravings.
Campral: reduces withdrawal symptoms and helps maintain abstinence.
Antabuse: helps deter use of alcohol by producing uncomfortable side effects upon consumption.

5.) Aftercare & Relapse Prevention: clinicians and researchers agree that addiction recovery requires ongoing care. Just like physical fitness, one’s mind needs tending to throughout the lifespan in order to maintain a certain degree of health. “Aftercare” is a general term that encompasses the variety of services and strategies to aid in recovery and maintain progress after initial engagement. Sometimes the aftercare will be quite involved, at other times, more modest. Recovery coaches, case managers, mental health therapists, 12-Step groups and supportive housing are examples of aftercare services. Connection to informal supports, like healthy friends and family, is also integral to recovery.

Conclusion

As some have said, “80 percent of life is showing up.”[35] If you’re struggling with an addiction, whether mild, moderate or severe, the key is to take one step now toward your recovery. You can “show up” by talking to a trusted friend; trying a 12-step meeting; calling a therapist; or enrolling in that residential program you’ve been contemplating for a while now. Remember that there’s strength in vulnerability; try to let go of any shame or pride that gets in the way of looking honestly at yourself, and subsequently reaching out to others. Don’t delay, don’t minimize; like all disease states, the earlier you intervene, the better. After all, you matter – and what’s more important than your health!

Resources:

SAMHSA Behavioral Health Treatment Services Locator: an online search tool for locating behavioral health providers specializing in addiction treatment. Phone numbers and additional resources can be found here.

National Institute on Drug Abuse – Information for Patients & Families

National Institute on Drug Abuse – Frequently Asked Questions

References:

Disclaimer: the content provided here and throughout HealthyPsych.com is for informational purposes only and is not intended as medical advice. Please consult directly with your medical provider on your specific needs. Our full disclaimer and terms of use can be found here: Terms of Use.

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