Behavioral Therapies

A substantial body of research supports the use of behavioral therapies for treating SUDs. Various approaches have emerged from empirical research as effective for treatment of SUDs, including contingency management and community reinforcement, cognitive-behavioral therapy, family and couples therapy, motivational therapy, and 12-step facilitation (Carroll, 2005; Carroll and Onken, 2005; Moos, 2007). A meta-analysis of treatment interventions for alcohol use disorders suggested that the psychosocial interventions with the most consistent evidence of effectiveness include brief interventions based on motivational enhancement therapy, social skills training, community reinforcement approaches, behavior contracting, and behavioral marital therapy (Miller and Wilbourne, 2002). A recent meta-analysis comparing effectiveness between psychosocial treatments for alcohol use disorders found that therapies on average had no difference in effect sizes when compared with one another, suggesting that while each of these treatments has demonstrated effectiveness when compared to control or non-treatment conditions, the relative effectiveness of these types of treatments is more or less equivalent (Imel et al., 2008). For other substance abuse beyond just alcohol, a meta-analysis of 34 treatments for SUDs found that psychosocial treatments had a moderate effect size (comparable to those of other efficacious psychiatric interventions); contingency management had the greatest effect sizes; and interventions for cannabis use were the most efficacious (Dutra et al., 2008). The therapeutic approaches that have consistently garnered the most empirical support are briefly reviewed in this section. As discussed earlier in this chapter, it should also be noted that the skill and experience of the therapist are presumably at least as important as the particular therapy that is delivered, a finding that is further supported by the Imel et al. (2008) meta-analysis.

Contingency management is a treatment approach based on operant conditioning theory and the principle that future behavior is based on the positive or negative consequences of past behavior. Positive (drug effects) and negative (withdrawal symptoms) reinforcers support continued substance use. To reinforce abstinence, other rewards are introduced. The challenge is to identify for a desired behavior a reward that is practical and sufficiently powerful. Recent effectiveness trials within the Clinical Trials Network confirm the value of providing inexpensive incentives for abstinence (contingency management) among stimulant users in outpatient (Petry et al., 2005) and methadone (Peirce et al., 2006) treatment settings. A Cochrane review of randomized controlled trials found that incorporating some form of contingency management or community reinforcement approach was associated with slightly better outcomes and improved retention in care among patients with stimulant use disorders (Knapp et al.,

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