Theory-based active ingredients of effective treatments for substance use disorders

Abstract

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches. The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients’ life contexts, and how much their influence varies depending upon clients’ demographic and personal characteristics.

Introduction

A considerable body of research has identified specific effective psychosocial treatments for substance use disorders among adults, including motivational interviewing (MI) and motivational enhancement therapy (MET), 12-step facilitation treatment (TSF), cognitive-behavioral treatment (CBT) and behaviorally oriented family counseling (BFC), and contingency management (CM) and community reinforcement approaches (CRA) (Finney et al., in press). However, we still know relatively little about precisely why these treatments work.

The perspective I espouse here is that the probable active ingredients that underlie effective psychosocial treatments for substance use disorders are conceptually comparable to the social processes that protect individuals from developing substance use problems (Oetting and Donnermeyer, 1998, Petraitis et al., 1995). In this regard, four related theories have been applied to identify key social processes that, if present, protect individuals against the initiation and development of substance use problems and facilitate their resolution. These four theories are social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory; they identify comparable protective social processes in several life domains, including families, friendship networks, and the workplace (Moos, 2006).

After describing these theories, I focus on the rationale underlying each of the four sets of proven psychosocial treatments for substance use disorders and briefly note evidence of their effectiveness. I then show how the four theories identify probable active ingredients of these psychosocial treatments. In conclusion, I raise six issues about the active ingredients involved in effective treatment for substance use disorders and suggest directions for future research. To note, this review focuses on the psychosocial processes involved in substance use disorders and does not address biogenetic or pharmacological factors.

According to social control theory, strong bonds with family, friends, school, work, religion, and other aspects of traditional society motivate individuals to engage in responsible behavior and refrain from substance use and other deviant pursuits. These bonds encompass monitoring or supervision and directing behavior toward acceptable goals and pursuits. When such social bonds are weak or absent, individuals are less likely to adhere to conventional standards and tend to engage in undesirable behavior, such as the misuse of alcohol and drugs. The main cause of weak attachments to existing social standards is inadequate monitoring and shaping of behavior, including families that lack cohesion and structure, friends who espouse deviant values and engage in disruptive behavior, and lack of supervision and vigilance in school and work settings (Hirschi, 1969).

Behavioral economics or behavioral choice theory, which is closely related to the social control perspective, focuses specifically on involvement in protective activities. In behavioral choice theory the key element of the social context is the alternative rewards provided by activities other than substance use. These rewards can protect individuals from exposure to substances and opportunities to use them, as well as from escalating and maintaining substance use. The theory posits that the choice of one rewarding behavior, such as substance use, depends in part on lack of effective access to alternative rewards through involvement in school and work pursuits, religious engagement, and participation in physical activity. For example, physical activity and substance use may both elevate mood and decrease anxiety, which may make them functionally similar and substitutable (Bickel and Vuchinich, 2000).

According to social learning theory, substance use originates in the substance-specific attitudes and behaviors of the adults and peers who serve as an individual's role models. Modeling effects begin with observation and imitation of substance-specific behaviors, continue with social reinforcement for and expectations of positive consequences from substance use, and culminate in substance use and misuse. In essence, this theory proposes that substance use is a function of positive norms and expectations about substances and family members and friends who engage in and model substance use (Bandura, 1977, Maisto et al., 1999).

Finally, stress and coping theory posits that stressful life circumstances emanating from family members and friends, school, and work, lead to distress and alienation and eventually to substance misuse. For example, the work stressors model suggests that employee substance use is a response to problems in the workplace, such as interpersonal conflict with supervisors and coworkers, unfair treatment, meaningless and low-level work, high work demands, and lack of participation in decision-making. Stressors are most likely to impel substance use among individuals who lack self-confidence and coping skills and who try to avoid facing problematic situations and escape from experiencing distress and alienation (Kaplan, 1996).

The key elements of social control theory involve bonding or support, structure or monitoring, and goal direction (Table 1). The salient elements of behavioral economics and behavioral choice theory are fostering involvement in traditional activities that provide relevant rewards and protect individuals from temptation to use and misuse substances. The most important aspects of social learning theory are observation and imitation of family and social norms and models and the formation of expectations about substance use. Stress and coping theory focuses heavily on the development of self-confidence and coping skills to manage high-risk situations and general life stressors. Each of the four sets of effective psychosocial treatments for substance use disorders relies on one or more of the social processes associated with these theories.