ReviewTheory-based active ingredients of effective treatments for substance use disorders
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.
Section snippets
Rationale and effectiveness
Motivational interviewing (MI) and motivational enhancement therapy (MET) are client-centered directive treatments that utilize elements of the counsellor–client relationship to activate and capitalize on clients’ motivation and commitment for change. MI and MET seek to help clients resolve their ambivalence about change, reinforce clients’ statements about why they want to change, and strengthen clients’ commitment to actually change their substance use behavior (Miller and Rollnick, 2002). MI
Rationale and effectiveness
Twelve-step facilitation (TSF) treatment is based primarily on principles of Alcoholics Anonymous (AA) and a disease model of addiction. With respect to the process of treatment, TSF relies on aspects of social control theory in its provision of support, structure, and goal direction by, for example, focusing on helping clients admit that they have a substance use problem and accept an alcoholic or addict identity, and by emphasizing the importance of abstinence as a treatment goal, reading
Rationale and effectiveness
Cognitive-behavioral treatments (CBT) and behavioral family counseling (BFC) include individual and group approaches, such as social skills, self-control, stress management, and relapse prevention training, as well as couple and family-based approaches that involve relationship-focused interventions in addition to skills training. CBT and BFC are based primarily on social learning theory, which posits that substance misuse is a learned behavior whose onset and continuation is influenced by
Rationale and effectiveness
Contingency Management (CM) and Community Reinforcement Approaches (CRA) are based on the idea that substance use is initiated and maintained by environmental factors and can be changed by altering its consequences. These approaches reflect behavioral economics theory and the assumption that the use of substances should decline as the cost of obtaining and using them increases. A corollary assumption is that substance use should decline when substitute rewards are available; that is, when there
Common components of effective treatment
This review suggests that the probable common active ingredients of effective treatments for substance use disorders include an emphasis on (a) support, structure, and goal direction; (b) provision of rewards for abstinence and planning rewarding activities that can replace substance use, (c) abstinence-oriented norms and models, and (d) building self-efficacy and coping skills.
Issues and future directions
More knowledge about the active components of effective treatment is needed to enhance our understanding of the underlying processes of change, improve training programs for counselors, and contribute to better substance use outcomes. Several key issues need to be addressed to achieve these aims.
Conclusion
A number of theory-based social processes appear to protect youngsters and young adults from initiating substance use and progressing toward misuse. These processes involve bonding, goal direction, and monitoring from family, friends, religion, and other aspects of traditional society; participating in rewarding activities that preclude or reduce the likelihood of substance use; selecting and emulating individuals who model conventional behavior and shun substance use; building self-confidence
Acknowledgements
Preparation of the manuscript was supported by the Department of Veterans Affairs Health Services Research and Development Service and NIAAA Grant AA15685. John Finney, Mark Litt, Barbara McCrady, Christine Timko, and Paula Wilbourne made helpful comments on an earlier draft of the manuscript. Bernice Moos compiled and organized the literature cited in the manuscript. The views expressed here are mine and do not necessarily represent the views of the Department of Veterans Affairs.
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