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Substance Use Disorder Treatment: Therapy and More

Substance Use Disorder Treatment: Therapy and More

Treatment for substance use disorder can be inpatient or outpatient and is unique to each individual.

Every person with substance use disorder (SUD) has walked a unique path. For many people, substance or alcohol use was a way to self-medicate for depression, anxiety, or another mental health condition. For others, perhaps it began as a way to stay motivated during long hours of working or studying.

Regardless of the reason, substance use becomes less of a choice over time. Long-term exposure leads to changes in brain function, and the person is no longer in control. SUD affects the parts of the brain involved in reward and motivation, learning and memory, and control over behavior.

This is where evidence-based treatments come in. They can help rewire the brain in a variety of ways to put the person back in the driver’s seat.

SUD treatment is administered in two basic settings: inpatient and outpatient. The primary goal is for the person with SUD to be in the most effective — but least restrictive — environment to get them started, and then move them along a continuum of care depending on their needs.

From least to most intensive, this continuum of care includes:

  • outpatient treatment
  • intensive outpatient treatment
  • residential treatment
  • inpatient hospitalization

Different SUD treatment programs are usually based on three basic models:

  • Psychological model. This may include behavioral or talk therapy and looks at emotional dysfunction or potentially harmful motivations as the main cause of SUD.
  • Medical model. This requires medication to relieve symptoms and treatment by a physician. It emphasizes the physiological, biological, or genetic causes of SUD.
  • Sociocultural model. This aims to alter the physical and social environment of a person with SUD to address possible deficiencies in that environment. It may include self-help or spiritual activities. Oftentimes, people who have personal experience with addiction and are in recovery themselves facilitate treatment.

When you have SUD, it’s important to match your needs to the right treatment. In general, the right choice will depend on several factors, including:

  • whether the SUD has been diagnosed as mild, moderate, or severe
  • how motivated the person is
  • what their sociocultural environment is like
  • their cognitive functioning and level of impulse control
  • whether the person has any other mental health conditions

For most people, the main goal of treatment is maintaining abstinence, as it is significantly linked to a positive long-term prognosis. But being completely substance-free is only the beginning.

Many people receiving treatment for SUD may have complex problems in different areas, including:

  • physical and mental health issues
  • relationship problems
  • poor social and work skills
  • legal or financial difficulties

This means the ideal treatment needs to:

  • address mental and physical well-being
  • help resolve relationship issues
  • help improve educational and vocational skills

Outpatient behavioral treatment involves a variety of programs, including individual or group substance use counseling or both. This may include:

  • cognitive behavioral therapy (CBT)
  • family therapy
  • motivational interviewing
  • contingency management (incentives)

Psychosocial treatments target aspects of a person’s social and cultural environment, as well as any psychological and behavioral patterns that may cause difficulties in their life.

Residential or inpatient treatments can be very effective, particularly for individuals with severe SUD and those with co-existing conditions. Licensed residential treatment facilities offer 24-hour structured care with medical attention.

Once a person has completed medically managed intensive inpatient treatment, sometimes known as detoxification, or “detox,” it’s often very helpful to temporarily relocate to a monitored sober community within the first year. This period is considered the early remission phase.

Living in this monitored community may be beneficial because the person’s old familiar environment may have influenced their substance use.

In general, residential facilities to help people taper off or remain sober may include:

  • Shorter-term residential treatment. This approach focuses on therapy for cessation (“detox”) and provides initial intensive counseling and preparation for treatment in a community-based setting.
  • Therapeutic communities. These are highly structured programs where people remain at a residence, usually for 6–12 months. The whole community works together to impact the person’s attitudes, understanding, and behaviors associated with substance use.
  • Recovery housing. This setting provides supervised, short-term housing for people, often following other types of inpatient or residential treatment. Recovery housing can help people make the transition to an independent life. This may involve helping them learn to manage their finances or look for a job and connect them to support services in the community.

Psychotherapy, or talk therapy, is helpful for those living with SUD. It can reinforce motivation to remain sober and target any underlying mental health issues, including anxiety and depression.

You also learn stress-coping skills and how to work through relationship problems.

Several psychological treatments are supported by research and have been deemed appropriate by the American Psychological Association (Division 12) for treating SUD.

Motivational interviewing (MI)

Motivational interviewing (MI) is client-centered counseling developed to help you find the internal motivation to quit. Many people with SUD have a low or moderate desire to quit, despite the health, financial, social, and legal consequences the SUD may be causing.

MI helps you figure out what you want for yourself — not what the counselor thinks is good for you.

The role of the MI therapist is to ask open questions to get you to explore your ideas, experiences, and perspectives, and encourage you to recognize and resolve your own ambivalence or fear of change.

The goal is to get people to realize they are not being forced to give up something they love but rather be motivated to pursue a life they’ve chosen for themselves.

Motivational enhancement therapy (MET)

Motivational enhancement therapy (MET) is a good choice for people not quite ready to make significant changes in their lives.

It combines the style of MI with psychological counseling. While the former targets your internal motivation, the latter guides you to a new way of thinking if you’re fearful or unsure about treatment.

Research suggests the success of MET may depend on the type of substance used. It appears to be more effective for people with alcohol or cannabis addictions. Results are mixed for those using heroin, nicotine, or cocaine or those using multiple substances.

Prize-based contingency management (CM)

Prize-based contingency management (CM) rewards drug abstinence. For instance, a client might have the opportunity to win $100 after having a drug-negative urine sample. In some programs, people have a better chance of winning the longer they remain drug-free.

With CM, the incentive acts as positive reinforcement. It competes with the reinforcing effects of the addictive substance, therefore increasing the chances abstinence will be maintained.

CM is among the most empirically supported strategies for helping clients stay drug-free. It’s particularly encouraged for those with cocaine use disorder.

Research has shown CM to be effective for various types of SUD, including SUDs involving alcohol, nicotine, cannabis, cocaine, and opiates. Still, scientists note that it may not be effective long term.

The treatment may last from 8 to 24 weeks and is often used as an adjunct therapy alongside other treatments, such as cognitive behavioral therapy (CBT) or 12-step programs.

Seeking Safety

Seeking Safety is a therapeutic approach designed for people with both an SUD and post-traumatic stress disorder (PTSD). It’s a commonly used group treatment among veterans.

The fundamental principle of the program is the belief that combining treatment for co-occurring PTSD and SUDs is more effective and yields better results than treating each disorder separately.

Seeking Safety educates clients about the link between trauma, substance use, and coping skills and acknowledges how people often use substances to cope with anxiety.

The program is designed to be used with other treatments and can be administered in an individual or group setting. The treatment teaches drug-alternative coping skills and helps people find other ways to “feel safe.”

Still, some research indicates that it may improve symptoms of PTSD to a greater degree than those of SUD. Plus, it may be most effective when combined with other treatment options.

Guided Self-Change (GSC)

Guided Self-Change (GSC) is a brief cognitive-behavioral and motivational approach first developed for people with alcohol use disorder and then expanded to treat other types of substance use.

GSC combines CBT with motivational counseling similar to what is used in MI.

The CBT aspect of the program helps people increase their awareness of substance-using habits and recognize situations that may not be safe.

GSC is recommended for people with an SUD that’s mild or moderate. Some research indicates that it may also be helpful as an early intervention for teens with SUD.

Medications may be used during SUD treatment to:

  • help manage withdrawal symptoms
  • prevent recurrence of the condition
  • treat co-occurring conditions

When tapering off of the substance, you can experience painful withdrawal symptoms. It’s best to be monitored closely in a treatment center while tapering off.

When appropriate, your doctor will prescribe medications to address the physical withdrawal symptoms and help you feel more comfortable throughout this process.

One study of treatment facilities found that almost 80% of people undergoing therapy for cessation received medications.

Withdrawal can involve physical symptoms such as:

  • body aches
  • fatigue
  • restlessness
  • tremors
  • sweating
  • insomnia
  • nausea

Many people also experience psychological symptoms such as:

  • anxiety
  • depression
  • thoughts of suicide
  • nightmares
  • hallucinations
  • delirium

Medication can also be used to help re-normalize brain function and decrease cravings.

Currently, pharmaceutical drugs are available to treat SUDs involving:

  • opioids, including prescription pain relievers and heroin
  • tobacco/nicotine
  • alcohol

Medications to help with opioid use disorder

  • Methadone and buprenorphine. These two medications help diminish withdrawal symptoms and relieve cravings.
  • Naltrexone. This medication blocks the effects of opioids at the receptor sites and should be given only to people who have already completed therapy for cessation.

Medications to help with tobacco/nicotine use disorder

  • Over-the-counter nicotine replacement therapies. These include patches, sprays, lozenges, and gums.
  • Bupropion and varenicline. These prescription medications have been approved by the Food and Drug Administration (FDA) for nicotine addiction. They’re deemed more effective when combined with behavioral therapies.

Medications to help with alcohol use disorder

Three medications have been approved by the FDA for alcohol use disorder:

  • Naltrexone. This medication helps block the rewarding effects of drinking and reduces cravings.
  • Acamprosate. This medication may reduce symptoms of withdrawal such as restlessness, anxiety, insomnia, and dysphoria.
  • Disulfiram. This medication causes unpleasant effects after drinking alcohol, such as nausea, flushing, and irregular heartbeat.

Once you’re on the road to recovery, it’s important to engage in self-care, which may include attending a recovery support group and finding activities you enjoy.

Recovery support groups

Research has shown that peer-delivered recovery support services, including 12-step programs, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), can be beneficial for people recovering from SUD.

However, 12-step programs may not work for everyone.

While AA and NA may be best known, an internet search for “recovery support groups near me” may give you additional choices.

Self-care

Before going through treatment for cessation, the drug may have been a top priority in your life. Much of your time may have been spent thinking about the drug, seeking it out, using, and recovering.

Now you’ll need to fill that space with healthy and enjoyable pursuits. Consider participating in positive activities, such as exercise, meditation, and other recreational pastimes.

Not only does exercise offer all of the obvious health benefits, but it also shows promise for those in recovery from SUD.

A 2020 review of 59 studies found that both physical fitness programs (that include aerobic and strength exercises) and body-mind exercises (like yoga, tai chi, or qigong) can help improve mental disorders, craving, and quality of life in people with SUD.

Another study suggests that mindfulness meditation may improve emotion regulation and self-control, which may benefit people with SUDs, though more research is needed.

Treatment for SUD generally happens either in an inpatient or outpatient setting. It involves a form of talk or behavioral therapy and sometimes medication.

Regardless of how you got here, if you’re not happy with the path you’re on now, you can change your direction. Many people have been where you are now, and just as many are wanting to help you.

If you think you have a SUD, consider reaching out to a trusted healthcare professional for an evaluation and to discuss your treatment options.

If you want to learn more or are unsure where to begin, these resources may be worth checking out:

  • SAMHSA. You can call the Substance Abuse and Mental Health Services Administration (SAMHSA) helpline at 1-800-662-4357. This is a free, confidential, 24/7 treatment referral and information service available in English and Spanish.
  • Drugs and Me. Created by a group of educators, scientists, and analysts, Drugs and Me provides a detailed list of educational materials for different types of substance use.
  • National Harm Reduction Coalition. If you’re looking for advocacy, the National Harm Reduction Coalition is an action-oriented group for people with SUD.

Substance use during the pandemic

Opioid and stimulant use is on the rise—how can psychologists and other clinicians help a greater number of patients struggling with drug use?

Vol. 52 No. 2
Print version: page 22

The ongoing stress and uncertainty of COVID-19 have led to increased demand for mental health services from psychologists in the United States—but conditions like anxiety and depression aren’t the only mental health issues people are facing. Experts say misuse of opioids and stimulants is also on the rise—and psychologists are in a good position to help.

On top of the other risks arising with substance misuse, those with substance use disorders (SUD) are both more likely to develop COVID-19 and experience worse COVID-19 outcomes, including higher risk of hospitalization and mortality (Wang, Q., et al., Molecular Psychiatry, 2020).

According to the Centers for Disease Control and Prevention, as of June 2020, 13% of Americans reported starting or increasing substance use as a way of coping with stress or emotions related to COVID-19. Overdoses have also spiked since the onset of the pandemic. A reporting system called ODMAP shows that the early months of the pandemic brought an 18% increase nationwide in overdoses compared with those same months in 2019. The trend has continued throughout 2020, according to the American Medical Association, which reported in December that more than 40 U.S. states have seen increases in opioid-related mortality along with ongoing concerns for those with substance use disorders.

Mandy Owens, PhD, a clinical psychologist and researcher at the University of Washington Alcohol and Drug Abuse Institute, says she’s observed a spike in substance use that includes an increase in both quantity and frequency of drug use during the pandemic. Some people who use substances may have also started new drugs if their usual substances became more difficult to access. For example, Owens says Washington state has seen an uptick in the use of fentanyl, a synthetic opioid that’s increasingly produced illicitly, due to a shift in drug supply availability. But precise data on use and drug type are hard to come by, according to Wilson Compton, MD, MPE, deputy director of the National Institute on Drug Abuse.

Health care records are the primary source of data on substance use, and it can take months for medical providers to provide toxicology reports for overdose incidents to the CDC, says Sharon Walsh, PhD, a professor of behavioral science, pharmacology, pharmaceutical sciences, and psychiatry at the University of Kentucky (UK) and director of the UK Center on Drug and Alcohol Research. Tracking substance use accurately also heavily depends on the ability to do door-to-door household or school-based surveys, which have been more difficult to conduct during the pandemic.

However, Walsh says state-level data are a bit clearer. According to her research, Kentucky has seen increased emergency room visits for overdose-related incidents during the pandemic. By contrast, the state experienced a decline in emergency medical service runs for non-opioid related emergencies. “It really magnifies the opioid problem when you look at it against a decline in presentation at the hospital for other conditions,” she says.


Treatment of Substance Use Disorders Among Women of Reproductive Age by Depression and Anxiety Disorder Status, 2008-2014

Background: Comorbid substance use disorder and mental health conditions are common in women of reproductive age. We sought to understand the prevalence of substance use and substance use disorder by depression and anxiety disorder status and the independent association between depression and anxiety disorder status with receiving substance use treatment. Materials and Methods: A sample of 106,142 women ages 18-44 years was drawn from the 2008 to 2014 National Survey on Drug Use and Health. Differences in demographics, substance use, substance use disorders, and treatment by major depressive episode (MDE), and anxiety disorder status, were assessed with chi-squared tests. The independent association between MDE and anxiety disorder with substance use treatment was assessed with adjusted prevalence ratios. Results: Women with MDE and/or anxiety disorder had higher prevalence of substance use and substance use disorder than women with no MDE or anxiety disorder (p < 0.001). Less than a quarter of women with substance use disorders and both MDE and anxiety disorder received mental health and substance use treatment. After adjustment, women with substance use disorder and MDE and anxiety disorder, MDE only, or anxiety disorder only were more likely to receive substance use treatment (respectively, 2.4, 1.6, and 2.2 times) than women with no MDE or anxiety disorder (p < 0.001). Conclusions: Women with MDE and/or anxiety disorder are significantly more likely to suffer from substance use and substance use disorders than their counterparts. Integrating substance use treatment services and mental health services in settings frequently visited by reproductive-aged women may increase receipt of combined treatment.

Keywords: anxiety depression substance use disorder treatment women.


Treatment:

Oregon DUII Information/Early Intervention

12 Hours of class room instruction completed over 1 month competitively priced

Washington Alcohol and Drug Information School

8 Hours of class room instruction completed over 1 month competitively priced

Intensive Outpatient (Phase I)

Our Intensive Outpatient Program involves several contacts per week. The program is individualized for each client with the total time in treatment dependent upon progress and behavior. Services include:

  1. Groups three times weekly at three hours per session for a total of 9 hours per week
  2. Individual sessions as indicated
  3. Random Urinalysis submitted for testing
  4. Family Group

Outpatient (Phase II):

Many clients will begin treatment in Intensive Outpatient described above and then move to the Outpatient level of care. Some clients start services in Outpatient (Phase II) services.

Clients in this level of care attend treatment one to three times per week. The length of stay is individualized for each client and depends upon progress and behavior. Services include:

  1. Groups 1-3 times per week for two hours per session (6 hours or less per week)
  2. Individual sessions as indicated
  3. Random Urinalysis submitted for testing
  4. Family Group

Outpatient & Relapse Prevention (Phase III):

After completing Intensive Outpatient or Outpatient treatment, clients move to Phase III that consists of:

  1. Groups are once weekly for 2 hours (and may step down to twice per month)
  2. Individual sessions as indicated
  3. Random Urinalysis submitted for testing
  4. Family Group

Outpatient & Deferred Prosecution (Phase IV):

For Washington State Deferred Prosecution clients, this Phase IV is for two years following completion of Phase III. Services include:

  1. Groups monthly for 2 hours per session
  2. Individual sessions as indicated by client need
  3. Random Urinalysis submitted for testing

Topics:

The program includes many topics, including but not limited to the following:


Dialectical Behavior Therapy for Substance Use Disorders

Following the initial evidence supporting DBT for suicide and non-suicidal self-injury (NSSI) in the early 1990s, Marsha Linehan and colleagues introduced modifications to target substance use disorders (SUD) as one of the greatest risk factors for fatal outcomes. DBT-SUD developed by adding new principles, strategies, protocols, and modalities to address common problems and complications of addiction, while maintaining all of those from the original model for NSSI. For example, individuals with BPD and SUDs tend to demonstrate “butterfly attachment,” characterized by limited treatment inclination, fleeting commitment, and minimal attachment to providers whereas those with BPD without SUDS more often show an opposite attachment-seeking pattern. Therefore, a number of Attachment Strategies were added, such as assigning regular phone check-ins to build connection, orienting social networks to help reconnect with “lost” clients, and reinforcement of treatment participation. Some added DBT-SUD modalities include social networking meetings supporting attachment, urine toxicology screening, and pharmacotherapy to provide replacement medication for opioid addiction given its empirical support.

Is DBT-SUD really that different from standard DBT?

Before reviewing some of the specific modifications (for a more thorough review see McMain et al., 2007), it’s important to note that the general strategies of DBT-SUD for helping individuals with addictions are much the same as the standard DBT approach to orientation and commitment, behavioral targeting, validation, and problem solving. As with NSSI and suicide, substance-related targets are understood as efforts to emotionally regulate in the face of challenging circumstances and experiences, with similar learning histories related to benefits such as emotional relief, numbness, or pleasant emotions — at least in the short term. As with standard DBT, clients are oriented to the option of developing new capabilities through DBT for responding to problems in ways that are consistent with their values and with moving towards lives that they would experience as worth living. Substance-related targets are monitored on diary cards, prioritized as the top quality of life-interfering behavior, explored through behavioral chain analysis, problem-solved using solution analysis, and coached with phone consultation (even after using if it is deemed that skills might be generalized).

The Dialectic of SUD Treatment

In dialectical fashion, DBT-SUD synthesizes the two polarized and dominant SUD treatment approaches, including abstinence models such as 12-step programs and harm-reduction models such as cognitive-behavioral relapse prevention. The middle position of dialectical abstinence recognizes the wisdom and strengths of each by establishing a solid commitment to abstinence that cuts off all known paths to use (the Burning Bridges skill), with a total acceptance of slips as part of learning to establish more secure pathways toward abstinence. This synthesis leaves out the main limitations of the two approaches, namely the shame and resignation that typically transform lapses into full relapses within the abstinence approach (i.e., the abstinence violation effect), and the continuing substance use (i.e., non-abstinence) that tends to match the treatment expectation communicated by the harm avoidance approach. While initially articulated for treating addictions, dialectical abstinence was already fully present in standard DBT in its approach to treating suicide and NSSI. With those examples in mind, its practice would likely already be quite familiar to DBT providers.

The Dialectic of Kicking the Habit

A dialectic of common substance use states of mind is also included among the DBT-SUD skills with an Addict Mind consumed by the rationales, physical cravings, and emotional benefits of using (e.g., “no one will know,” “I deserve to,” etc.), which often vacillates with a Clean Mind that pushes away from the physical, cognitive, and emotional consequences of using. Unfortunately, Clean Mind tends to push so hard against Addict Mind that it inevitably lands on overly simplistic solutions for remaining abstinent (e.g., “I’ve learned my lesson,” “never again,” etc.), setting the stage for further repetition. The Clear Mind synthesis is fully open to both sides, fully pursuing abstinence while accounting for the draw of using. For example, the Alternate Rebellion skill involves practicing new expressions of rebellious pleasures that do not harm oneself, goals, or others, such as wearing outrageous T-shirts or “going commando.” Additional DBT-SUD skills include Community Reinforcement of abstinent behaviors, Building Bridges to new stimuli to condition abstinence, and Adaptive Denial of unbearable expectations of remaining abstinent. Over time, Linehan observed that the DBT-SUD skills are also very well-suited and relevant for targeting any habitual problematic behavior such as “addictions” to food, NSSI, social media, work, etc. (Linehan, 2014).

DBT-SUD Research Support

With five randomized controlled trials (RCTs) supporting it, DBT is the recognized treatment of choice for co-occurring BPD and SUD (Lee, Cameron, & Jenner, 2015). Three RCTs supported DBT-SUD for reducing substance use relative to treatment as usual (TAU Linehan et al., 1999) or for reducing use over time in a way that was comparable to somewhat stronger than comparison manualized SUD treatments (Linehan et al., 2002 Linehan et al., 2009). Two RCTs found that standard DBT without SUD modifications outperformed TAU and treatment by experts in substance use outcomes (Harned et al., 2008 van den Bosch et al., 2002). Harned and colleagues (2008) found that 87.5% of those with substance dependence who received DBT achieved full remission for at least 4 weeks, as compared to only 33.3% of those who received comparison treatment by experts. DBT-SUD findings were recently generalized in three important ways within a large pre-post effectiveness trial of primary SUD (i.e., no BPD inclusion criterion), Native-American clients, and adolescents (Beckstead et al., 2015).

Some practice tips for responding to Lying:

A common obstacle in treating clients with SUD is patterns of lying about their use, which may be particularly challenging for DBT providers committed to acceptance and validation. The following are DBT-consistent recommendations for managing this.

  • Be mindful of the Active-Passivity/Apparent Competence dialectical dilemma and the accompanying secondary target of inaccurate communication. These are individuals doing the best they can who learned that others are unavailable, uninterested, uncaring, and/or punitive of failings. As such, they’ve learned to protect themselves from disappointment or attack.
  • Be ready to validate lying based on the wisdom from past learning and expectations (level-4 validation).
  • If you find yourself feeling hurt or angry, seek the support of your team for getting back to a phenomenologically empathic formulation where “lying” can be descriptive and without judgment.
  • State your desire to develop a different, supportive, honest, and collaborative relationship.
  • Assess and validate any concerns that there could be actual consequences to their honesty with you (level-5 validation), such as information that could negatively affect legal decisions if shared including probation, disability status, child protective services, divorce proceedings, etc. Balance your commitment to being “on their side” with openness about the limitations of confidentiality.
  • Remain committed to acceptance regardless of their honesty, as well as committed to following the data including tox-screen results as part of addictions best-practices.
  • Be clear that although dishonesty may keep you at a distance and prevent treatment from working (and could ultimately necessitate a vacation from therapy if not surmounted), this is a shared problem you have together and it will not affect your experience of them as a person.
  • Listen to your gut. If the self-report is superficially plausible but doesn’t feel right, use level-three-validation mindreading such as, “As much as I would love to believe that what you’re telling me is true, and perhaps it is, I’d like you to know that I’m also completely open to the possibility that you’re not able to tell me what’s really going on right now. In fact, given the way things have gone before, you have to admit that it would be foolish of me to act as if I assumed what you’re saying is true.”
  • Continue to express availability, interest in understanding, regret for lost opportunities, and the desire to work together when possible.
  • Do not ask if they are telling the truth, and avoid outright accusations of lying. Such actions will only serve to back them further away from the truth.
  • The use of non-demanding mindreading opens the door toward more honest communication, if not in the moment, then over time.

References

  • Beckstead, D. J., Lambert, M. J., DuBose, A. P., & Linehan, M. (2015). Dialectical behavior therapy with American Indian/Alaska Native adolescents diagnosed with substance use disorders: Combining an evidence based treatment with cultural, traditional, and spiritual beliefs. Addictive behaviors, 51, 84-87.
  • Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T., Murray, A., Comtois, K. A., & Linehan, M. M. (2008). Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. Journal of Consulting and Clinical Psychology, 76(6), 1068.
  • Linehan, M. M., Lynch, T. R., Harned, M. S., Korslund, K. E., & Rosenthal, Z. M. (November, 2009). Preliminary outcomes of a randomized controlled trial of DBT vs. drug counseling for opiate-dependent BPD men and women. Presented at the 43rd Annual Convention of the Association for Behavior and Cognitive Therapies, New York, NY.
  • Linehan, M. M. (2014). DBT skill training manual (2nd ed.). New York: Guilford.
  • Lee, N. K., Cameron, J., & Jenner, L. (2015). A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug and alcohol review, 34(6), 663-672.
  • McMain, S., Sayrs, J. H., Dimeff, L. A., & Linehan, M. M. (2007). Dialectical behavior therapy for individuals with borderline personality disorder and substance dependence. Dialectical behavior therapy in clinical practice: Applications across disorders and settings, 145-173.
  • van den Bosch, L. M., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.

Learn More

If you’d like to learn more about the DBT addiction skills that Dr. Axelrod describes, you may be interested in our video series titled DBT Addiction Skills with Dr. Marsha Linehan.

Seth Axelrod, PhD, is a clinical psychologist and Associate Professor of Psychiatry at the Yale University School of Medicine, where he leads DBT and DBT for Substance Use Disorder teams for Yale-New Haven Psychiatric Hospital’s Adult Intensive Outpatient Program. He received his doctorate from the University of Kentucky, completed his internship with the Connecticut Department of Mental Health and Addiction Services, and did personality disorders postdoctoral training at the Yale School of Medicine. He co-founded the annual Yale NEA-BPD Conference, founded the Connecticut DBT Network, and is a member of Marsha Linehan’s annual DBT Strategic Planning Meeting. Dr. Axelrod’s research and publications are in the areas of borderline personality disorder and DBT adaptations.


Types of Counseling Offered

Initial Assessment

All registered UCF students are entitled to an initial assessment to determine what the focus of therapy will be and what type of services are most appropriate for a particular problem.

Individual Counseling

In a one-on-one interaction with a counselor, you are helped to express feelings, examine thoughts and beliefs, reflect on patterns of behavior, and work toward making healthy changes in your life.

Group Counseling and Workshops

Groups led by professional staff offer students a supportive and stimulating environment to explore common issues of concern. We encourage you to learn more about Group Counseling and to browse our complete list of current groups offered this semester at CAPS. CAPS also offers workshops. A workshop is an “in-house” psycho-educational program on a variety of topics. For a complete list of workshops and dates, go to this page.

Couples/Conjoint Counseling

Couples may seek premarital, marital, divorce, sexual adjustment, or alternative life-style counseling. Any two students, such as roommates, may also utilize this service to improve their relationship or to work out communication problems.

Both students must be enrolled at UCF to be eligible.

Crisis Counseling

Our staff offers crisis intervention services during regular office hours. Students under 18 years of age can be seen on a limited basis without parental consent while they are in crisis. Check our Emergency Services page for more information.

Therapy Assistance Online (TAO) Treatment

Therapy Assistance Online (TAO) is an up to 8 week, interactive, online therapy program that provides assistance for anxiety, depression, and other concerns. TAO is based on well researched and highly effective strategies for helping students in these areas. Throughout treatment, clients will watch videos and complete exercises individually for up to 2 hours per week, and then meet with a therapist via videoconferencing for a 10-15 minute appointment.

Therapy Assistance Online (TAO) Self Help

TAO Self Help is an interactive, web-based program that provides assistance to help overcome anxiety, depression, and other concerns. TAO is based on well researched and highly effective strategies. You can choose to view short, but helpful videos, take part in brief exercises, use logs to track moods and progress, and have access to a Mindfulness Library.

Kognito

Kognito is a set of role-play, avatar modules to educate faculty, staff, and students about mental health and suicide prevention.

Enrollment Key: centralflorida


Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE): Patient Workbook

Abstract

Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) is a an integrated treatment cognitive-behavioral psychotherapy program designed for patients who have posttraumatic stress disorder (PTSD) and a co-occurring alcohol or drug use disorder. COPE represents an integration of two evidence-based treatments: Prolonged Exposure (PE) therapy for PTSD and Relapse Prevention for substance use disorders, where both the PTSD and substance use disorder are addressed concurrently in therapy by the same clinician, and patients can experience substantial reductions in both PTSD symptoms and substance use severity. The program includes information about how PTSD symptoms and substance use interact with one another information about the most common reactions to trauma techniques to help the patient manage cravings and thoughts about using alcohol or drugs coping skills to help the patient prevent relapse to substances a breathing retraining relaxation exercise and in vivo (real life) and imaginal exposures to target the patient's PTSD symptoms.

Bibliographic Information

Authors

Sudie E. Back, author Professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina

Edna B. Foa, author Professor of Clinical Psychology in Psychiatry, University of Pennsylvania

Therese K. Killeen, author Associate Professor, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina

Katherine L. Mills, author Associate Professor, National Drug and Alcohol Research Centre, University of New South Wales

Maree Teesson, author NHMRC Senior Research Fellow, National Drug and Alcohol Research Centre, University of New South Wales

Bonnie Dansky Cotton, author Senior Manager, Microsoft

Kathleen M. Carroll, author Albert E. Kent Professor of Psychiatry, Yale University School of Medicine

Kathleen T. Brady, author Distinguished University Professor and Associate Provost for Clinical and Translational Science, Medical University of South Carolina


Procedure

CRA is a multi-modal treatment of substance abuse, meaning it offers a variety of interventions targeting key domains of social functioning that are likely to promote a sober lifestyle. The entire set of components is rarely offered systematically, except for functional analysis and treatment planning modules, which serve as starting points for all clients. Depending on clients’ needs, they can navigate through the modules in any way they see fit. What follows is a list of modules that can be used under the umbrella of the CRA intervention.

(a) Functional analysis: In line with the CBT evaluation method, functional analysis is an essential part of assessment. Information collected here focuses on the context of substance use, both external (e.g., situation, time, social setting, presence of key members of social group) and internal (e.g., thoughts, feelings, sensations, emotions). Details of the consumption behavior, like the nature, quantity, and consumption method, are gathered. The consequences of the behavior, both negative and positive, are also part of the evaluation. A well-conducted functional analysis will set the stage for a successful treatment (Meyers & Smith, 1995).

(b) Treatment plan: The CRA treatment plan entails the completion of two questionnaires, the Happiness Scale and the Goals of Counselling form. The Happiness Scale measures self-reported degree of satisfaction in ten areas of social life (e.g., work, relationships, personal habits). Based on the Happiness Scale, domains are selected for a targeted intervention. Once the domains of intervention are established, the client uses the Goals of Counselling form to specify goals to attain in each of the ten identified domains. Strategies to reach said goals, with the projected timeframes, are also included on the form (Meyers & Smith, 1995).

(c) Sobriety sampling: Instead of beginning treatment by stating that clients should achieve complete abstinence, which can be an overwhelming goal for the client, CRA proposes to negotiate a period of soberness. During this period, clients are taught some behavioral skills to stay sober, and the therapist highlights the advantages of sobriety. After the prescribed time period ends, the client and therapist renegotiate the benefits of another sobriety period (Meyers & Smith, 1995).

(d) Behavioral skills training: Therapists and clients may rapidly identify that some behavioral skills are lacking. This module offers clients the opportunity to work on three behaviors: problem solving, assertive communication, and substance refusal. The short behavioral training topics comprise segments on psychoeducation, suggested behaviors, and role-playing exercises to consolidate acquired skills (Meyers & Smith, 1995).

(e) Job skills: For many individuals, work is a key component of social life. Beyond simply obtaining and keeping a job, CRA also promotes the belief that a job should be intellectually, socially, and financially satisfying. The first phase of job-seeking relies heavily upon the Job Club Counselor’s manual, and previously described behavioral skills are taught as job-maintenance strategies (Meyers & Smith, 1995).

(f) Social and recreational counselling: Many intervention models believe that by lowering consumption, clients will immediately find new activities from which to seek enjoyment and satisfaction. Yet, some clients seem to struggle when reorienting their lives after terminating their substance abuse. In this CRA module, clients are encouraged to identify and try different social activities. The clients’ concerns about socializing when sober, and the challenges of having a social circle mostly built around substance use are also discussed. Beyond counseling, attending a CRA social club is another possibility, to help clients learn that sober socializing can be enjoyable in a non-threatening setting (Meyers & Smith, 1995).

(g) Relationship counseling: CRA’s community approach also applies to intimate relationships. In some cases, clients wish to address their relationship with their significant other. Couples start by setting objectives for themselves, using the Happiness Scale and the Perfect Relationship form (an adaptation of the Goals of Counselling form), at the beginning of meetings. For example, to reintroduce pleasant activities in the relationship, couples can set a daily reminder to be nice and to appreciate one another (Meyers & Smith, 1995).

(h) Relapse prevention: This module gathers most of its material for intervention in the functional analysis and behavioral skills module. Clients and therapists investigate each of the triggers for substance use, and use behavioral skills (e.g., problem solving, assertive communication, substance refusal) to avoid future relapse (Meyers & Smith, 1995).


Research

The substance use disorder specialty is strongly based in a harm-reduction model, allowing for nuanced views and understanding of various substances. To this end, the majority of research being conducted by current students involves the use of psychedelic substances as viable treatment options for mental health issues. Current research projects are focused on the use of psilocybin for PTSD, MDMA with couple’s therapy, and the standardization of integration therapy with Ketamine.