Therapy

By Lauren Smith

Last updated: 19 March 2024 & medically reviewed by Dr. Jenni Jacobsen

What is mental health therapy?

Talking therapies such as cognitive behavior therapy (CBT), motivational interviewing (MI), and dialectical behavioral therapy (DBT) have all been proven to help with a variety of mental health conditions, ranging from depression to post-traumatic stress disorder (PTSD). 

Most talking therapy involves a client or patient speaking in sessions (individual or group) about their experiences, fears, and outlook with a trained counselor (used interchangeably with therapist) who will then use their skills to explore the client's issues and help guide them to a resolution. This can also involve working to change to client’s thought processes and emotional reactions to certain situations to prevent future issues and develop stronger mental health. 

Therapy can be used to treat a wide range of conditions and disorders such as depression, anxiety disorders, eating disorders, substance use disorders (addiction), and bipolar disorder. It can also be used for more holistic purposes such as achieving self-actualization, becoming more emotionally resilient, developing professional skills, and building stronger relationships.

Types of talking therapy

Several types of talking therapy may be used for people with addiction, depending on their location and any co-occurring mental health conditions they have.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy emerges from the understanding that psychological problems, including addiction, are partly caused by faulty or unhealthy ways of thinking and learned patterns of unhealthy behavior. 

CBT teaches patients to identify distortions in their thinking, reassess them in light of reality, and replace and reframe them with healthier ways of thinking. For example, a maladaptive thought that may contribute to addiction is: “I can’t have fun without drinking.” A healthier replacement would be: “Many people enjoy themselves without alcohol and I can too.”

CBT also teaches them to develop coping mechanisms and problem-solving skills to deal with stress, build confidence in their abilities, and gain a greater understanding of the behaviors and motivations of others.^[1]

Dialectical behavioral therapy (DBT)

Dialectical behavioral therapy is a structured, empirically-based therapy that draws on techniques from CBT and mindfulness to teach patients to regulate their emotions, tolerate distress, and build and maintain healthy relationships. The “dialectical” in the name refers to its simultaneous goals of helping patients to accept the reality of their lives and behaviors while also helping them to change these.^[2]

DBT may be used by people who experience borderline personality disorder alongside addiction or for whom their addiction emerged from an attempt to soothe intense emotions.

Group therapy

In group therapy, one or more psychotherapists leads a group of patients with similar difficulties, such as addiction, social anxiety, grief and loss, eating disorders, etc. Group therapy can deliver unique benefits: patients may feel less alone, learn from each other, gain hope from each other’s successes, develop social skills, and improve their self-esteem by helping each other.^[3]

Rational emotive behavior therapy (REBT)

Rational emotive behavior therapy holds that negative emotions aren’t caused by events in our lives but rather by our interpretation of those events. These interpretations can be disputed and replaced by new rational beliefs, which lead to new feelings. REBT, developed by doctor Albert Ellis in the 1950s, draws on stoic philosophy and has some similarities to CBT.^[4]

Motivational interviewing (MI)

Motivational interviewing, also known as motivational enhancement therapy (MET), is a counseling method that uses non-confrontational conversations to help individuals understand the discrepancy between where they are now and where they want to be and to acknowledge and resolve their ambivalence about making changes to reach their goals. It emphasizes personal choice and self-control.^[5] Therapists use techniques such as open-ended questions, affirmations, reflective listening, and summarising.^[6]

Contingency management (CM)

Contingency management is a reinforcement-based treatment in which positive behaviors such as abstinence are reinforced such as through rewards like vouchers, coupons, and privileges, and negative behaviors such as using are punished.

Trauma therapy

Trauma therapy is designed to help people recover from traumatic experiences and the lingering emotional effects, such as PTSD.

There are several different forms of trauma therapy:

• Trauma-focused cognitive behavioral therapy (TF-CBT): a type of CBT adapted for PTSD, used to modify beliefs about the trauma (such as: “I’m to blame for the event”), modify unhelpful behaviors, such as avoidance and self-isolation, and neutralize the fear response to reminders of the trauma.

• Prolonged exposure (PE): a therapy that combines psychotherapy with exposure therapy, in which the patient is gradually exposed to reminders of the trauma in order to desensitize them and reduce fear response and hyperarousal.

• Cognitive processing therapy (CPT): a form of CBT that teaches the patient to challenge and alter unhelpful beliefs about the trauma and arrive at a new understanding of the event in order to reduce its impact on their life.

• Eye movement desensitization and reprocessing (EMDR): see below

Eye movement desensitization and reprocessing (EMDR)

EMDR is a structured therapy intended to reduce the strength of and emotions associated with traumatic memories. It’s based on the theory that PTSD and other traumatic responses develop because a traumatic memory wasn’t properly processed by the brain and seeks to alter the way these memories are stored. During a session, the patient recalls a traumatic memory while experiencing bilateral stimulation: typically side-to-side eye movements or hand tapping.^[7]

EMDR may be used for people with addiction who experience PTSD or other mental health conditions emerging from trauma.

Types of holistic therapy

Holistic therapies can help treat the stress, poor nutrition, and lack of sleep that many people with addiction experience. It can also improve their relationship with their bodies, boost self-confidence promote relaxation, build resilience to cravings, and reduce the appeal of substance use.

While holistic therapies alone can’t cure addiction, they’re used to augment psychotherapy and medication.

Biofeedback and neurofeedback

Biofeedback is a mind-body therapy that helps people connect with their bodies and change the way they function, for example, to reduce anxiety or pain. 

During an appointment, a practitioner places monitoring equipment on your body to measure bodily functions such as breathing, heart rate, blood pressure, muscle tension, and skin temperature. Real-time information from these sensors is displayed on a screen for both you and the practitioner to see. The practitioner will then suggest strategies that may change these vital signs. For example, altering your breathing may reduce anxiety and lower your heart rate and blood pressure. Relaxing muscles may reduce pain and reduce anxiety. When you learn to have control over these bodily functions, you can deploy these skills to calm yourself during times of stress.^[8]

You may also be exposed to frightening or traumatic situations while wearing the sensors as part of exposure-response therapy for PTSD, phobias, OCD, and anxiety.

Neurofeedback is a type of biofeedback in which brain activity is non-invasively monitored, usually through electroencephalography (EEG). It can show patients how their brains react to certain triggers and teach them to recreate healthy states, such as relaxation, and avoid those such as stress.

Acupuncture

In acupuncture, very thin, sterilized needles are inserted into the body at pressure points in order to stimulate the nervous system and rebalance energy flow within the body. Acupuncture, particularly ear acupuncture, has a long history of being used for addiction treatment, usually following a protocol from the National Acupuncture Detoxification Association (NADA). [9] It’s thought to decrease cravings and ease withdrawal symptoms. It may work by stimulating the release of endogenous opiates such as endorphins.^[10]

Acupuncture is an alternative form of pain relief and may be beneficial to people who have developed addictions to painkillers while trying to ease chronic pain.

Massage therapy

In massage therapy, a trained professional manipulates the body’s soft tissues, including muscles, connective tissues, tendons, ligaments, and skin, applying movement and pressure. In addiction, therapy, massage can reduce stress and stimulate the release of dopamine, the body’s feel-good chemical.

Art therapy

In art therapy, people are guided to creative techniques such as drawing, painting, sculpture, and collage to express feelings that may be beyond words, process trauma, and promote healing and relaxation. Artistic expression may become a coping mechanism they use in the future to deal with difficult feelings and experiences rather than turning to substances. 

Other similar creative therapies include dance therapy, drama therapy, music therapy, and writing therapy.

Wilderness therapy

In wilderness therapy, individuals participate in outdoor activities such as hiking, camping, and team sports to equip participants with problem-solving skills, promote accountability and responsibility, teach them new skills and coping mechanisms, improve their self-esteem, enhance their social skills, and foster mindfulness. Some rehab programs take place entirely in the wilderness while other programs will incorporate wilderness outings and activities.

Animal-assisted therapy

In animal-assisted therapy, individuals spend time with trained therapy animals such as dogs and horses. 

For example, in equine-assisted therapy, individuals may participate in horseback riding but also assist in the care of the horses, including their grooming and feeding. Through these interactions, the individual can improve their physical health, gain new skills, learn responsibility, and build self-confidence. They also develop a bond with an animal, working to gain its trust and learning to moderate emotions that might startle the horse. Additionally, because horses can read and mirror human emotions, interacting with them can help individuals reflect on their own feelings and behaviors.

Experimental therapies

Despite the array of available therapies, addiction treatment is difficult and relapse rates are high: 40 to 60%.^[11] Many people have to try multiple treatment pathways before getting and staying sober. So there’s an urgency to develop new treatments for alcohol and drug dependence, with ongoing promising research into psychedelics, brain surgery, and even vaccines.

Psychedelic therapy

Psychedelic drugs have been proposed as treatments for addiction since LSD was administered to alcoholics in the 1950s. Criminalization of these substances in the 1960s froze research for decades but a recent thawing of attitudes has led to a resurgence in interest in their use to treat both substance abuse and other mental health conditions.

For example, early proof-of-concept studies found that psilocybin (the active ingredient in magic mushrooms) helped alcoholics drink less when it was paired with motivational interviewing and helped people quit smoking when it was delivered as part of a CBT-based program.^[12][13]

It’s thought these substances work by dissolving the ego and promoting neuroplasticity, breaking the brain out of its existing unhealthy patterns, such as those that perpetuate addiction and depression, and allowing for the formation of healthier connections. This makes the individual more receptive to psychotherapy. Psychedelics themselves have also been found to not be physically addictive and positive effects can be achieved in as little as one or two doses, further limiting the risk of abuse.

As most psychedelics are Schedule 1 controlled substances, psychedelic treatment isn’t widely available. However, ketamine, a widely used anesthetic, is less restricted and infusions are prescribed off-label by some doctors for mental health conditions, which may include substance abuse. Regulators and scientists have suggested that other psychedelics may be approved as medication in the next few years.

Related: Ketamine infusions for depression

Deep brain stimulation (DBS)

Trials are currently being conducted performing deep brain stimulation (DBS) on people with substance abuse problems. A treatment initially used for Parkinson’s disease and essential tremor, DBS is the surgical implantation of electrodes in the brain, where they deliver electrical stimulation, powered by a pacemaker-like device implanted in the chest. For addiction, the electrodes are usually implanted in the nucleus accumbens. 

Data is extremely limited—largely anecdotal or based on animal studies—but promising. Several people have had DBS for addiction and stopped using heroin, alcohol, or cigarettes.^[14]

Vaccines and monoclonal antibodies

There’s interest in recruiting the body’s immune system to combat addiction. In the proposed mechanism, antibodies would bind to the drug molecule and prevent it from crossing the blood-brain barrier, therefore ensuring it doesn’t produce a high and reducing the risk of toxicity and overdose. These antibodies could be produced in a lab—these are called monoclonal antibodies—and injected into the patient. Alternatively, a vaccine could induce the immune system to produce the antibodies itself, similar to the way the coronavirus and flu vaccines work.

Trials have been conducted on vaccines or monoclonal antibodies for nicotine, cocaine, methamphetamine, and opioids. Trials of nicotine and cocaine vaccines have been the most advanced but showed limited efficacy and no treatments have been approved by the FDA so far.^[15]

Therapy and medication

The use of non-addictive prescription drugs may reduce cravings, prevent drugs from having pleasurable effects, ease withdrawal symptoms, and treat co-morbid mental health conditions.

Medication-assisted treatment (MAT)

Medication-assisted treatment refers to the use of drugs that reverse some of the neurochemical changes associated with substance abuse, to reduce withdrawal symptoms and cravings.

For example, opioid use disorder may be treated with the following medications:

• Methadone: a full opioid agonist that binds to opioid receptors, like heroin, morphine, and opioid pain medications, but does so more slowly and without producing rewarding effects like euphoria. Therefore, methadone reduces withdrawal symptoms and cravings. It’s been used for more than 40 years to treat opioid use disorder and is typically taken long-term.

• Buprenorphine: a partial opioid agonist that binds to opioid receptors but less strongly than full agonists and so it doesn’t produce euphoria. Like methadone, it reduces withdrawal symptoms and cravings. It’s taken as a tablet, sublingual film, 6-month subdermal buprenorphine implant, or once monthly injection.

• Naltrexone: an opioid agonist that blocks the activation of opioid receptors and prevents opioids from producing rewarding effects. Patients may struggle to tolerate naltrexone or adhere to daily dosing. An injectable, long-acting form may produce better results.^[16]

The FDA has approved three medications to treat alcohol use disorder:

• Naltrexone: an opioid antagonist which may block the positive reinforcing effects of alcohol and has been shown to reduce the amount and frequency of alcohol consumption. 

• Disulfiram: a medication that inhibits the enzyme acetaldehyde dehydrogenase and therefore blocks the breakdown of alcohol in the body. When even a little alcohol is consumed in the presence of disulfiram, very unpleasant symptoms occur, including nausea, vomiting, headache, and flushing.

• Acamprosate: a medication that can stabilize chemical signaling in the brain that is disrupted by alcohol abuse and reduce cravings.^[17]

Antidepressants

Antidepressants, usually SSRIs or SNRIs, may be administered to people recovering from addiction to make talking therapy more effective and treat the underlying mental health conditions that drive substance abuse.