Substance Abuse Treatment – What Really Works?

When I began working in the substance abuse treatment field over 30 years ago, the general philosophy seemed to be that the individual fit into the program model rather than the other way around.  There was little individualized care being offered.  While there are still treatment programs following this model of “one size fits all,” quality treatment programs today follow the philosophy of providing individualized care for each person based upon his or her particular needs or problems.  In order to provide effectively for this individualized care, programs today must have access to an array of treatment services to meet the particular needs of their patients, whether within the program itself or through links to specialized services outside of the program.

Since my expertise is in outpatient treatment settings, I will focus on effective services provided on an outpatient basis.  The array of services that should be offered on an outpatient basis includes, at a minimum, the following: a comprehensive assessment; individual, group, and family counseling; recovery education; toxicology and breathalyzer screening; psychiatric monitoring; medical care; addiction medicine; and access to community recovery support.

Effective treatment of substance use disorders begins with a thorough assessment of a person’s history.  The assessment should include a review of the individual’s substance use and treatment history, including use of objective screening tools to confidently ascertain that there is a diagnosable Substance Use Disorder (SUD).  The substance use history should attempt to understand whether the factors leading to an SUD are associated with physiological, psychological, social, environmental, or spiritual factors.  The assessment should include a review of mental health factors, including objective screening tools for signs of mood disorders, anxiety disorders, psychotic disorders, trauma, brain injury, and other compulsive behaviors (e.g., gambling, sex, eating).  A comprehensive assessment looks at the person’s physical health, and refers the individual for a physical examination as indicated.  A review of the individual’s family and social history is needed to understand the significance of relationships present and past, as well as the individual’s interpersonal functioning.  A review of education and employment history is important, including educational or vocational deficits.  Understanding a person’s living environment and leisure activities is very important.  It is also useful to be aware of any legal issues that may be impacting an individual’s life.  It is this comprehensive assessment that should be the basis of someone’s individualized treatment program.  I would recommend finding an alternative treatment program if this kind of assessment does not occur soon after enrolling in a program, or if the program offered to you appears to have no association to the problem areas identified in the assessment.

Effective treatment programs must include an array of individual, group, and family counseling services.  The counseling services offered should be associated with the assessment issues identified. If a patient is identified as ambivalent about complete abstinence from substance use, this factor should help determine the proper placement in particular groups or individual counseling that can address this ambivalence.  If the patient is found to have significant co-occurring mental disorders, this should also be taken into account in the placement of counseling services.  The frequency of group and individual sessions should be individualized to the particular issues of the patient.  Furthermore, family treatment and couple counseling should be provided either on-site or as a referral to outside resources when indicated.

Some degree of recovery education is expected in an effective treatment program.  This education should include: developing new coping skills to deal with urges and cravings; dealing with drug refusal skills; understanding the process of recovery; and understanding addictive disorders from biological, psychological, social, and spiritual perspectives.  This education should be provided by a qualified professional who is comfortable with the material covered and can answer questions effectively.

Effective outpatient programs should include toxicology screening and breathalyzer screenings as needed and on a random basis.  Many participants in outpatient programs report that the screenings were a helpful deterrent to continued substance use.  When they felt a strong urge to use a substance, believing that a toxicology screening or breathalyzer might be awaiting them at the treatment center helped them choose not to use the substance.  Also, fear and shame lead participants to hide or minimize substance use.  Regular toxicology and breathalyzer screenings allow the treatment team to monitor progress and dangerous relapse patterns. 

In Part Two of this blog, we will focus on the remaining services recommended as part of an effective treatment program.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

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