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Rural Health Information Hub

Behavioral Therapy Models

Behavioral therapies focus on changing an individual's behaviors concerning substance misuse, in part by teaching life skills that help them to better cope with situations that may lead to substance misuse and relapse. Several behavioral therapies have shown effectiveness in treating substance use disorders (SUDs), and some therapies are better suited for a particular type of substance. The National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Evidence-Based Practices Resource Center provide additional information about the evidence base for behavioral therapy models.

Evidence-Based Models that Focus on the Individual

  • Cognitive-Behavioral Therapy (CBT) – Originally designed for the treatment of depression, CBT is effective in treating multiple types of SUDs. CBT teaches people how to identify problem behaviors and triggers for substance misuse and to develop coping strategies. Research has shown that the effects of CBT continue after therapy sessions are complete. NIDA considers CBT an evidence-based approach for treating a range of SUDs. Learn more about the benefits and costs of CBT.
  • Contingency Management Interventions – Contingency management interventions encourage behavior modification through the provision of tangible rewards for a target behavior (for example, abstaining from substance use or attending a meeting). When a patient tests negative for drugs, they receive a reward such as money, vouchers, gift certificates, clinic privileges, or other tokens. Research suggests that contingency management interventions may be effective in the increase of treatment retention and abstinence from drugs. NIDA considers contingency management interventions an evidence-based approach for treating a range of SUDs. Learn more about the benefits and costs of lower cost and higher cost contingency management interventions.
  • Community Reinforcement Approach (CRA) Plus Vouchers – CRA Plus Vouchers is an outpatient therapy that uses multiple treatment strategies, including building motivation, analyzing substance use patterns, positive reinforcement, and the involvement of family members in order to engage participants. SAMHSA and NIDA consider CRA an evidence-based approach for treating a range of SUDs. Learn more about the benefits and costs of CRA Plus Vouchers.
  • Motivational Interviewing (MI) – MI is a counseling style that is especially beneficial at addressing ambivalence toward unhealthy behaviors. This evidence-based treatment builds an individuals' confidence in their ability to successfully make a change (self-efficacy), and helps people with SUD explore their own desire for change and begin the process of making a change. MI is designed as a brief intervention and could therefore be beneficial in rural primary care settings where access to specialists may not be possible. NIDA considers MI an evidence-based approach for treating SUD. Learn more about the benefits and costs of MI.
  • Motivational Enhancement Therapy – Motivational enhancement therapy (MET) uses motivational interviewing approaches to strengthen motivation for behavioral change. This approach can be used for addressing behaviors from healthy eating to physical activity and behaviors associated with chronic disease. SAMHSA and NIDA consider MET an evidence-based approach for treating a range of SUDs. Learn more about the benefits and costs of MET.
  • The Matrix Model – The Matrix Model is an intensive outpatient treatment intervention that has demonstrated particular effectiveness in the treatment of stimulant use disorder. This model is a multi-component intervention, using counseling, recovery skills development, relapse prevention techniques, and social supports to help maintain abstinence. The Matrix Model includes education for friends and family members of the individual with SUD. SAMHSA and NIDA consider the Matrix Model an evidence-based approach for treating SUD. Learn more about the benefits and costs of the Matrix Model.
  • Twelve Step Facilitation Therapy – Twelve step facilitation therapy is a brief, structured program that has behavioral, spiritual, and cognitive components. This intervention is based on the principles of 12 step peer support programs like Alcoholics Anonymous and Narcotics Anonymous. However, twelve step facilitation is a therapeutic intervention with a counselor. The therapy can be conducted either in individual or group sessions. SAMHSA and NIDA consider twelve-step facilitation therapy an evidence-based approach for the treatment of SUD.

Evidence-Based Models that Focus on the Family

Family therapy focuses on using the strength and assets of the family to address substance misuse and reduce the impact of the misuse on the individual and family. There are several common family therapy models used to treat SUD.

  • Family Behavior Therapy (FBT) – FBT is unique from other therapies in that it involves not only the patient, but a family member or significant other. FBT involves vocational skills training, communication skills training, and training on resisting urges, among other interventions. This intervention has shown positive results in both adults and in adolescents. In addition to treating SUD, FBT also addresses co-occurring issues like child mistreatment, depression, conduct disorders, and family conflict. SAMHSA and NIDA consider FBT an evidence-based approach for the treatment of SUD. Learn more about the benefits and costs of FBT.
  • Functional Family Therapy (FFT) – In FFT, therapists work with adolescents and their families to identify the youth's strengths and protective and risk factors. FFT consists of 12 sessions on average. During this time, therapists work to establish credibility with the family while exploring the dynamics that may affect and change an individual's behavior while motivating them and also provide the family with resources such as relapse plans. In addition to treating SUD, FFT also addresses delinquency and violence. SAMHSA and NIDA consider FFT an evidence-based approach for the treatment of SUD in adolescents.
  • Multisystemic Therapy (MST) – MST is an intensive family and community-based treatment program targeting adolescents aged 12 to 17 who already have a history of arrests related to substance misuse. MST focuses on behavior change among the youth and the parenting skills of their caregivers. MST therapists meet with adolescents at home, school, or other places convenient to the adolescent and family. NIDA considers MST an evidence-based approach for the treatment of SUD in adolescents.
  • Multidimensional Family Therapy (MDFT) – MDFT is a family-based outpatient treatment program for adolescents with SUD and co-occurring disorders. MDFT can be offered in a variety of settings. The program is delivered in 12 to 16 weekly or multi-weekly sessions, focusing on interpersonal relationships with parents and peers, parenting practices, parent-adolescent interaction, and improved family communication. NIDA and the National Institute of Justice consider MDFT an evidence-based approach for the treatment of SUD in adolescents. Learn more about the benefits and costs of MDFT.
  • Brief Strategic Family Therapy (BSFT) – BSFT was designed to prevent, reduce, and/or treat behavioral issues among adolescents, including substance misuse. Sessions can be conducted in the home or at other locations convenient to the family and are generally delivered in 12 to 16 family sessions. Research indicates that BSFT reduces substance use among adolescents as well as decreases alcohol abuse among parents. NIDA considers BSFT an evidence-based approach for the treatment of SUD in adolescents.
  • Behavioral Couples Therapy – In behavioral couples therapy (BCT), therapists work with the individual who has an SUD and their spouse or partner. Spouses and partners are included in SUD treatment to provide support with abstinence and help to prevent relapse. Couples attend therapy sessions together, developing a recovery contract, completing homework assignments, and learning effective communication skills. Research shows that BCT leads to increased abstinence and improved relationships when compared to individual-based treatments. BCT is listed in Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health as an evidence-based treatment for SUD.

Examples of Behavioral Therapy Models

  • The Southwest Montana Community Health Center in Butte, Montana, has provided training in motivational interviewing for all staff and provides cognitive behavioral therapy as part of its SUD screening and treatment program.
  • Great Lakes Recovery Centers, serving the counties located in Michigan's Upper Peninsula, offers a variety of outpatient services for alcohol use disorder and other SUDs. The centers provide SUD assessment and counseling, as well as individual and group counseling.
  • The Na'nizhoozhi Center, Inc., in Gallup, New Mexico, has adapted the community-reinforcement approach to serve Navajo Native Americans with alcohol use disorder in a residential program.
  • Appalachian State University has conducted a study in rural western North Carolina on implementing the Matrix Model in rural communities. Preliminary findings have shown that the Matrix Model resulted in high percentages of clients demonstrating continuous abstinence from stimulants.

Considerations for Implementation

To be effectively implemented, many behavioral therapies require training. Trainings may be either in person or online. Travel, certification fees, and other training expenses may be a barrier for rural providers.

Some behavioral therapy models have tested computerized or web-based versions with promising results. Examples of effective electronic-based therapies include:

A computer-assisted or web-based version of behavioral therapy could have significant benefits on the expansion of behavioral therapy interventions to rural communities where transportation and access to care are barriers to treatment.

Implementing contingency management interventions does not necessarily require a counselor or other staff who have been formally trained in behavioral therapy. The ability to implement the intervention with other healthcare providers can benefit rural communities with limited mental health providers. Limitations to using contingency management include costs for incentive items and lack of familiarity with the intervention.

The community reinforcement approach (CRA) also offers benefits to rural communities, including flexibility and adaptability for implementation. CRA has been integrated into a family therapy approach (community reinforcement and family training, or CRAFT) where concerned family members or significant others receive assistance addressing resistance to treatment from the person with SUD. Additionally, CRA Plus Vouchers has been effectively adapted for adolescents aged 13 to 25.

While MI is typically used as a brief intervention for facilitating patients' entry into treatment, MI can be used effectively as a stand-alone treatment in rural communities where patients may experience challenges accessing treatment programs. MI can be integrated into a variety of treatment settings, making it beneficial to rural communities that may lack intensive inpatient treatment programs.

Program Clearinghouse Example

Resources to Learn More

CLARE|MATRIX
Website
Provides two-day training for organizations and individuals in the Matrix Model, an evidence-based outpatient SUD treatment and behavioral health program that can be customized for different needs and settings. Offers on-site trainings in multiple locations.

Cognitive-Behavioral Therapy for Substance Use Disorders
Document
Provides background information on the use of cognitive behavioral therapy (CBT) for SUDs, covering the treatment elements and common challenges.
Author(s): McHugh., R., Hearon, B., & Otto, M.
Citation: The Psychiatric Clinics of North America, 33(3), 511-525
Date: 9/2010

Enhancing Motivation for Change in Substance Use Disorder Treatment
Document
Offers SUD treatment providers background information on motivational interviewing and tips on its implementation.
Organization(s): Substance Abuse and Mental Health Services Administration
Date: 10/2019

Functional Family Therapy (FFT)
Document
Provides background information and evidence of effectiveness supporting functional family therapy (FFT) as a treatment methodology for SUD in adolescents.
Organization(s): County Health Rankings & Roadmaps
Date: 7/2016

Program Profile: Adolescent Community Reinforcement Approach
Document
Describes the Adolescent Community Reinforcement Approach (A-CRA), an effective outpatient program for adolescents to replace alcohol and drug use with positive behaviors. Presents information on evaluation outcomes and methodology used in case studies.
Organization(s): National Institute of Justice
Date: 6/2011