Different Therapeutic Approaches
Introduction
Substance use disorders (SUDs) represent complex biopsychosocial conditions affecting approximately 284 million individuals globally (World Health Organization, 2023). These disorders, characterised by impaired control, social impairment, risky use, and pharmacological criteria such as tolerance and withdrawal, present significant challenges for therapeutic intervention. It has been established that effective treatment typically requires a multifaceted approach addressing biological, psychological, and social dimensions of addiction (Volkow et al., 2021). This article examines how practitioners from varying therapeutic orientations—Rogerian counsellors, family therapists, Gordian therapists, traditional hypnotherapists, cognitive hypnotherapists, and psychotherapists—conceptualise and treat substance use disorders, with particular attention being paid to the theoretical underpinnings, clinical applications, and empirical support for each methodology. The analysis is framed within the context of cognitive behaviour therapy (CBT), strategic therapy, Gordian therapy (GT), dialectical therapy, and acceptance and commitment therapy (ACT) approaches.
Theoretical Conceptualisations of Substance Use Disorders
Person-Centred Understanding
From a Rogerian perspective, substance use disorders may be conceptualised as manifestations of incongruence between the self-concept and experience, wherein substances are utilised to manage psychological distress arising from conditions of worth and self-alienation (Mearns et al., 2022). It has been observed that individuals with SUDs often demonstrate conditional self-regard, whereby acceptance is contingent upon meeting external standards or expectations. The person-centred approach emphasises the therapeutic relationship as the primary mechanism of change, wherein the core conditions of empathy, unconditional positive regard, and congruence facilitate the client’s reconnection with their organismic valuing process.
Systemic Perspectives
Family therapists conceptualise substance use disorders within relational dynamics, whereby substance use may be understood as both impacting and being maintained by family interaction patterns (Carr, 2019). It has been established that family responses to substance use can inadvertently reinforce problematic behaviours through processes of enabling, codependency, or homeostatic maintenance. Strategic therapy within family systems approaches targets these patterns through interventions designed to disrupt maintaining cycles and establish new relational patterns around substance use.
Gordian Model
Within the Gordian framework developed by Young (2008), substance use disorders are understood to be maintained by the ‘cognitive attentional syndrome’ (CAS), comprising worry, rumination, threat monitoring, and maladaptive coping behaviours. Particular attention is paid to cognitive beliefs about substances, such as “I need alcohol to cope with anxiety” or “Craving means I must use.” Treatment from this perspective aims to modify these cognitions rather than focusing primarily on the content of substance-related thoughts or environmental triggers.
Hypnotherapeutic Conceptualisations
Traditional hypnotherapy approaches substance use disorders through accessing altered states of consciousness in which new learning and behavioural responses may be facilitated. It has been suggested that hypnotic trance enables access to unconscious processes that maintain addictive behaviours, allowing for therapeutic suggestion to be implemented at a deeper level (Molina del Peral et al., 2019). Strategic hypnotherapy integrates hypnotic techniques with cognitive-behavioural principles, targeting both conscious cognitions and unconscious processes that maintain substance use (Alladin, 2023).
Psychodynamic Understanding
Psychodynamic approaches conceptualise substance use disorders as potentially rooted in developmental traumas, attachment difficulties, and unconscious conflicts (Khantzian, 2018). It has been proposed that substances may serve as self-medication for painful affects or to compensate for deficits in self-regulation, with treatment focusing on insight development, emotional processing, and the therapeutic relationship as vehicles for change.
Therapeutic Approaches and Clinical Applications
Person-Centred Therapy and ACT Integration
Rogerian counsellors treating substance use disorders create a therapeutic environment characterised by empathy, unconditional positive regard, and congruence. Through this relationship, clients may develop greater self-acceptance and authenticity, reducing the need for substances as emotional regulators. The parallels between this approach and ACT are evident in the emphasis on values-based living and acceptance processes, though ACT more explicitly targets experiential avoidance through structured interventions.
A clinical example might involve a client who has developed alcohol dependence following workplace bullying that triggered early experiences of inadequacy. The Rogerian counsellor might provide a non-judgmental space wherein the client’s experience is accepted without condition, gradually enabling the development of self-acceptance and reducing reliance on alcohol as a coping mechanism. It has been documented that this non-directive approach facilitates the client’s intrinsic motivation for change, a factor strongly associated with positive outcomes in addiction treatment (Cooper et al., 2021).
Family Therapy and Strategic Interventions
Family therapists address substance use disorders by intervening in systemic patterns that maintain problematic use. It may be observed that in some family systems, substance use serves functions such as distracting from marital conflict or maintaining a member in the ‘sick role’, thereby preserving system homeostasis. Strategic interventions might include reframing the meaning of substance use within the family context or prescribing relational rituals that disrupt enabling patterns.
For instance, in a case where parental overprotection inadvertently reinforces a young adult’s inability to cope without substances, the therapist might guide the family toward interactions that activate the individual’s agency whilst maintaining appropriate support. Evidence suggests that family-based treatments for substance use disorders demonstrate strong efficacy, particularly when systems-level maintaining factors are identified and modified effectively (Carr, 2019).
Gordian Therapy and Attentional Processes
Gordian therapy targets the processes that maintain substance use disorders rather than the content of addiction-related thoughts or environmental triggers. Young’s’ Gordian model positions beliefs about craving and substance-related thoughts as central to the maintenance of addictive behaviour. Treatment involves techniques such as detached mindfulness and attention training, which have demonstrated promising efficacy in reducing substance use through modification of cognitive processes (Spada et al., 2019).
A therapist employing this approach might work with a client who experiences persistent thoughts about using cocaine. Rather than employing traditional relapse prevention strategies focused on avoiding triggers, the therapist would guide the client to develop cognitive awareness of their relationship to craving thoughts. Through techniques such as the cognitive detachment exercise, the client develops evidence against the belief that cravings must be acted upon, thereby disrupting the addictive cycle.
Hypnotherapy and Unconscious Processes
In traditional hypnotherapy, substance use disorder treatment often involves inducing a trance state wherein suggestions for reduced craving, enhanced self-efficacy, and alternative coping strategies are administered. It has been documented that hypnotic phenomena such as time distortion and positive hallucination can be harnessed therapeutically for addiction treatment (Molina del Peral et al., 2019).
Strategic hypnotherapy integrates cognitive restructuring with hypnotic techniques. Research by Alladin (2023) indicates that this integration may be particularly effective for addressing the unconscious processes implicated in addiction whilst simultaneously modifying conscious cognitions. A clinical application might involve hypnotically assisted cognitive restructuring, wherein access to a relaxed state facilitates the integration of more adaptive beliefs about coping without substances.
Psychodynamic Approaches and Dialectical Integration
Psychodynamic therapy for substance use disorders often explores developmental origins of affect regulation difficulties and the unconscious functions served by substance use. Khantzian’s (2018) self-medication hypothesis has been influential in understanding how substances may be selected based on their specific psychological effects. Elements of dialectical behaviour therapy may be integrated into treatment, particularly the balance between acceptance and change strategies for managing emotional distress.
A clinical example might involve a client whose opioid use emerged following significant trauma. The therapeutic work would involve exploring the connection between substance use and emotional numbing while simultaneously developing concrete skills for distress tolerance, reflecting the dialectical stance of acceptance and change that characterises effective addiction treatment.
Integrative Considerations and Evidence Base
The comparative efficacy of these therapeutic approaches has been the subject of extensive research. It has been established through meta-analyses that while CBT has the most substantial evidence base for substance use disorders, other approaches demonstrate promising results, particularly when tailored to individual client presentations and stages of change (Magill et al., 2022). Approaches such as motivational interviewing, which shares philosophical foundations with person-centred therapy, have demonstrated particular efficacy in enhancing engagement and retention in treatment.
It may be observed that common factors across effective treatments include: (1) establishing a strong therapeutic alliance, (2) enhancing motivation for change, (3) developing coping skills for managing craving and negative affect, and (4) addressing the wider social context of substance use, including family dynamics and peer relationships.
Conclusion
The treatment of substance use disorders across different therapeutic orientations reveals both distinctive methodologies and underlying commonalities. It has been observed that Rogerian counselling provides a foundation of acceptance that facilitates intrinsic motivation for change; family therapy addresses systemic patterns that maintain problematic use; Gordian therapy targets the cognitive processes underlying addictive behaviour; hypnotherapy accesses unconscious resources for change; and psychodynamic approaches explore developmental origins of substance use.
The integration of these perspectives, informed by evidence-based practices such as CBT, strategic therapy, GT, dialectical therapy, and ACT, offers a comprehensive framework for addressing the multifaceted nature of substance use disorders. The refinement of therapeutic approaches should continue to be guided by empirical research whilst maintaining sensitivity to individual client needs, preferences, and the stage of change at which they present.
References
Alladin, A. (2023). Cognitive hypnotherapy in the treatment of addictions: A systematic review. American Journal of Clinical Hypnosis, 65(3), 246-267.
Carr, A. (2019). Family therapy and systemic interventions for child-focused problems: The current evidence base. Journal of Family Therapy, 41(2), 153-213.
Cooper, M., Watson, J. C., & Hölldampf, D. (2021). Person-centred and experiential therapies: Contemporary approaches and issues in practice (2nd ed.). SAGE Publications.
Khantzian, E. J. (2018). The self-medication hypothesis and attachment theory: Pathways for understanding and ameliorating addictive suffering. In H. Arkowitz, W. B. Stiles, & J. L. Duncan (Eds.), The evolving relationship of attachment and addiction (pp. 33-57). Oxford University Press.
Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Tonigan, J. S., & Carroll, K. (2022). A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: A third update. Addiction, 117(1), 49-68.
Mearns, D., Thorne, B., & McLeod, J. (2022). Person-centred counselling in action (5th ed.). SAGE Publications.
Molina del Peral, J. A., González-Ordi, H., Carrasco-Ortiz, M. Á., & Domínguez-Ortega, L. (2019). Hypnotic treatment synergizes the psychological treatment of fibromyalgia: A pilot study. American Journal of Clinical Hypnosis, 58(1), 81-99.
Volkow, N. D., Koob, G. F., & McLellan, A. T. (2021). Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine, 374(4), 363-371.
World Health Organization. (2023). World drug report 2023. United Nations Office on Drugs and Crime.
