The 'Third Wave' of Substance Use Treatment

By Debra Rothschild PhD 02/05/15

How the culture and treatment of addiction are finally changing.


For many years, society viewed addiction as a moral failing, and substance misusers were almost always referred to with the familiar language of stigmatization—drunks, junkies, crackheads. So, addiction came as a double whammy—the addiction itself plus the burden of stigma, which compounded the lethality. “Addicts” were generally sent off to find help in 12-step programs outside of the medical and treatment communities. Eventually the concept of addiction as a biopsychosocial disease began to take hold, albeit one that had a simplistically envisioned goal—abstinence from everything for everybody. A variety of treatment approaches were developed, many extremely effective, but these developed alongside an enormous dose of attention from the criminal justice system. Psychologist and psychoanalyst Debra Rothschild argues that we are shifting again in our view of addiction, to a “Third Wave” of treatment that appreciates the myriad complexities that each client brings to treatment. —Richard Juman

Substance use treatment is generally described as having progressed from a “Moral Model” to a “Disease Model” of conceptualizing alcoholism and addiction. Early on, drunkenness and intoxication were considered a sin and addressed through the church. Those who were publicly inebriated were brought into the church through their community, the Salvation Army or other such organizations, and were told to pray for salvation and find moral rightness. In the 1940s, Emil Jellinek changed all this by writing about alcoholism as a progressive disease and speaking about it as such. In fact, Jellinek was referring to ideas from a much earlier time. He quoted Thomas Trotter, a British naval physician, who, in 1804, spoke clearly and eloquently about how alcoholism should be treated as a medical condition and not a moral one. Jellinek quoted Trotter as saying, “I consider drunkenness, strictly speaking, to be a disease.” Jellinek’s articles are often cited as the moment of shift between the Moral Model and the Disease Model of addictive disorders.

That Disease Model, which has continued to dominate, was an improvement over labeling anyone who drank or drugged too much a sinner, to be sure. However, although it has helped many, it has allowed others to slip through the cracks. Considering substance misuse a disease led to a Medical Model in which, like all medical models, diagnosis guides treatment. Hence, the diagnosis of addiction yielded a universal prescription for treatment based on the concept of it as a progressive disease that needs to be stopped and controlled. A doctor-patient paradigm evolved in which the “patient,” (the user) would only get well by following the advice of the “doctor” (or expert, which could be a counselor or someone advanced in recovery). The default protocol became: “Stop drinking or drugging, attend 12-step meetings and, if necessary, go to a rehab program.” Rehabilitation facilities all offered basically the same combination of education about the progressive nature of addictive diseases, group counseling, some individual work, a few days or a week of family involvement and heavy emphasis on becoming involved in AA. This model worked well for some people and they passed on what they got to the next generation, and so forth.  

Unfortunately, far too many people could not benefit from this. Many people are not able to give up their substance before treatment begins, or even at the very early stages of it. Many are not ready or willing to give it up at all. Many don’t need to give it up in order to get well. Substance misuse varies widely and that model did not allow for people in early stages of misusing who might want to learn to control their use before it got out of hand. Nor did it have room for someone who, for example, was in trouble with heroin, but could always drink moderately. It was an “abstinence-only and totally” model, based on the belief that addiction is addiction is addiction—all addiction is a progressive disease, which is ultimately fatal, if not interrupted. In addition, the model also did not allow for people who were uncomfortable in large groups, or people who object to the spiritual or some other component of AA. Most significantly, it failed to address any underlying psychological factors that may have led to using in the first place. The incidence of relapse was staggering, generally cited as over 50%. People would go to the hospital to detox, stay clean while in rehab, come out, and because their situations in the world hadn’t changed and their psychological issues were not fully addressed, they returned to what they knew would soothe in the moment—they relapsed, many, again and again.

Today, there is a new paradigm gradually replacing the medical disease model. It is a Harm Reduction approach, and I think of it as the "Third Wave" in the history of treatment, following the Moral Model, then the Disease Model, which is now waning. The Harm Reduction approach directly addresses some of the failings of the universal disease model approach. It allows for treatment of anyone who wants it, regardless of what stage their use is at; it allows for a range of goals in treatment; and it is based on the principles of psychology and psychotherapeutic approaches. It also attempts to combat the remnants of the Moral Model, which have prevailed, not in treatment protocols per se, but in the stigmatization and criminalization of people who use.

Harm Reduction is a public health-based means of intervention into substance use (as opposed to a criminal justice one) in which the goal is to reduce harm to the user, or others, in whatever small or large ways possible. Acknowledging the complex multiplicity of factors involved in substance misuse, Harm Reduction includes medical interventions, psychological interventions, and work toward socio-political changes to impact the stressful environments, which can contribute to substance use as well as the stigma and punitive policies that surround it.  

The psychological interventions in this paradigm are known as Harm Reduction Psychotherapy (or Harm Reduction Therapy, HRT). The stated tenets of Harm Reduction Therapy are the same as the principles of most good psychotherapies. These include respect for the individuality of the client, mutuality and collaboration between client and therapist, and an open and curious attitude. Many harm reduction therapists are licensed mental health clinicians, psychologists, social workers or psychiatrists, and most pay attention to the underlying psychological causes and consequences of overusing a substance when they are engaging in treatment. In my mind, this is a basic aspect of what characterizes the Third Wave. 

The Third Wave is about more than curtailing substance use. Like all psychotherapy, it is about helping people learn new skills for living, and it’s about healing, growth, mental health and happiness. Psychotherapy contains different schools of thought, cognitive behavioral and psychodynamic being the two major categories, and some clinicians tend to use primarily one or the other. I find a combination of both to be the most beneficial. Cognitive behavioral techniques can be used to help somebody change how they act and how they think about something. So, for example, helping somebody learn how to pause and think through the consequences of their actions, rather than act on impulse, can help them not use at all or not have the third drink, if they believe they don’t want to. Psychodynamic approaches concentrate not only on understanding the underlying meaning and function of substance use so it can be replaced with something equally effective while much less destructive, but also how what happens in the therapeutic relationship impacts the treatment and leads to new ways of being. 

In a psychodynamic approach, the relationship with the therapist matters a lot and what happens in the relationship determines a lot of the therapy. Being cared for, respected and listened to, may be a brand new experience for someone—it is therapeutic in and of itself. In addition, so much of what takes place between people takes place without words, but nevertheless represents important communications. Good therapists pick up on these nonverbal cues and use them to help their clients understand things about themselves that they can then use to initiate changes. Here is an example: I had a client who could not understand why he used cocaine despite all the terrible consequences. After seeing me for a while, he had gone from using a few times a week to only once every few weeks. He was frustrated. Each time he used, he felt awful and regretful, yet about once a month, he would “find” himself calling his dealer and using. It was only during our therapy sessions that his underlying loneliness and depression became clear and only after he identified that he used whenever those feelings were especially powerful that he was able to begin to get a handle on his behavior. He had to become conscious of feeling that way in order to be aware that he was having an urge before automatically calling. Only after that could he begin to use my behavioral suggestions to find alternate ways of soothing himself when he felt bored, sad or lonely at night. 

This relates to another aspect of bringing psychodynamic and behavioral work together. Some people who have suffered a lot of trauma in life develop a coping mechanism called dissociation. This means that they are not aware of certain parts of themselves while they are living through a different part. Because of this, they lack an ability to step back, take perspective and reflect on what they are doing or feeling in any particular moment. As with my patient above, this can translate into wanting very much to be sober (or moderate) in one moment, then being completely unaware of that desire at another moment in time. Therapy can help bridge those dissociative gaps and enable someone to recognize that they may feel more than one way about something at the same time—to want to use a substance to feel better, yet not want it because of the consequences, and thereby to evaluate and make a conscious choice about using or not.  

In summary, the Third Wave of treating substance misuse is based in a biopsychosocial model which recognizes that substance use results from and creates a complex dynamic including medical-biological factors as well as social-environmental and psychological ones. It addresses all of these, and includes medical interventions, social change and psychotherapy, like the treatment described. Harm Reduction Therapy is the psychotherapy aspect. Clinicians working this way recognize that all people are individuals with their own histories, needs, fears and desires and that substance use exists on a spectrum. It is not a disease that either exists or does not. Treatment is not a one-size fits all model. Everyone is different, every treatment is different and for each, we do what we can to reduce harm and increase happiness and health.

Debra Rothschild, PhD is a NYC-based clinical psychologist, psychoanalyst and CASAC offering psychotherapy, psychoanalysis, supervision and consultation; a faculty member at the NYU Postdoctoral Program in Psychotherapy and Psychoanalysis; and a member of the Executive Board of the New York State Psychological Association Division on Addictions. She publishes and lectures widely on the integration of psychodynamic concepts and psychotherapy with substance use treatment. 

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Debra Rothschild, PHD.,is a psychologist and psychoanalyst in New York City. She is also a credentialed alcoholism and substance abuse counselor, a clinical associate professor at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis, and a clinical supervisor at City College, Yeshiva University and Long Island University clinical psychology programs. She is on the executive board of the New York State Psychological Association Division on Addictions. She publishes and lectures widely on the integration of psychoanalytic thought with harm reduction psychotherapy and substance use treatment.