This article was originally published in The Los Angeles Psychologist Magazine by LACPA
Conceptualizing and Treating Substance Use Disorders
Tara Shultz, Psy.D.
— Licensed Clinical Psychologist
March 11, 2026
Introduction
Addiction in the United States is a prevalent issue that many mental health practitioners face in clinical work. In 2024, 48.4 million people 12 or older met criteria for a substance use disorder (SUD), and 10.2 million people with SUD received treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2025). Despite more training and awareness for SUD becoming available across the nation, mental health practitioners who find themselves working with this population report sparse training and assessment of SUDs in graduate school (Rigg et al., 2025). More importantly, completing a graduate-level program, gaining licensure, and being exposed to addiction do not require in-depth training in SUD, including classwork or practicum experience (Gaiser et al., 2025). Therefore, greater educational and structural training that integrates multiple theoretical approaches should be employed to equip clinicians to provide effective and compassionate interventions.
Before research on addiction was conducted and disseminated, society approached alcoholics and drug abusers as having a moral failing with the implication that substance use reflected a personal choice and an immoral character (Frank & Nagel, 2017). They were placed in inebriate asylums that occasionally resembled jails utilizing shame as a common tactic for reform. In the 1990s, the brain disease model of addiction (BDMA) was developed to reduce the shameful effects of moralization on addiction (Leshner, 1997). The BDMA maintains that someone with a propensity for addiction has pathways in the brain that differ from someone who can use substances without developing addictive behaviors. The BDMA provided evidence that affected individuals are not merely making voluntary choices but are instead struggling with a disease that impacts the mesolimbic reward system. The BDMA promotes abstinence and medication as treatment. It recognizes relapse as a common aspect of the recovery process that must be acknowledged and addressed. Nevertheless, moralization persists today, as most people, including clinicians, do not fully understand the underpinnings of addiction.
There are many critics of the BDMA approach to addiction treatment. For example, Lewis (2017) argues that addiction should not be viewed soley as a set of brain differences. Instead, he emphasizes the role of other contributory factors such as the self-medication theory, trauma, shame, and social alienation that disrupt cognitive and emotional development during childhood and adolescence. Lewis asserts that addiction should be treated utilizing a developmental-learning model aimed to give control back to the addicted individual. Rather than imposing shame or prescribing pharmaceutical interventions, Lewis’ approach empowers the individual to perpetuate growth through the intrinsic desire to work on themselves.
Just as the BDMA and opponents have the same goal of reducing the moralization of addiction and finding more effective treatments that do not focus on shame, psychodynamic theory and cognitive behavioral theory (CBT) can be more effective when integrated. By conceptualizing from a psychodynamic and cognitive behavioral therapy perspective, clinicians can focus on early attachment, sense of self, and core beliefs that contribute to the motivation to abuse substances as a form of avoiding emotions, which perpetuates the cycle.
Psychodynamic Theory
Alghufaulia (2025), in her article illustrating how object relations can be used to conceptualize addiction, pulls from theorists such as Donald Winnicott and Ronald Fairbairn to describe how an individual will abuse substances to avoid painful emotions that arise from negative internalizations developed from early relational experiences. Substances serve as objects that provide comfort to the individual, as their inability to internalize a good object during childhood prevents them from developing adaptive ways to self-soothe.
Early negative internalizations lead to the development of a false self as a protective factor, and substances are used to regulate and escape the painful reality that one’s authentic sense of self is perceived as damaged. Furthermore, when individuals lack a sense of self and experience the primitive defense of splitting, they fear abandonment from others and tend to engage in maladaptive codependent behaviors. When this individual perceives rejection, they are inevitably left with a fragmented self that is terrified of being alone and gravitates towards substances to alleviate the pain.
From this lens, treatment should focus on emotional regulation through the development of mature defense mechanisms and on the therapist becoming a good-enough object for the client to internalize and learn self-soothing. Additional interventions should focus on helping the client develop a stable sense of self (Fuchshuber & Unterrainer, 2020).
Cognitive Behavioral Therapy
Similar to the work found in psychodynamic therapy, CBT therapists help clients reflect on their beliefs about themselves, others, and the world around them through interventions such as “socratic questioning.” Conceptualization of addiction through the lens of CBT states that maladaptive thinking patterns can lead to overwhelming negative emotions, which are then managed with substances, perpetuating a cycle of addiction (Newman, 2019). An effective intervention in CBT is challenging negative beliefs about oneself that lead to cravings and trigger relapse. These negative beliefs, or cognitive distortions, are connected to subconscious core beliefs about oneself. These core beliefs can also be seen as unconscious feelings about the true self, which were internalized from early objects.
Self-monitoring is another effective CBT tool that helps the client become aware of and eventually gain insight into their maladaptive thinking patterns and how often they engage in negative self-talk (Newman, 2019). Newman underscores the importance of understanding that challenging thoughts alone will not alleviate the addicted person’s plight; however, it is noted that it adds significantly to the process of developing insight, hope, and self-esteem.
Twelve-Step Groups
Alcoholics Anonymous was developed by Bill Wilson and Robert Smith in 1935 to help individuals struggling with alcoholism find a solution. An updated systematic review found that AA leads to increased rates and lengths of abstinence compared with other standard treatments (Kelly et al., 2020).
The 12 steps share similar approaches to those of psychodynamic therapy and CBT (Marcovitz et al., 2020). For instance, in psychodynamic therapy, the therapist guides the client in exploring unconscious beliefs and emotions that lead to addiction. In AA, an individual gains similar benefits by listening to peers describe their childhoods prompting an individual to recognize that their own childhood may have negatively affected their sense of self. In psychodynamic therapy, the client is encouraged to explore their maladaptive relationship patterns, and the therapist might use transference and countertransference to gain insight into the client’s behaviors. The 4th step of the Twelve-step program parallels this idea, as a sponsor helps the individual examine maladaptive patterns in relationships, take accountability, and prepare to correct behavior.
Twelve-step work also incorporates many aspects of CBT (Marcovitz, et al., 2020). The steps provide a framework to challenge maladaptive thoughts related to substances, the self, spirituality, relationships, and fears that perpetuate addictions. Sponsors, along with other members of the group, will continue to challenge members’ maladaptive thought processes through advice and feedback.
Conclusion
The integration of psychodynamic therapy and CBT can more effectively help the client identify and process negative emotions that originated from internalized messages from objects, which are perpetuated through negative, automatic thoughts, and avoided through substances and defense mechanisms. Moreover, having a corrective experience with the therapist as an adaptive object and learning how to challenge old beliefs about the self and others can more effectively maintain recovery.
Shultz, T. (2026, Spring). Conceptualizing and treating substance use disorder. Los Angeles County Psychological Association Magazine.
