and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. counselors are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. it's very common to see them also work with family members who are affected by the addictions of the individual, or in a community to prevent addiction and educate the public. counselors should be able to recognize how addiction affects the whole person and those around him or her. counseling is also related to "intervention"; a process in which the addict's family and loved ones request help from a professional to get an individual into drug treatment. this process begins with a professionals' first goal: breaking down denial of the person with the addiction. denial implies a lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, instead of continuing the destructive behavior. once this has been achieved, the counselor coordinates with the addict's family to support them in getting the individual to drug rehabilitation immediately, with concern and care for this person. otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. an intervention can also be conducted in the workplace environment with colleagues instead of family. one approach with limited applicability is the sober coach. in this approach, the client is serviced by the provider(s) in his or her home and workplace—for any efficacy, around-the-clock—who functions much like a nanny to guide or control the patient's behavior. twelve-step programs the disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displays addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. this conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network that can help them remain sober. such approaches are the quintessential features of twelve-step programs, originally published in the book alcoholics anonymous in 1939. these approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological and legal grounds. opponents also contend that it lacks valid scientific evidence for claims of efficacy. however, there is survey-based research that suggests there is a correlation between attendance and alcohol sobriety. different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care. smart recovery smart recovery was founded by joe gerstein in 1994 by basing rebt as a foundation. it gives importance to the human agency in overcoming addiction and focuses on self-empowerment and self-reliance. it does not subscribe to disease theory and powerlessness. the group meetings involve open discussions, questioning decisions and forming corrective measures through assertive exercises. it does not involve a lifetime membership concept, but people can opt to attend meetings, and choose not to after gaining recovery. objectives of the smart recovery programs are: building and maintaining motivation, coping with urges, managing thoughts, feelings, and behaviors, living a balanced life. this is considered to be similar to other self-help groups who work within mutual aid concepts. client-centered approaches in his influential book, client-centered therapy, in which he presented the client-centered approach to therapeutic change, psychologist carl rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. rogers believed the presence of these three items, in the therapeutic relationship, could help an individual overcome any troublesome issue, including but not limited to alcohol use disorder. to this end, a 1957 study compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in the outcome. surprisingly, client-centered therapy proved most effective. it has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques. the authors note two-factor theory involves stark disapproval of the clients' "irrational behavior" (p. 350); this notably negative outlook could explain the results. a variation of rogers' approach has been developed in which clients are directly responsible for determining the goals and objectives of the treatment. known as client-directed outcome-informed therapy (cdoi), this approach has been utilized by several drug treatment programs, such as arizona's department of health services. psychoanalysis psychoanalysis, a psychotherapeutic approach to behavior change developed by sigmund freud and modified by his followers, has also explained substance use. this orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. it is hypothesized specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. the addiction syndrome is also hypothesized to be associated with life trajectories that have occurred within the context of teratogenic processes, the phases of which include social, cultural, and political factors, encapsulation, traumatophobia, and masturbation as a form of self-soothing. such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings to regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. additionally, homosexual content is not implicated as a necessary feature in addiction. relapse prevention an influential cognitive-behavioral approach to addiction recovery and therapy has been alan marlatt's (1985) relapse prevention approach. marlatt describes four psycho-social processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancy, attributions of causality, and decision-making processes. self-efficacy refers to one's ability to deal competently and effectively with high-risk, relapse-provoking situations. outcome expectancy refers to an individual's expectations about the psychoactive effects of an addictive substance. attributions of causality refer to an individual's pattern of beliefs that relapse to drug use is a result of internal, or rather external, transient causes (e.g., allowing oneself to make exceptions when faced with what are judged to be unusual circumstances). finally, decision-making processes are implicated in the relapse process as well. substance use is the result of multiple decisions whose collective effects result in the consumption of the intoxicant. furthermore, marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation. for example: as a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. this will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. if this individual can employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (path 1) and heighten his efficacy for future abstinence. if, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (path 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. so doing results in what marlatt refers to as the abstinence violation effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. this is a dangerous pathway, marlatt proposes, to full-blown relapse. cognitive therapy an additional cognitively-based model of substance use recovery has been offered by aaron beck, the father of cognitive therapy and championed in his 1993 book cognitive therapy of substance abuse. this therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). these core beliefs, such as "i am undesirable," activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. once craving has been activated, permissive beliefs ("i can handle getting high just this one more time") are facilitated. once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. the cognitive therapist's job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunction. as with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment. emotion regulation and mindfulness a growing literature is demonstrating the importance of emotion regulation in the treatment of substance use. considering that nicotine and other psychoactive substances such as cocaine activate similar psycho-pharmacological pathways, an emotion regulation approach may be applicable to a wide array of substance use. proposed models of affect-driven tobacco use have focused on negative reinforcement as the primary driving force for addiction; according to such theories, tobacco is used because it helps one escape from the undesirable effects of nicotine withdrawal or other negative moods. acceptance and commitment therapy (act), is showing evidence that it is effective in treating substance use, including the treatment of polysubstance use disorder and tobacco smoking. mindfulness programs that encourage patients to be aware of their own experiences in the present moment and of emotions that arise from thoughts, appear to prevent impulsive/compulsive responses. research also indicates that mindfulness programs can reduce the consumption of substances such as alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates. dual diagnosis people who are diagnosed with a mental health disorder and a simultaneous substance use disorder are known as having a dual diagnosis. for example, someone with bipolar disorder who also has an alcohol use disorder would have dual diagnosis. on such occasions, two treatment plans are needed with the mental health disorder requiring treatment first. according to the national survey on drug use and health (nsduh), 45 percent of people with addiction have a co-occurring mental health disorder. behavioral models behavioral models make use of principles of functional analysis of drinking behavior. behavior models exist for both working with the person using the substance (community reinforcement approach) and their family (community reinforcement approach and family training). both these models have had considerable research success for both efficacy and effectiveness. this model lays much emphasis on the use of problem-solving techniques as a means of helping the addict to overcome his/her addiction. the way researchers think about how addictions are formed shapes the models we have. four main behavioral models of addiction exist: the moral model, disease model, socio-cultural model and psycho-dynamic model. the moral model of addiction theorizes that addiction is a moral weakness and that it is the sole fault of the person for becoming addicted. supporters of the moral model view drug use as a choice, even for those who are addicted, and addicts as people of bad character. disease model of addiction frames substance abuse as 'a chronic relapsing disease that changes the structure and function of the brain'. research conducted on the neurobiological factors of addiction has proven to have mixed results, and the only treatment idea it offers is abstinence. the socio-cultural model tries to provide an explanation of how certain populations are more susceptible to substance abuse than others. it focuses on how discrimination, poor quality of life, lack of opportunity and other problems common in marginalized communities can make them vulnerable to addiction. the psycho-dynamic model looks at trauma and mental illness as a precursor to addiction. many rehabilitation centers treat "co-occurring" disorders, which refer to substance abuse disorder paired with a mental health diagnosis. barriers to treatment in the us barriers to accessing drug treatment may worsen negative health outcomes