COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral treatments represent a group of approaches, grounded in social learning theories of substance abuse, that hold that lack of effective coping skills may be one factor underlying the development or perpetuation of substance use disorders. Cognitive behavioral treatments have been among the most well defined and rigorously studied of the psychosocial treatments for substance abuse and dependence, and have a comparatively high level of empirical support across the addictions. For example, in their review of cost and effectiveness data for treatments for alcohol use disorders, Holder and colleagues (1991) included social skills training, self-control training, stress management training, and the Community Reinforcement Approach (Azrin et al., 1976), all broad-spectrum CBT approaches, as having good empirical evidence of effectiveness. Recent meta-analyses (Irvin et al., 1999) and reviews of the effectiveness of treatments for substance abuse (APA Workgroup on Substance Use Disorders, 1996; DeRubeis & Crits-Christoph 1998) have identified this group of approaches as having among the highest level of empirical support for the treatment of substance use disorders.

OVERVIEW AND STRUCTURE OF CBT

Cognitive-behavioral treatments are typically highly structured in comparison to other approaches for substance use disorders. That is, these treatment approaches are typically comparatively brief (12-24 weeks) and organized closely around well-specified treatment goals. There is typically an articulated agenda for each session and discussion remains focused around issues directly related to substance use. Progress toward treatment goals is monitored closely and frequently, and the therapist takes an active stance throughout treatment.

Cognitive-behavioral approaches typically include a range of skills to foster or maintain abstinence and to prevent relapse. These typically include strategies for:

1. reducing availability and exposure to the substance and related cues,
2. fostering resolution to stop substance use through exploring positive and negative consequences of continued use,
3. self-monitoring to identify high risk situations and to conduct functional analyses of substance use,
4. recognition of conditioned craving and development of strategies for coping with craving,
5. identification of seemingly irrelevant decisions which can culminate in high risk situations,
6. preparation for emergencies and coping with a relapse to substance use,
7. substance refusal skills, and
8. identifying and confronting thoughts about the substance.

The techniques of teaching these coping responses include a combination of direct verbal instruction, modeling of appropriate skills through role play, and rehearsal of the skills within the therapy session (Marlatt & Gordon, 1985). Material discussed during sessions is typically supplemented with extra-session tasks (i.e., homework) intended to foster practice and mastery of coping skills.

Broad-spectrum cognitive-behavioral approaches such as that described by Monti and colleagues (1989), and adapted for use in Project MATCH (Kadden et al., 1992), expand to include interventions directed to other problems in the individual's life that are seen as functionally related to substance use. These may include general problem-solving skills, assertiveness training, strategies for coping with negative affect, awareness of anger and anger management, coping with criticism, increasing pleasant activities, enhancing social support networks, job seeking skills, and so on.

There are a variety of manuals available (Monti et al., 1989; Kadden et al. 1992, Carroll, 1998) which describe key CBT strategies and techniques, as well as guidelines for its implementation with a variety of types of substance users. The classic resource in this area remains the Marlatt and Gordon's (1985) landmark book on relapse prevention.

The goals of cognitive-behavioral treatments tend to be somewhat broader than those of 'strict' behavioral approaches, and the choice of treatment goals will dictate the specific interventions implemented. For example, in broad spectrum cognitive-behavioral treatments (e.g., Azrin et al., 1976; Monti et al., 1989), the patient and therapist may select a wide range of target behaviors in addition to a treatment goal of abstinence, including improved social skills or social functioning, reduced psychiatric symptoms, and reduced social isolation, entry into the work force. Cognitive behavioral therapy also differs from cognitive therapy through greater emphasis on building specific behavioral skills (e.g., coping with craving, avoiding high risk situations, understanding behavioral patterns) and somewhat lesser emphasis on targeting and challenging maladaptive cognitions in the earlier stages of abstinence.

STRENGTHS AND WEAKNESSES

Strengths of cognitive-behavioral approaches have been summarized by Rotgers (1996) and include:

1. flexibility in meeting individual needs,
2. acceptability to a wide range of substance-abusing individuals seen in clinical settings,
3. solid grounding in established principles of behavior theory and behavior change,
4. an emphasis on linking science to treatment,
5. well-specified treatment goals and clear guidelines for assessing treatment progress,
6. emphasis on building self-efficacy, and
7. a comparatively strong level of empirical support.

These approaches are highly flexible, and can be used in a number of treatment modalities and settings, can be applied across different types of substance use with minor modifications, and are compatible with a wide range of other treatment approaches, including family therapy and pharmacotherapy. Another advantage is that these approaches have emphasized clear specification of treatment and a variety of manuals are available, thus allowing a high level of technology transfer. Disadvantages of this group of approaches include:

1. research evaluating these approaches have tended not to emphasize the importance of isolating and evaluating the specific 'active ingredients' associated with behavior change,
2. comparative underutilization of these approaches outside of academic treatment settings (Rotgers, 1996), and
3. lack of emphasis on patient motivation and specific procedures for addressing the patient's readiness for change.

SUMMARY

Cognitive behavioral treatments have emerged in the last decade as a leading approach to the treatment of substance use disorders. Solidly grounded in well-established principles of behavior change, with strong empirical support, and applicable to a wide range of individuals with substance use disorders, these well-defined approaches should be a part of any clinician's treatment repertoire.

BIBLIOGRAPHY

American Psychiatric Association, Work Group on Substance Use Disorders (1995). Practice guideline for the treatment of patients with substance use disorders: Alcohol, cocaine, opioids. American Journal of Psychiatry, 152 (sup), 2-59.

Azrin, N. H. (1976). Improvements in the community-reinforcement approach to alcoholism. Behavior Research and Therapy, 14, 339-348.

Carroll, K. M. (1998). A Cognitive-Behavioral Approach: Treating Cocaine Addiction. NIH Publication 98-4308. Rockville, MD: National Institute on Drug Abuse.

Carroll, K. M. (1999). Behavioral and cognitive behavioral treatments. In B. S. McCrady & E. E. Epstein (eds.), Addictions: A Comprehensive Guidebook (pp. 250-267). New York: Oxford University Press.

Chaney, E. F., O' Leary, M. R., & Marlatt, G.A. (1978) Skill training with problem drinkers. Journal of Consulting and Clinical Psychology, 46, 1092-1104.

DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.

Holder, H. D., Longabaugh, R., Miller, W. R., & Rubonis, A. V. (1991). The cost effectiveness of treatment for alcohol problems: A first approximation. Journal of Studies on Alcohol, 52, 517-540.

Irvin JE, Bowers CA, Dunn ME, Wong MC. Efficacy of relapse prevention: A meta-analytic review. J Consult Clin Psychology. 1999;67:563-570.

Kadden, R., Carroll, K. M., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., & Hester, R. (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series Volume 3, DHHS Publication No. (ADM) 92-1895. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Marlatt, G. A., & Gordon, J. R., (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford.

Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence: A coping skills training guide in the treatment of alcoholism. New York: Guilford.

Rotgers, F. (1996). Behavioral theory of substance abuse treatment: Bringing science to bear on practice. In F. Rotgers, D. Keller, & J. Morgenstern (eds.), Treating Substance Abusers: Theory and Technique (pp. 174-201). New York: Guilford.

Kathleen M. Carroll