by Kathleen M. Carroll, PhD
Cognitive-Behavioral Therapy: An Overview
Cognitive-behavioral coping skills treatment (CBT) is a short-term, focused approach to helping cocaine-dependent individuals (In this manual, the term cocaine abuser or cocaine-dependent individual is used to refer to individuals who meet DSM-IV criteria for cocaine abuse or dependence.) become abstinent from cocaine and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of cocaine abuse and dependence. These same learning processes can be used to help individuals reduce their drug use.
Very simply put, CBT attempts to help patients recognize, avoid, and cope. That is, RECOGNIZE the situations in which they are most likely to use cocaine, AVOID these situations when appropriate, and COPE more effectively with a range of problems and problematic behaviors associated with substance abuse.
Several important features of CBT make it particularly promising as a treatment for cocaine abuse and dependence:
- CBT is a short-term, comparatively brief approach well suited to the resource capabilities of most clinical programs.
- CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support as treatment for cocaine abuse. In particular, evidence points to the durability of CBT's effects as well as its effectiveness with subgroups of more severely dependent cocaine abusers (see Appendix B).
- CBT is structured, goal-oriented, and focused on the immediate problems faced by cocaine abusers entering treatment who are struggling to control their cocaine use.
- CBT is a flexible, individualized approach that can be adapted to a wide range of patients as well as a variety of settings (inpatient, outpatient) and formats (group, individual).
- CBT is compatible with a range of other treatments the patient may receive, such as pharmacotherapy.
- CBT's broad approach encompasses several important common tasks of successful substance abuse treatment.
Components of CBT
CBT has two critical components:
- Functional analysis
- Skills training
For each instance of cocaine use during treatment, the therapist and patient do a functional analysis, that is, they identify the patient's thoughts, feelings, and circumstances before and after the cocaine use. Early in treatment, the functional analysis plays a critical role in helping the patient and therapist assess the determinants, or high-risk situations, that are likely to lead to cocaine use and provides insights into some of the reasons the individual may be using cocaine (e.g., to cope with interpersonal difficulties, to experience risk or euphoria not otherwise available in the patient's life). Later in treatment, functional analyses of episodes of cocaine use may identify those situations or states in which the individual still has difficulty coping.
CBT can be thought of as a highly individualized training program that helps cocaine abusers unlearn old habits associated with cocaine abuse and learn or relearn healthier skills and habits. By the time the level of substance use is severe enough to warrant treatment, patients are likely to be using cocaine as their single means of coping with a wide range of interpersonal and intrapersonal problems. This may occur for several reasons:
- The individual may have never learned effective strategies to cope with the challenges and problems of adult life, as when substance use begins during early adolescence.
- Although the individual may have acquired effective strategies at one time, these skills may have decayed through repeated reliance on substance use as a primary means of coping. These patients have essentially forgotten effective strategies because of chronic involvement in a drug-using lifestyle in which the bulk of their time is spent in acquiring, using, and then recovering from the effects of drugs.
- The individual's ability to use effective coping strategies may be weakened by other problems, such as cocaine abuse with concurrent psychiatric disorders. Because cocaine abusers are a heterogeneous group and typically come to treatment with a wide range of problems, skills training in CBT is made as broad as possible. The first few sessions focus on skills related to initial control of cocaine use (e.g., identification of high-risk situations, coping with thoughts about cocaine use). Once these basic skills are mastered, training is broadened to include a range of other problems with which the individual may have difficulty coping (e.g., social isolation, unemployment). In addition, to strengthen and broaden the individual's range of coping styles, skills training focuses on both intrapersonal (e.g., coping with craving) and interpersonal (e.g., refusing offers of cocaine) skills. Patients are taught these skills as both specific strategies (applicable in the here and now to control cocaine use) and general strategies that can be applied to a variety of other problems. Thus, CBT is not only geared to helping each patient reduce and eliminate substance use while in treatment, but also to imparting skills that can benefit the patient long after treatment.
CBT addresses several critical tasks that are essential to successful substance abuse treatment (Rounsaville and Carroll 1992).
- Foster the motivation for abstinence. An important technique used to enhance the patient's motivation to stop cocaine use is to do a decisional analysis which clarifies what the individual stands to lose or gain by continued cocaine use.
- Teach coping skills. This is the core of CBT - to help patients recognize the high-risk situations in which they are most likely to use substances and to develop other, more effective means of coping with them.
- Change reinforcement contingencies. By the time treatment is sought, many patients spend most of their time acquiring, using, and recovering from cocaine use to the exclusion of other experiences and rewards. In CBT, the focus is on identifying and reducing habits associated with a drug-using lifestyle by substituting more enduring, positive activities and rewards.
- Foster management of painful affects. Skills training also focuses on techniques to recognize and cope with urges to use cocaine; this is an excellent model for helping patients learn to tolerate other strong affects such as depression and anger.
- Improve interpersonal functioning and enhance social supports. CBT includes training in a number of important interpersonal skills and strategies to help patients expand their social support networks and build enduring, drug-free relationships.
Parameters of CBT
An individual format is preferred for CBT because it allows for better tailoring of treatment to meet the needs of specific patients. Patients receive more attention and are generally more involved in treatment when they have the opportunity to work with and build a relationship with a single therapist over time. Individual treatment affords greater flexibility in scheduling sessions and eliminates the problem of either having to deliver treatment in a "rolling admissions" format or asking patients to wait several weeks until sufficient numbers of patients are recruited to form a group. Also, the comparatively high rates of retention in programs and studies may reflect, in part, particular advantages of individual treatment.
However, a number of researchers and clinicians have emphasized the unique benefits of delivering treatment to substance users in the group format (e.g., universality, peer pressure). It is relatively straightforward to adapt the treatment described in this manual for groups. This generally requires lengthening the sessions to 90 minutes to allow all group members to have an opportunity to comment on their personal experiences in trying out skills, give examples, and participate in role-playing. Treatment will also be more structured in a group format because of the need to present the key ideas and skills in a more didactic, less individualized format.
CBT has been offered in 12 to 16 sessions, usually over 12 weeks. This comparatively brief, short-term treatment is intended to produce initial abstinence and stabilization. In many cases, this is sufficient to bring about sustained improvement for as long as a year after treatment ends. Preliminary data suggest that patients who are able to attain 3 or more weeks of continuous abstinence from cocaine during the 12-week treatment period are generally able to maintain good outcome during the 12 months after treatment ends. For many patients, however, brief treatment is not sufficient to produce stabilization or lasting improvement. In these cases, CBT is seen as preparation for longer term treatment. Further treatment is recommended directly when the patient requests it or when the patient has not been able to achieve 3 or more weeks of continuous abstinence during the initial treatment. We are currently evaluating whether additional booster sessions of CBT during the 6 months following the initial treatment phase improves outcome. The maintenance version of CBT focuses on the following:
- Identifying situations, affects, and cognitions that remain problematic for patients in their efforts to maintain abstinence or which emerge after cessation or reduction of cocaine use.
- Maintaining gains through solidifying the more effective coping skills and strategies the subject has implemented.
- Encouraging patient involvement in activities and relationships that are incompatible with drug use. Rather than introducing new material or skills, the maintenance version of CBT focuses on broadening and mastering the skills to which the patient was exposed during the initial phase of treatment.
Treatment is usually delivered on an outpatient basis for several reasons:
- CBT focuses on understanding the determinants of substance use, and this is best done in the context of the patient's day-to-day life. By understanding who the patients are, where they live, and how they spend their time, therapists can develop more elaborate functional analyses.
- Skills training is most effective when patients have an opportunity to practice new skills and approaches within the context of their daily routine, learn what does and does not work for them, and discuss new strategies with the therapist.
CBT has been evaluated with a broad range of cocaine abusers. The following are generally not appropriate for CBT delivered on an out-patient basis:
- Those who have psychotic or bipolar disorders and are not stabilized on medication
- Those who have no stable living arrangements
- Those who are not medically stable (as assessed by a pretreatment physical examination)
- Those who have other concurrent substance dependence disorders, with the exception of alcohol or marijuana dependence (although we assess the need for alcohol detoxification in the former)
No significant differences have been found in outcome or retention for patients who seek treatment because of court or probation pressure and those who have DSM-IV diagnoses of antisocial personality disorder or other Axis II disorders, nor has outcome varied by patient race/ethnicity or gender.
Compatibility With Adjunctive Treatments
CBT is highly compatible with a variety of other treatments designed to address a range of comorbid problems and severities of cocaine abuse:
- Pharmacotherapy for cocaine use and/or concurrent psychiatric disorders
- Self-help groups such as Cocaine Anonymous (CA) and Alcoholics Anonymous (AA)
- Family and couples therapy
Vocational counseling, parenting skills, and so on When CBT is provided as part of a larger treatment package, it is essential for the CBT therapist to maintain close and regular contact with other treatment providers.
Active Ingredients of CBT
All behavioral or psychosocial treatments include both common and unique factors or "active ingredients." Common factors are those dimensions of treatment that are found in most psychotherapies - the provision of education, a convincing rationale for the treatment, enhancing expectations of improvement, provision of support and encouragement, and, in particular, the quality of the therapeutic relationship (Rozenzweig 1936; Castonguay 1993). Unique factors are those techniques and interventions that distinguish or characterize a particular psychotherapy.
CBT, like most therapies, consists of a complex combination of common and unique factors. For example, in CBT mere delivery of skills training without grounding in a positive therapeutic relationship leads to a dry, overly didactic approach that alienates or bores most patients and ultimately has the opposite effect of that intended. It is important to recognize that CBT is thought to exert its effects through this intricate interplay of common and unique factors.
A major task of the therapist is to achieve an appropriate balance between attending to the relationship and delivering skills training. For example, without a solid therapeutic alliance, it is unlikely that a patient will stay in treatment, be sufficiently engaged to learn new skills, or share successes and failures in trying new approaches to old problems. Conversely, empathic delivery of skills training as tools to help patients manage their lives more effectively may form the basis of a strong working alliance.
Essential and Unique Interventions
The key active ingredients that distinguish CBT from other therapies and that must be delivered for adequate exposure to CBT include the following:
- Functional analyses of substance abuse
- Individualized training in recognizing and coping with craving, managing thoughts about substance use, problemsolving, planning for emergencies, recognizing seemingly irrelevant decisions, and refusal skills
- Examination of the patient's cognitive processes related to substance use
- Identification and debriefing of past and future high-risk situations
- Encouragement and review of extra-session implementation of skills
- Practice of skills within sessions
Recommended But Not Unique Interventions
Interventions or strategies that should be delivered, as appropriate, during the course of each patient's treatment but that are not necessarily unique to CBT include those listed below.
- Discussing, reviewing, and reformulating the patient's goals for treatment
- Monitoring cocaine abuse and craving
- Monitoring other substance abuse
- Monitoring general functioning
- Exploring positive and negative consequences of cocaine abuse
- Exploring the relationship between affect and substance abuse
- Providing feedback on urinalysis results
- Setting the agenda for the session
- Making process comments as indicated
- Discussing advantages of an abstinence goal
- Exploring the patient's ambivalence about abstinence
- Meeting resistance with exploration and a problemsolving approach
- Supporting patient efforts
- Assessing level of family support
- Explaining the distinction between a slip and a relapse
- Including family members or significant others in up to two sessions
Four interventions are not required or strongly recommended as part of CBT but are not incompatible with this approach:
- Exploring self-help involvement as a coping skill
- Identifying means of self-reinforcement for abstinence
- Exploring discrepancies between a patient's stated goals and actions
- Eliciting concerns about substance abuse and consequences
Interventions Not Part of CBT
Interventions that are distinctive of dissimilar approaches to treatment and less consistent with a cognitive-behavioral approach include those listed below.
- Extensive self-disclosure by the therapist
- Use of a confrontational style or a confrontation-of-denial approach
- Requiring the patient to attend self-help groups
- Extended discussion of 12-step recovery, higher power, "Big Book" philosophy
- Use of disease model language or slogans
- Extensive exploration of interpersonal aspects of substance abuse
- Extensive discussion or interpretation of underlying conflicts or motives
- Provision of direct reinforcement for abstinence (e.g., vouchers, tokens)
- Interventions associated with Gestalt therapy, structural interventions, rational-emotive therapy, or other prescriptive treatment techniques
CBT Compared to Other Treatments
It is often easier to understand a treatment in terms of what it is not. This section discusses CBT for cocaine abuse in terms of its similarities to and differences from other psychosocial treatments for substance abuse.
CBT is most similar to other cognitive and behavioral therapies, all of which understand substance abuse in terms of its antecedents and consequences. These include Beck's Cognitive Therapy (Beck et al. 1991) and the Community Reinforcement Approach (CRA) (Azrin 1976; Meyers and Smith 1995), and particularly, Marlatt's Relapse Prevention (Marlatt and Gordon 1985), from which it was adapted.
Cognitive therapy "is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions" (Beck et al. 1991, p. 10).
CBT is particularly similar to cognitive therapy in its emphasis on functional analysis of substance abuse and identifying cognitions associated with substance abuse. It differs from cognitive therapy primarily in terms of emphasis on identifying, understanding, and changing underlying beliefs about the self and the self in relationship to substance abuse as a primary focus of treatment. Rather, in the initial sessions of CBT, the focus is on learning and practicing a variety of coping skills, only some of which are cognitive.
In CBT, initial strategies stress behavioral aspects of coping (e.g., avoiding or leaving the situation, distraction, and so on) rather than "thinking" one's way out of a situation. In cognitive therapy, the therapist's approach to focusing on cognitions is Socratic and based on leading the patient through a series of questions; in CBT, the approach is somewhat more didactic. In cognitive therapy, the treatment is thought to reduce substance use by changing the way the patient thinks; in CBT, the treatment is thought to work by changing what the patient does and thinks.
Community Reinforcement Approach
The Community Reinforcement Approach (CRA) "is a broad-spectrum behavioral treatment approach for substance abuse problems...that utilizes social, recreational, familial, and vocational reinforcers to aid clients in the recovery process" (Meyers and Smith 1995, p. 1).
This approach uses a variety of reinforcers, often available in the community, to help substance users move into a drug-free lifestyle. Typical components of CRA treatment include (1) functional analysis of substance use, (2) social and recreational counseling, (3) employment counseling, (4) drug refusal training, (5) relaxation training, (6) behavioral skills training, and (7) reciprocal relationship counseling. In the very successful approach developed by Higgins and colleagues for cocaine-dependent individuals (Higgins et al. 1991, 1994), a contingency management component is added that provides vouchers for staying in treatment. The vouchers are redeemable for items consistent with a drug-free lifestyle and are contingent upon the patient's provision of drug-free urine toxicology specimens.
Thus, CRA and CBT share a number of common features, most importantly, the functional analysis of substance abuse and behavioral skills training. CBT differs from CRA in not typically including the direct provision of either contingency management (vouchers) for abstinence or intervening with patients outside of treatment sessions or the treatment clinic, as do community-based interventions (job or social clubs).
Motivational Enhancement Therapy
CBT has some similarities to Motivational Enhancement Therapy (MET) (Miller and Rollnick 1992). MET "is based on principles of motivational psychology and is designed to produce rapid, internally motivated change. This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client's own change resources" (Miller et al. 1992, p. 1).
CBT and MET share an exploration, early in the treatment process, of what patients stand to gain or lose through continued substance use as a strategy to build patients' motivation to change their substance abuse.
CBT and MET differ primarily in emphasis on skill training. In MET, responsibility for how patients are to go about changing their behavior is left to the patients; it is assumed that patients can use available resources to change behavior and training is not required. CBT theory maintains that learning and practice of specific substance-related coping skills foster abstinence. Thus, because they focus on different aspects of the change process (MET on why patients may go about changing their substance use, CBT on how patients might do so), these two approaches may be seen as complementary. For example, for a patient with low motivation and few resources, an initial focus on motivational strategies before turning to specific coping skills (MET before CBT) may be the most productive approach.
While it is important to recognize that all psychosocial treatments for drug abuse share a number of features and may overlap or closely resemble one another in several ways, some approaches differ significantly from CBT.
CBT is dissimilar to 12-step, or disease-model approaches, in a number of ways. Twelve-Step Facilitation (TSF) (Nowinski et al. 1994) "is grounded in the concept of alcoholism as a spiritual and medical disease. The content of this intervention is consistent with the 12 Steps of Alcoholics Anonymous (AA), with primary emphasis given to Steps 1 through 5. In addition to abstinence from all psychoactive substances, a major goal of the treatment is to foster the participant's commitment to and participation in AA or Cocaine Anonymous (CA). Participants are actively encouraged to attend self-help meetings and to maintain journals of their AA/CA attendance and participation" (Project MATCH Research Group 1993).
While CBT and TSF share some concepts - for example, the similarity between the disease model's "people, places, and things" and CBT's "high-risk situations" - there are a number of important differences. The disease-model approaches are grounded in a concept of addiction as a disease that can be controlled but never cured. In CBT, substance abuse is a learned behavior that can be modified. The emphasis in disease model approaches is on patients' loss of control over substance abuse and other aspects of their lives; the emphasis in CBT is on self-control strategies, that is, what patients can do to recognize the processes and habits that underlie and maintain substance use and what can be done to change them.
Similarly, the major change agent in disease-model approaches is involvement with the fellowship of AA/CA and working the 12 Steps, that is, the way to cope with nearly all drug-related problems is by going to meetings or deepening involvement with fellowship activities. In CBT, coping strategies are much more individualized and based on the specific types of problems encountered by patients and their usual coping style.
While attending AA or CA meetings is not required or strongly encouraged in CBT, some patients find attending meetings very helpful in their efforts to become or remain abstinent. CBT therapists take a neutral stance to attending AA; they encourage patients to view going to meetings as a, not the coping strategy. The CBT therapist may explore with the patient the ways in which going to a meeting when faced with strong urges to use may be a very useful and important strategy to cope with craving; however, therapists will also encourage patients to think about and have ready a range of other strategies as well.
CBT is also different from interpersonal and short-term dynamic approaches such as Interpersonal Psychotherapy (IPT) (Rounsaville and Carroll 1993) or Supportive-Expressive Therapy (SE) (Luborsky 1984). IPT "is based on the concept that many psychiatric disorders, including cocaine dependence, are intimately related to disorders in interpersonal functioning which may be associated with the genesis or perpetuation of the disorder. IPT, as adapted for cocaine dependence, has four definitive characteristics: (1) adherence to a medical model of psychiatric disorders, (2) focus on patients' difficulties in current interpersonal functioning, (3) brevity and consistency of focus, and (4) use of an exploratory stance by the therapist that is similar to that of supportive and expressive therapies."
IPT differs from CBT in several ways: CBT has a structured approach, whereas IPT is more exploratory. Extensive efforts are made in CBT to teach and encourage patients to use skills to control their substance abuse, while in the more exploratory IPT approaches, substance abuse is viewed as a symptom of other difficulties and conflicts and thus may deal less directly with the substance use.
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