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CBT - Treating Cocaine Addiction - Session 1

Session 1: Introduction to Treatment and CBT

Tasks for Session 1

Take history and establish relationship
Enhance motivation
Present the CBT model
Introduce functional analysis
Negotiate treatment goals and treatment contract
Provide a rationale for extra-session tasks

Session Goals

The first session is the most important and often the most difficult because the therapist must address several areas.

Begin to establish a relationship with the patient
Assess the nature of the patient's substance use and other problems that may be important factors in treatment
Provide a rationale for the treatment
Establish the structure for the remaining sessions
Initiate skills training

Because of the complexity of the tasks involved in the first session, the therapist should allow 90 minutes, rather than rely on the typical 1-hour session.

Key Interventions

History and Relationship Building

Therapists should spend a considerable amount of time during the first session getting to know the patients, obtaining histories of them and their substance use, getting a sense of their level of motivation, and determining what led them to seek treatment. This can occur through a series of open-ended questions that should cover at least the following areas. Reasons for seeking treatment and treatment history

What brought you here today?
Have you ever been in treatment for cocaine abuse before?
If yes, when was that? How long did you stay there? What was it like? What did you like or not like about the program? Why did you leave?
Have you ever been in treatment for abuse of other substances, like heroin, alcohol, or benzodiazepines?

History and current pattern of cocaine abuse

What is your cocaine use right now? How do you use it?
How often do you use cocaine? How much do you use?
What is your longest period of abstinence from cocaine? When did it start? Stop?
What is the longest period of abstinence you've had in the last 3 months? How did that start and end?
What have you tried to do to cut down on your cocaine use?
How do you get cocaine?
How much alcohol do you drink? How does drinking affect your cocaine use?
How long have you been able to not drink?
What other types of drugs are you using?
How do you feel after using cocaine?
How did your cocaine use get started?

CBT - Treating Cocaine Addiction - Medication

Integrating CBT and Medication

CBT is highly compatible with pharmacotherapy. When used in combination with medication, the range of CBT interventions expands to include a focus on enhancing medication compliance. Generally, medication response and compliance are monitored during the early part of each session (i.e., the first third of a 20/20/20 session). The following specific strategies (Adapted from Carroll and O'Malley 1996.) have been found useful:

Inquire as to patients' previous experience with medication.
- Therapists should ask patients about their prior history with pharmacotherapy for any psychiatric disorder or condition.
- Why was it prescribed?
- Was it helpful?
- Under what conditions was it terminated?
- Did they take the medication as prescribed?
Previous noncompliance should alert therapists to the need to establish the patients' view of why they did not comply previously and to attempt to address those issues proactively.
Address patients' concerns about medication.During all sessions, therapists should listen carefully for any concerns, misunderstandings, or prejudices about taking medication and address these rapidly and assertively. These may include misconceptions about expected medication effects, time needed to experience the effect, side effects, dosing, and interactions with cocaine and other substances. Therapists should provide clarification in clear, familiar terms and frequently check back with patients to be sure they understand.

When medication effects may not be immediately apparent, it is important to inform patients that it may take several weeks before therapeutic effects emerge; thus, patients should be encouraged to expect gradual rather than all-or-nothing change. Explaining the gradual emergence of medication effects provides an opportunity for the therapist to emphasize that patients should not expect to benefit from an entirely passive stance regarding CBT treatment simply because they are taking medication. Mastery and implementation of coping skills remain an essential and important part of treatment; medication may be an additional, useful adjunct or tool.

Assess medication compliance since last session.Close, consistent, and careful monitoring is one of the most effective strategies for enhancing compliance with medications. Thus, a portion of each session should be devoted to evaluating medication compliance and working through any difficulties that might arise. In general, until the patients' compliance pattern is clearly established, therapists should, at each meeting, inquire about medication compliance, day by day, since the last session. This should include asking when patients take the medication, how they take the medication, and a thorough discussion of any deviation from the prescribed dose and schedule.
Fawcett et al. (1987) noted that compliance and retention are most difficult to achieve early and late in treatment - early if the patient is not receiving obvious benefit, and later if the patient, after obtaining a partial or full therapeutic response, does not appreciate the need to continue treatment. Thus, therapists should be particularly attentive to compliance and motivation issues during early and late sessions.
Praise medication compliance.Therapists should also convey confidence in the medication and inform patients of the likely benefits. Therapists should be strongly on the side of compliance and praise patients' compliance enthusiastically and genuinely.
"I see you have taken your medication every day since our last meeting. That's really great. I know you had your doubts about whether the medication would work for you, and I'm glad you were willing to give it a try. Have you noticed any positive changes you think might be related to the medication?"
Relate patients' clinical improvement to compliance and lack of improvement to noncompliance.A crucial role of the therapist is to establish and stress the connection between medication compliance, psychotherapy sessions, and improvement. Therapists should make explicit causal links between patients' compliance and improvement in cocaine abuse and other appropriate target symptoms. Conversely, therapists might tie poor compliance to failure to improve.
"Since you've been taking the medication, I can see a lot of positive changes in your life....you've cut way down on your cocaine use and you say you've been feeling a lot better. I think the changes indicate that the medication is helping you. What do you think?"

"I know you're discouraged about how you've been feeling, but since we've begun to work together, you've also told me you haven't been taking the medication every day. As we've discussed, I don't think you'll notice a real change until you take the medication more consistently. How about giving it a try?"
Use a problemsolving strategy for noncompliance.When patients are not compliant with medication, therapists should take a practical, objective approach. They should try to help patients clarify reasons or obstacles to compliance and generate practical solutions. For example, patients may report difficulty remembering to take the medication. Practical strategies to cue the patient (e.g., notes on the bathroom mirror, taking the medication at a regular mealtime, enlisting family support and reminders) should be generated and followed up on in the next session. In all of these discussions, therapists should be nonjudgmental and nonconfrontational. Efforts should be made to help patients feel ownership of the plan. This can be done by having them take the primary role in developing the plan, rather than having therapists telling them what to do.

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CBT - Treating Cocaine Addiction - Sessions

CBT - Treating Cocaine Addiction - Principles

Basic Principles of CBT

CBT is collaborative. The patient and therapist consider and decide together on the appropriate treatment goals, the type and timing of skills training, whether a significant other is brought into some of the sessions, the nature of outside practice tasks, and so on. Not only does this foster the development of a good working relationship and avoid an overly passive stance by the therapist, but it also assures that treatment will be most useful and relevant to the patient.

Learned Behavior

CBT is based on social learning theory. It is assumed that an important factor in how individuals begin to use and abuse substances is that they learn to do so. The several ways individuals may learn to use drugs include modeling, operant conditioning, and classical conditioning.

Modeling

People learn new skills by watching others and then trying it themselves. For example, children learn language by listening to and copying their parents. The same may be true for many substance abusers. By seeing their parents use alcohol, individuals may learn to cope with problems by drinking. Teenagers often begin smoking after watching their friends use cigarettes. So, too, may some cocaine abusers begin to use after watching their friends or family members use cocaine or other drugs.

Operant Conditioning

Laboratory animals will work to obtain the same substances that many humans abuse (cocaine, opiates, and alcohol) because they find exposure to the substance pleasurable, that is, reinforcing. Drug use can also be seen as behavior that is reinforced by its consequences. Cocaine may be used because it changes the way a person feels (e.g., powerful, energetic, euphoric, stimulated, less depressed), thinks (I can do anything, I can only get through this if I am high), or behaves (less inhibited, more confident).

The perceived positive (and negative) consequences of cocaine use vary widely from individual to individual. People with family histories of substance abuse, a high need for sensation seeking, or those with a concurrent psychiatric disorder may find cocaine particularly reinforcing. It is important that clinicians understand that any given individual uses cocaine for important and particular reasons.

Classical Conditioning

Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating). Over time, cocaine abuse may become paired with money or cocaine paraphernalia, particular places (bars, places to buy drugs), particular people (drug-using associates, dealers), times of day or week (after work, weekends), feeling states (lonely, bored), and so on. Eventually, exposure to those cues alone is sufficient to elicit very intense cravings or urges that are often followed by cocaine abuse.

Functional Analysis

The first step in CBT is helping patients recognize why they are using cocaine and determining what they need to do to either avoid or cope with whatever triggers their use. This requires a careful analysis of the circumstances of each episode and the skills and resources available to patients. These issues can often be assessed in the first few sessions through an open-ended exploration of the patients' substance abuse history, their view of what brought them to treatment, and their goals for treatment. Therapists should try to learn the answers to the following questions.

Deficiencies and Obstacles

Have the patients been able to recognize the need to reduce availability of cocaine?
Have they been able to recognize important cocaine cues?
Have they been able to achieve even brief periods of abstinence?
Have they recognized events that have led to relapse?
Have the patients been able to tolerate periods of cocaine craving or emotional distress without resorting to drug use?
Do they recognize the relationship of their other substance abuse (especially alcohol) in maintaining cocaine dependence?
Do the patients have concurrent psychiatric disorders or other problems that might confound efforts to change behavior?

Skills and Strengths

What skills or strengths have they demonstrated during any previous periods of abstinence?
Have they been able to maintain a job or positive relationships while abusing drugs?
Are there people in the patients' social network who do not use or supply drugs?
Are there social supports and resources to bolster the patients' efforts to become abstinent?
How do the patients spend time when not using drugs or recovering from their effects?
What was their highest level of functioning before using drugs?
What brought them to treatment now?
How motivated are the patients?

Determinants of Cocaine Use

What is their individual pattern of use (weekends only, every day, binge use)?
What triggers their cocaine use?
Do they use cocaine alone or with other people?
Where do they buy and use cocaine?
Where and how do they acquire the money to buy drugs?
What has happened to (or within) the patients before the most recent episodes of abuse?
What circumstances were at play when cocaine abuse began or became problematic?
How do they describe cocaine and its effects on them?
What are the roles, both positive and negative, that cocaine plays in their lives?

Relevant Domains

In identifying patients' determinants of drug abuse, it may be helpful for clinicians to focus their inquiries to cover at least five general domains:

Social: With whom do they spend most of their time? With whom do they use drugs? Do they have relationships with those individuals that do not involve substance abuse? Do they live with someone who is a substance abuser? How has their social network changed since drug abuse began or escalated?
Environmental: What are the particular environmental cues for their drug abuse (e.g., money, alcohol use, particular times of the day, certain neighborhoods)? What is the level of their day-to-day exposure to these cues? Can some of these cues be easily avoided?
Emotional: Research has shown that feeling states commonly precede substance abuse or craving. These include both negative (depression, anxiety, boredom, anger) and positive (excitement, joy) affect states. Because many patients initially have difficulty linking particular emotional states to their substance abuse (or do so, but only at a surface level), affective antecedents of substance abuse typically are more difficult to identify in the initial stages of treatment.
Cognitive: Particular sets of thought or cognition frequently precede cocaine use (I need to escape, I can't deal with this unless I'm high, With what I am going through I deserve to get high). These thoughts are often charged and have a sense of urgency.
Physical: Desire for relief from uncomfortable physical states such as withdrawal has been implicated as a frequent antecedent of drug abuse. While controversy surrounding the nature of physical withdrawal symptoms from cocaine dependence continues, anecdotally, cocaine abusers frequently report particular physical sensations as precursors to substance abuse (e.g., tingling in their stomachs, fatigue or difficulty concentrating, thinking they smell cocaine).

Assessment Tools

Standardized instruments may also be useful in rounding out the therapist's understanding of the patient and identifying treatment goals. The following assessment tools have been helpful.

Substance abuse and related problems
- The Addiction Severity Index (McLellan et al. 1992) assesses the frequency and severity of substance abuse as well as the type and severity of psychosocial problems that typically accompany substance abuse (e.g., medical, legal, family/ social, employment, psychiatric).
- The Change Assessment Scale (DiClemente and Hughes 1990) assesses the patient's current position on readiness for change (e.g., precontemplation, contemplation, commitment), which may be an important predictor of response to substance abuse treatment (Prochaska et al. 1992).
- A record of daily substance use can be used to collect inform-ation on cocaine and other substance use day by day over a significant period.
- The Treatment Attitudes and Expectation form, a self-report instrument, has been adapted from the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al. 1985) and modified for use with cocaine abusers. Greater congruence between patients' expectations of treatment and beliefs about the causes of substance use and those of the treatment they receive may result in improved outcome, as compared to persons whose treatment expectations contrast with the treatment received (Hall et al. 1991).
Psychiatric diagnosis and symptoms
- The Structured Clinical Interview for DSM-IV (SCID) and SCID-P (First et al. 1995) provides DSM-IV diagnoses (for Axis I and II psychiatric diagnoses). It can also be used to assess severity of cocaine dependence by the total number of dependence syndrome elements endorsed (from the DSM-III-R substance abuse criteria).
- The California Psychological Inventory Socialization Scale (CPI-So) has been found to be a valid continuous measure of sociopathy in alcoholics (Cooney et al. 1990) and an important variable for patient-treatment matching in alcoholics (Kadden et al. 1989).
- The self-report Beck Depression Inventory (BDI) (Beck et al. 1961) and a clinician-rated instrument, the Hamilton Depression Rating Scale (Hamilton 1960), assess depression. The Symptom Checklist (SCL-90) (Derogatis et al. 1973) assesses a broader range of symptoms.
Baseline level of coping skills and self-efficacy
- The Cocaine Use Situations Inventory monitors changes in patients' self-efficacy and expectations of abstinence. This self-report form lists approximately 30 different types of high-risk situations and helps clinicians pinpoint specific situations that the patient does not cope with effectively. This instrument was derived from the self-efficacy instrument developed by Condiotte and Lichtenstein (1981) for use with alcoholics.

Skills Training

Learning serves as an important metaphor for the treatment process throughout CBT. Therapists tell patients that a goal of the treatment is to help them "unlearn" old, ineffective behaviors and "learn" new ones. Patients, particularly those who are demoralized by their failure to cease their cocaine abuse, or for whom the consequences of cocaine abuse have been highly negative, are frequently surprised to consider cocaine abuse as a type of skill, as something they have learned to do over time. After all, they are surprised when they think of themselves as having learned a complex set of skills that enabled them to acquire the money needed to buy cocaine (which often led to another set of licit or illicit skills), acquire cocaine without being arrested, use cocaine and avoid detection, and so on. Patients who can reframe their self-appraisals in terms of being skilled in this way often see that they also have the capacity to learn a new set of skills that will help them remain abstinent.

Learning Strategies Aimed at Cessation of Cocaine Use

In CBT, it is assumed that individuals essentially learn to become cocaine abusers through complex interplays of modeling, classical conditioning, or operant conditioning. Each of these principles is used to help the patient stop abusing cocaine.

Modeling is used to help the patient learn new behaviors by having the patient participate in role-plays with the therapist during treatment. The patient learns to respond in new, unfamiliar ways by first watching the therapist model those new strategies and then practicing those strategies within the supportive context of the therapy hour. New behaviors may include how to refuse an offer of drugs or how to break off or limit a relationship with a drug-using associate.

Operant conditioning concepts are used several ways in CBT.

Through a detailed examination of the antecedents and consequences of substance abuse, therapists attempt to understand why patients may be more likely to use in a given situation and to understand the role that cocaine plays in their lives. This functional analysis of substance abuse is used to identify the high-risk situations in which they are likely to abuse drugs and, thus, to provide the basis for learning more effective coping behaviors in those situations.
Therapists attempt to help patients develop meaningful alternative reinforcers to drug abuse, that is, other activities and involvements (relationships, work, hobbies) that serve as viable alternatives to cocaine abuse and help them remain abstinent.
A detailed examination of the consequences, both long- and short-term, of cocaine and other substance abuse is employed as a strategy to build or reinforce the patient's resolve to reduce or cease substance abuse.

Classical conditioning concepts also play an important role in CBT, particularly in interventions directed at reducing some forms of craving for cocaine. Just as Pavlov demonstrated that repeated pairings of a conditioned stimulus with an unconditioned stimulus could elicit a conditioned response, he also demonstrated that repeated exposure to the conditioned stimulus without the unconditioned stimulus would, over time, extinguish the conditioned response. Thus, the therapist attempts to help patients understand and recognize conditioned craving, identify their own idiosyncratic array of conditioned cues for craving, avoid exposure to those cues, and cope effectively with craving when it does occur so that conditioned craving is reduced.

Generalizable Skills

Since CBT treatment is brief, only a few specific skills can be introduced to most patients. Typically, these are skills designed to help the patient gain initial control over cocaine and other substance abuse, such as coping with craving and managing thoughts about drug abuse. However, the therapist should make it clear to the patient that any of these skills can be applied to a variety of problems, not just cocaine abuse.

The therapist should explain that CBT is an approach that seeks to teach skills and strategies that the patient can use long after treatment. For example, the skills involved in coping with craving (recognizing and avoiding cues, modifying behavior through urge-control techniques, and so on) can be used to deal with a variety of strong emotional states that may also be related to cocaine abuse. Similarly, the session on problemsolving skills can be applied to nearly any problem the patient faces, whether drug abuse-related or not.

Basic Skills First

This manual describes a sequence of sessions to be delivered to patients; each focuses on a single or related set of skills (e.g., craving, coping with emergencies). The order of presentation of these skills has evolved with experience with the types of problems most often presented by cocaine-abusing patients coming into treatment.

Early sessions focus on the fundamental skills of addressing ambivalence and fostering motivation to stop cocaine abuse, helping the patient deal with issues of drug availability and craving, and other skills intended to help the patient achieve initial abstinence or control over use. Later sessions build on these basic skills to help the patient achieve stronger control over cocaine abuse by working on more complex topics and skills (problemsolving, addressing subtle emotional or cognitive states). For example, the skills patients learn in achieving control over craving (urge control) serve as a model for helping them manage and tolerate other emotional states that may lead to cocaine abuse.

Match Material to Patient Needs

CBT is highly individualized. Rather than viewing treatment as cookbook psychoeducation, the therapist should carefully match the content, timing, and nature of presentation of the material to the patient. The therapist attempts to provide skills training at the moment the patient is most in need of the skill. The therapist does not belabor topics, such as breaking ties with cocaine suppliers, with a patient who is highly motivated and has been abstinent for several weeks. Similarly, the therapist does not rush through material in an attempt to cover all of it in a few weeks; for some patients, it may take several weeks to truly master a basic skill. It is more effective to slow down and work at a pace that is comfortable and productive for a particular individual than to risk the therapeutic alliance by using a pace that is too aggressive.

Similarly, therapists should be careful to use language that is compatible with the patient's level of understanding and sophistication. For example, while some patients can readily understand concepts of conditioned craving in terms of Pavlov's experiments on classical conditioning, others require simpler, more concrete examples, using familiar language and terms.

Therapists should frequently check with patients to be sure they understand a concept and that the material feels relevant to them. The therapist should also be alert to signals from patients who think the material is not well suited to them. These signals include loss of eye contact and other forms of drifting away, overly brief responses, failure to come up with examples, failure to do homework, and so on.

An important strategy in matching material to patient needs (and providing treatment that is patient driven rather than manual driven) is to use, whenever possible, specific examples provided by the patients, either through their history or relating events of the week. For example, rather than focusing on an abstract recitation of "Seemingly Irrelevant Decisions," the therapist should emphasize a recent, specific example of a decision made by the patient that ended in an episode of cocaine use or craving. Similarly, to make sure the patient understands a concept, the therapist should ask the patient to think of a specific experience or example that occurred in the past week that illustrates the concept or idea.

"It sounds like you had a lot of difficulty this week and wound up in some risky situations without quite knowing how you got there. That's exactly what I'd like to talk about this week, how by not paying attention to the little decisions we make all the time, we can land in some rough spots. Now, you started out talking about how you had nothing to do on Saturday and decided to hang out in the park, and 2 hours later you were driving into the city to score with Teddy. If we look carefully at what happened Saturday, I bet we can come up with a whole chain of decisions you made that seemed pretty innocent at the time, but eventually led to you being in the city. For example, how did it happen that you felt you had nothing to do on Saturday?"

Use Repetition

Learning new skills and effective skill-building requires time and repetition. By the time they seek treatment, cocaine users' habits related to their drug abuse tend to be deeply ingrained. Any given patient's routine around acquiring, using, and recovering from cocaine use is well established and tends to feel comfortable to the patient, despite the negative consequences of cocaine abuse. It is important that therapists recognize how difficult, uncomfortable, and even threatening it is to change these established habits and try new behaviors. For most patients, mastering a new approach to old situations takes several attempts.

Moreover, many patients come to treatment only after long periods of chronic use, which may affect their attention, concentration, and memory and thus their ability to comprehend new material. Others seek treatment at a point of extreme crisis (e.g., learning they are HIV positive, after losing a job); these patients may be so preoccupied with their current problems that they find it difficult to focus on the therapist's thoughts and suggestions. Thus, in the early weeks of treatment, repetition is often necessary if a patient is to be able to understand or retain a concept or idea.

In fact, the basic concepts of this treatment are repeated throughout the CBT process. For example, the idea of a functional analysis of cocaine abuse occurs formally in the first session as part of the rationale for treatment, when the therapist describes understanding cocaine abuse in terms of antecedents and consequences. Next, patients are asked to practice conducting a functional analysis as part of the homework assignment for the first session. The concept of a functional analysis then recurs in each session; the therapist starts out by asking about any episodes of cocaine use or craving, what preceded the episodes, and how the patient coped.

The idea of cocaine use in the context of its antecedents and consequences is inherent in most treatment sessions. For example, craving and thoughts about cocaine are common antecedents of cocaine abuse and are the focus of two early sessions. These sessions encourage patients to identify their own obvious and more subtle determinants of cocaine abuse, with a slightly different focus each time. Similarly, each session ends with a review of the possible pitfalls and high-risk situations that may occur before the next session, to again stimulate patients to become aware of and change their habits related to cocaine abuse.

While key concepts are repeated throughout the manual, therapists should recognize that repetition of whole sessions, or parts of sessions, may be necessary for patients who do not readily grasp these concepts because of cognitive impairment or other problems. Therapists should feel free to repeat session material as many times and in as many different ways as needed with particular patients.

Practice Mastering Skills

We do not master complex new skills by merely reading about them or watching others do them. We learn by trying out new skills ourselves, making mistakes, identifying those mistakes, and trying again.

In CBT, practice of new skills is a central, essential component of treatment. The degree to which the treatment is skills training over merely skills exposure has to do with the amount of practice. It is critical that patients have the opportunity to try out new skills within the supportive context of treatment. Through firsthand experience, patients can learn what new approaches work or do not work for them, where they have difficulty or problems, and so on.

CBT offers many opportunities for practice, both within sessions and outside of them. Each session includes opportunities for patients to rehearse and review ideas, raise concerns, and get feedback from the therapist. Practice exercises are suggested for each session; these are basically homework assignments that provide a structured way of helping patients test unfamiliar behaviors or try familiar behaviors in new situations.

However, practice is only useful if the patient sees its value and actually tries the exercise. Compliance with extra-session assignments is a problem for many patients. Several strategies are helpful in encouraging patients to do homework.

Give a Clear Rationale

Therapists should not expect a patient to practice a skill or do a homework assignment without understanding why it might be helpful. Thus, as part of the first session, therapists should stress the importance of extra-session practice.

"It will be important for us to talk about and work on new coping skills in our sessions, but it is even more important to put these skills into use in your daily life. You are really the expert on what works and doesn't work for you, and the best way to find out what works for you is to try it out. It's very important that you give yourself a chance to try out new skills outside our sessions so we can identify and discuss any problems you might have putting them into practice. We've found, too, that people who try to practice these things tend to do better in treatment. The practice exercises I'll be giving you at the end of each session will help you try out these skills. We'll go over how well they worked for you, what you thought of the exercises, and what you learned about yourself and your coping style at the beginning of each session."

Get a Commitment

We are all much more likely to do things we have told other people we would do. Rather than assume that patients will follow through on a task, CBT therapists should be direct and ask patients whether they are willing to practice skills outside of sessions and whether they think it will be helpful to do so. A clear "yes" conveys the message that the patient understands the importance of the task and its usefulness. Moreover, it sets up a discussion of discrepancy if the patient fails to follow through.

On the other hand, hesitation or refusal may be a critical signal of clinical issues that are important to explore with the patient. Patients may refuse to do homework because they do not see the value of the task, because they are ambivalent about treatment or renouncing cocaine abuse, because they do not understand the task, or for various other reasons.

Anticipate Obstacles

It is essential to leave enough time at the end of each session to develop or go over the upcoming week's practice exercise in detail. Patients should be given ample opportunity to ask questions and raise concerns about the task. Therapists should ask patients to anticipate any difficulties they might have in carrying out the assignment and apply a prob-lemsolving strategy to help work through these obstacles. Patients should be active participants in this process and have the opportunity to change or develop the task with the therapist, to plan how the skill will be put into practice, and so on.

Working through obstacles may include a different approach to the task (e.g., using a tape recorder for self-monitoring instead of writing), thinking through when the task will be done, whether someone else will be asked to help, and so on. The goal of this discussion should be the patient's expressed commitment to do the exercise.

Monitor Closely

Following up on assignments is critical to improving compliance and enhancing the effectiveness of these tasks. Checking on task completion underscores the importance of practicing coping skills outside of sessions. It also provides an opportunity to discuss the patient's experience with the tasks so that any problems can be addressed in treatment.

In general, patients who do homework tend to have therapists who value homework, spend a lot of time talking about homework, and expect their patients to actually do the homework. The early part of each session must include at least 5 minutes for reviewing the practice exercise in detail; it should not be limited to asking patients whether they did it. If patients expect the therapist to ask about the practice exercise, they are more likely to attempt it than are patients whose therapist does not follow through.

Similarly, if any other task is discussed during a session (e.g., implementation of a specific plan to avoid a potential high-risk situation), be sure to bring it up in the following session. For example, "Were you able to talk to your brother about not coming over after he gets high?"

Use the Data

The work patients do in implementing a practice exercise and their thoughts about the task convey a wealth of important information about the patients, their coping style and resources, and their strengths and weaknesses. It should be valued by the therapist and put to use during the sessions.

A simple self-monitoring assignment, for example, can quickly reveal patients' understanding of the task or basic concepts of CBT, level of cognitive flexibility, insight into their own behavior, level of motivation, coping style, level of impulsivity, verbal skills, usual emotional state, and much more. Rather than simply checking homework, the CBT therapist should explore with the patients what they learned about themselves in carrying out the task. This, along with the therapist's own observations, will help guide the topic selection and pacing of future sessions.

Explore Resistance

Some patients literally do the practice exercise in the waiting room before a session, while others do not even think about their practice exercises. Failure to implement coping skills outside of sessions may have a variety of meanings: patients feel hopeless and do not think it is worth trying to change behavior; they expect change to occur through willpower alone, without making specific changes in particular problem areas; the patients' life is chaotic and crisis ridden, and they are too disorganized to carry out the tasks; and so on. By exploring the specific nature of patients' difficulty, therapists can help them work through it.

Praise Approximations

Just as most patients do not immediately become fully abstinent on treatment entry, many are not fully compliant with practice exercises. Therapists should try to shape the patients' behavior by praising even small attempts at working on assignments, highlighting anything they reveal was helpful or interesting in carrying out the assignment, reiterating the importance of practice, and developing a plan for completion of the next session's homework assignment.

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CBT - Treating Cocaine Addiction - Overview

by Kathleen M. Carroll, PhD
Yale University

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.

Why CBT?

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

Functional Analysis

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.

Skills Training

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.

Critical Tasks

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

Format

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.

Length

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.

Setting

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.

Patients

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

Acceptable Interventions

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.

Similar Approaches

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

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.

Dissimilar Approaches

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.

Twelve-Step Facilitation

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.

Interpersonal Psychotherapy

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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CBT - Treating Cocaine Addiction - Foreword

by Kathleen M. Carroll, PhD
Yale University

Foreword

More than 20 years of research has shown that addiction is clearly treatable. Addiction treatment has been effective in reducing drug use and HIV infection, diminishing the health and social costs that result from addiction, and decreasing criminal behavior. The National Institute on Drug Abuse (NIDA), which supports more than 85 percent of the world's research on drug abuse and addiction, has found that the most effective treatment approaches include both biological and behavioral components.

To ensure that treatment providers apply the most current science-based approaches to their patients, NIDA has supported the development of the "Therapy Manuals for Drug Addiction" series. This series reflects NIDA's commitment to rapidly applying basic findings in real-life settings. The manuals are derived from those used efficaciously in NIDA-supported drug abuse treatment studies. They are intended for use by drug abuse treatment practitioners, mental health professionals, and all others concerned with the treatment of drug addiction.

The manuals present clear, helpful information to aid drug treatment practitioners in providing the best possible care that science has to offer. They describe scientifically supported therapies for addiction and give specific guidance on session content and how to implement these techniques. Of course, there is no substitute for training and supervision, and these manuals may not be applicable to all types of patients nor compatible with all clinical programs or treatment approaches. These manuals should be viewed as a supplement to, but not a replacement for, careful assessment of each patient, appropriate case formulation, ongoing monitoring of clinical status, and clinical judgment.

The therapies presented in this series exemplify the best of what we currently know about treating drug addiction. As our knowledge evolves, new and improved therapies are certain to emerge. We look forward to continuously bringing you the latest scientific findings through manuals and other science-based publications. We welcome your feedback about the usefulness of this manual series and any ideas you have on how it might be improved.

Alan I. Leshner
Director
National Institute on Drug Abuse

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Bullying - What influences bullying?

Bullying:

What influences bullying?

Not all students bully or are bullied in the same way. Consider the following information about how race/ethnicity, gender/sexual identity, and gender seem to influence bullying among young people.

How Does Bullying Differ Among Students?

Race and/or Ethnicity

There is very little information about racial/ethnic differences in bullying and victimization among young people. According to the NICHD survey, Hispanic youth reported bullying others only marginally more than white or black youth; however, black youth reported being bullied significantly more than white or Hispanic youth. In contrast, Graham and Juvonen (2002) found that African American students were more likely to be nominated as aggressive than Latino and multi-ethnic urban middle school students. In another study by Moran and colleagues (1993), Asian and white students aged 9 to 15 did not differ with respect to the frequency of bullying others or being bullied. However, the content of the bullying experience was different in that 50 percent of the bullied Asian children were called names because of their skin color while none of the white children experienced this form of bullying.

"Collectively, the relation between race/ethnicity and bullying is complex and is potentially influenced by the racial/ethnic composition of the classroom, school, or community (Juvonen, Nishina, & Graham, 2001) (p. 372)." - Espelage and Swearer (2003)

Gender and/or Sexual Identity

Lesbian, gay, bisexual, and transgender (LGBT) youth are at particular risk for all forms of bullying. In 2001, the Gay, Lesbian and Straight Education Network conducted the National School Climate Survey ? the only national survey to document the experiences of LGBT youth in U.S. high schools. A total of 904 LGBT youth from 48 states and the District of Columbia completed the survey. The vast majority of respondents (84.3%) reported that they frequently or often hear homophobic remarks (e.g., words such as " faggot," " dyke," or " queer" ). Many further reported experiencing some form of harassment or violence, which broke down in the following manner:

83.2% reported being verbally harassed (e.g., name calling, threats) because of their sexual orientation
65.4% reported being sexually harassed (e.g., being the target of suggestive comments, being touched inappropriately)
74.2% of lesbian and bisexual young women reported being sexually harassed
73.7% of transgender students reported being sexually harassed
48.3% of LGBT students of color reported being verbally harassed because of both their sexual orientation and their race/ethnicity
41.9% reported being physically harassed (e.g., shoved or pushed) because of their sexual orientation
21.1% reported being physically assaulted (e.g., punched, kicked, injured with a weapon) because of their sexual orientation

Gender

Studies frequently reveal that boys bully and are bullied more often than girls. For example, according to the NICHD survey, 26 percent of boys and 14 percent of girls were moderate to frequent bullies. A similar pattern emerged with respect to victimization, with 21 percent of boys and 14 percent of girls reporting that they were moderate to frequent victims of bullies. These findings, however, may be due - at least in part - to the manner in which bullying is defined and/or identified by researchers. Bullying by girls tends to be more subtle and, as a result, more difficult to detect than bullying by boys. According to Olweus, boys are three to four times more likely than girls to use physical aggression when bullying others.

"Historically, many studies on aggression have excluded girls from the sample (Crick & Rose, 2001) and have defined aggression as overtly physical or verbal, but have failed to consider more subtle, covert forms." - Espelage and Swearer (2003)

While male bullies certainly use other tactics as well (e.g., verbal bullying, telling lies, and spreading rumors), the tendency toward physical aggression is a critical difference between boys and girls. Female bullies tend to engage in verbal bullying, such as direct teasing and indirect rumor-spreading, as well as social ostracism/isolation - but they rarely use physical tactics. Perhaps boys more than girls are able to label - and thus report - their experiences as bullying because of the direct and physical nature of the bullying incidents in which they are involved (both as bullies and as victims).

A Final Note About These Categories

Tensions related to race/ethnicity, gender, and gender/sexual identity among students often lead to a wide range of behaviors that can be classified as bullying. For example, in the 9th Biennial California Student Survey, conducted with 8,238 students in grades 7, 9, and 11, nearly one-fourth of the students reported having been bullied or harassed at school at least once because of their race/ethnicity, gender, sexual orientation, religion, or disability status. Race/ethnicity was the most frequently cited reason for being victimized (14%).

Bullying is a highly sensitive issue to address in the school setting. It becomes even more challenging as you come to realize that it is connected to other sensitive issues associated with race/ethnicity, gender, and gender/sexual identity. In order to truly understand and address the problem of bullying among students, school personnel need to appreciate the interconnectedness of these important issues. For example, many state and federal laws prohibit discrimination and harassment based on these and other identity characteristics. When a bully targets a victim specifically because of race/ethnicity, gender, or gender/sexual identity, the assault may actually be considered a hate crime.

Athealth.com Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Source: Adapted from Exploring the Nature and Prevention of Bullying

Page last modified by Department of Education on January 25, 2010

Page last modified or reviewed by athealth on January 31, 2014

Bullying:

Where and When Does Bullying Occur?

According to the NICHD survey, youth from urban, suburban, and rural areas were all equally likely to be bullied, while suburban youths were slightly less likely and rural youths were slightly more likely than the national average to bully others. Across all three settings, bullying tends to happen most often in and around schools, specifically in those areas where there is little or no adult supervision (e.g., playground, hallways, cafeteria, classroom before the lesson begins).

As for age differences, the bullying literature presents a rather inconsistent picture of the manner in which bullying rates change across the K-12 grade range. Some studies indicate that bullying is most prevalent during the elementary school years, while others show an increase and peak during early adolescence.

Consider the following:

In Olweus's Norwegian National Survey data, as well as many other studies, the percentage of students who reported being bullied at school decreased with increasing age and grade level. In fact, such studies indicate that there are approximately twice as many victims of bullying in the primary grades as in the secondary grades. In contrast, the number of self-reported bullies remained fairly stable across the years.

According to the NICHD survey, as well as many other studies, the typical trajectory of bullying is an increase and peak after elementary school, during the middle school years, followed by a decrease during the high school years. If this is the case, then the transition from elementary to middle school would be a particularly critical period for prevention and intervention efforts.

When asked about this inconsistency in the bullying literature, Susan Swearer, assistant professor of school psychology at the University of Nebraska-Lincoln and principal investigator of a comprehensive program of research examining the ecology of bullying and victimization in school-aged youth, made the following comment:

"I think that perhaps the most accurate statement is that bullying takes on different forms across the lifespan. For example, bullying in elementary school may be more physical and therefore, more easily observed. Bullying in high school may be more akin to sexual harassment and thus, more covert and less observable. Most research suggests that bullying peaks during the middle school years and researchers have hypothesized that the transition from elementary to middle school, the need to re-establish peer relationships, and puberty may all account for this 'increase.' In any case, I think the most defensible statement is that bullying is a problem across all ages!"

Athealth.com Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Source: Adapted from Exploring the Nature and Prevention of Bullying

Page last modified by Department of Education on January 25, 2010

Page last modified or reviewed by athealth on January 31, 2014

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Bullying - How common is bullying?

Bullying:

How Common Is Bullying?

In the United States:
Bullying may very well be the most prevalent form of school violence in the United States. While specific studies have revealed rates ranging from a low of 10 percent to a high of 75 percent of school-aged children who reported being bullied at least once during their school years, most studies indicate that approximately 15 percent to 20 percent of students will experiencing bullying at some point from kindergarten through high school graduation.

In a nationally representative survey of youth in grades 6 through 10, conducted in 1998 by the National Institute of Child Health and Human Development (NICHD), 3.2 million students reported that they were victims of bullying and 3.7 million students reported that they bullied others. Students were considered moderate to frequent bullies if they participated in bullying "sometimes" to "several times a week." Of these students, 1.2 million reported that they were both victims of bullies as well as bullies themselves. So, at the time of the survey, 30 percent of young people across the nation were involved in moderate to frequent bullying, either as perpetrators, victims, or both. See the chart below, taken from the recent report Bullying Prevention Is Crime Prevention by Fight Crime: Invest in Kids, for a more detailed breakdown of students' involvement in bullying.

(click on image to enlarge)

In other countries:
While bullying was not high on the list of school safety priorities in the United States until well into the 1990s, it has been the focus of wide public concern in Scandinavia since the early 1980s. In 1982, three Norwegian boys ages 10 to 14 committed suicide as a result of severe, long-term bullying. In response to widespread demand for governmental action by school administrators and the general public, Norway launched the Campaign Against Bullying in 1983. Dan Olweus, an internationally renowned pioneer and expert in this field, selected a representative sample of 715 schools participating in this campaign, with 130,000 students ranging in age from 8 to 16 years, for the Norwegian National Survey. To be considered a bully, a child had to have bullied others one or more times per week. The data revealed that approximately 15 percent of the students were actively involved in bullying to some degree, while 5 percent were involved in more serious bully behaviors.

Investigators in England, Ireland, the Netherlands, Australia, Japan, and Canada - many of whom used slight modifications of Olweus's survey - have reported even higher rates of bullying. For example, Canadian data from the World Health Organization Health and Behaviour Survey of School-Aged Children revealed that approximately 54 percent of boys and 32 percent of girls in grades 6, 8, and 10 reported that they had bullied others in the last six weeks, while 34 percent and 27 percent respectively reported being victimized at least once in the last six weeks.

Athealth.com Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Source: Adapted from Exploring the Nature and Prevention of Bullying

Page last modified by Department of Education on January 25, 2010

Page last modified or reviewed by athealth on January 31, 2014

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Bullies, Victims, and Bystanders: Types of Bully Bystanders

Bullies, Victims, and Bystanders

Types of bullies
Types of bully victims
Types of bully bystanders

Bully Bystanders

"I don't like it that he is bullied, but I can't do anything about it or they will turn on me, too."

While far too many students report that they are bullies, victims, or both, the vast majority of young people are neither bullies nor victims. Instead, most students fall into the category of bystander. This group includes everyone -- other than the bully and victim -- who is present during a bullying incident. According to John A. Calhoun, president and CEO of the National Crime Prevention Council (NCPC), 6 out of 10 American teenagers witness bullying in school one or more times each day. In addition to the terrible problems that bullying creates for those who are directly involved, student bystanders to bullying also experience feelings of fear, discomfort, guilt, and helplessness. According to the U.S. Department of Education, bystanders may experience the following:

Be afraid to associate with the victim for fear of either lowering their own status or of retribution from the bully and becoming victims themselves
Fear reporting bullying incidents because they do not want to be called a "snitch," a "tattler," or "informer"
Experience feelings of guilt and helplessness for not standing up to the bully on behalf of their classmate
Be drawn into bullying behavior by group pressure
Feel unsafe, unable to take action, or a loss of control

It is clear that bystanders display distinct patterns of behavior during a bullying incident; these responses represent students' attitudes toward the problem of bullying (e.g., positive, neutral-indifferent, negative) as well as the actions they are likely to take during an actual incident. The Bullying Circle below, based on Olweus' early research as well as the research of Salmivalli and colleagues, illustrate and describe each of these bystander roles.

"Bullying poisons the educational environment and affects the learning of every child." - Dan Olweus

(click the image to enlarge)

In addition to describing the various roles that students can play in a bullying situation, the Bullying Circle further depicts the importance of moving young people to the right -- specifically away from the bullies and their supporters and toward defenders of victims. In a study by Boulton and Underwood (1992), middle school students responded to the question, "What do you do when you see a child of your age being bullied?" in the following manner:

49 percent said they tried to help in some way.
29 percent said they did nothing, but thought that they should try to help.
22 percent said they would not help because it was none of their business.

A full third of the young people in this study indicated that they could see why bullying happened, which seems to suggest that they -- at some level -- accept and/or condone bullying behavior among their peers. And, in another study by Whitney and Smith (1993), 18 percent of the participating middle and high school students said that they would join in if their friends were bullying someone. While most attempts to reduce youth violence have focused on the perpetrator or the relationship between perpetrators and victims, it is increasingly recognized that such interventions do not go far enough in creating safe schools and communities. It is also critical to consider the role of bystanders, whose influence in perpetuating or escalating violence has often been overlooked.

"If we don't involve bystanders, we can't solve the problem. The most dangerous place in a school is the restroom because of isolation. Well, you also can have isolation in the middle of a cafeteria if a bully convinces everybody else not to intervene. If we can show bystanders how to become involved as bystanders, we reduce isolation (Caldwell, Autumn/Winter 1997)."-- Richard Hazler, professor of counselor education, Ohio University

Bystanders clearly have a range of choices when it comes to bullying. They can passively accept it, overtly encourage it, or denounce a bully's actions and provide support to the victims. In fact, it is clear that many students who possess characteristics typical of victims are protected against bullying because of such social factors as peer acceptance and supportive friends.

Sidebar:Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways./p>

Page last modified by Department of Education on January 25, 2010

Page last modified or reviewed by athealth on January 31, 2014

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Bullying - What influences bullying?

Bullying:

How Does Bullying Differ Among Students?

Race and/or Ethnicity

Gender and/or Sexual Identity

Gender

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Bullying - Where does bullying occur?

Bullying:

Where and When Does Bullying Occur?

Consider the following:

Bullying - How common is bullying?

Bullying:

How Common Is Bullying?

Bullies, Victims, and Bystanders: Types of Bully Bystanders

Bullies, Victims, and Bystanders

Bully Bystanders