Lecture Notes on Cognitive Behavioral Therapy for Substance Abuse

Contingency Management and Behavior Contracting

• Contingency Management: Actively change environmental factors influencing substance abuse.

  • Goal: Reduce/stop substance use and increase incompatible behaviors.

  • Weakening contingencies: Associate substance use evidence (e.g., drug-positive urine) with negative consequences.

  • Strengthening contingencies: Link behaviors incompatible with substance abuse to positive reinforcers.

Functional Analysis

• Investigates the circumstances surrounding a client's substance abuse.

  • Examines triggers and consequences, revealing the behavior's meaning to the client.

  • Identifies motivators and barriers to change.

  • Provides tools to manage/avoid triggers.

  • Maps interpersonal, intrapersonal, and environmental "catalysts" and reactions to substance use.

Example: Voucher Program (Silverman et al., 1998)

• Methadone-maintained opiate addicts with cocaine use history.

  • Cocaine-free urine samples earn vouchers with monetary value.

  • Value increases with consecutive clean samples.

  • Results: Decreased cocaine craving and increased abstinence in the contingent voucher group, along with increased opiate abstinence.

Example: Methadone Take-Home Privileges (Chutuape et al., 1999)

• Contingent on drug-free urine samples among methadone clients with multiple drug abuse.

  • Results: Marked reductions in drug use; nearly 25% met the criteria for marked reduction and 4 consecutive weeks of drug-free samples.

  • Control group: None met the criteria; only 2% showed decreased drug-positive urines.

  • Incentive program: Decreased drug use between 14-18%.

Effectiveness of Voucher Systems

• Effective in maintaining attendance at job-skills training programs for methadone clients (Silverman et al., 1996).

• Less evidence for contingency management in alcohol problems (Higgins et al., 1998).

Real-World Contingencies

• Programs incorporate take-home medication privileges.

• Example (Milby et al., 1996): Homeless substance abusers in intensive day treatment with contingent work therapy and housing.

  • Substance-free clients remained in work/housing programs.

  • Positive outcomes: Fewer cocaine-positive urines, fewer drinking days, fewer homeless days, and more employment days.

Naturalistic Contingencies

• Threatened loss of job, spouse, or driver's license related to positive treatment outcome for alcohol users (Krampen, 1989).

  • Less favorable prognosis if loss already experienced.

Behavior Contracting

• Written contracts to implement contingency management.

  • Includes target behavior, contingencies, and timeframe.

  • Ritual signifying commitment to change.

  • Client includes reinforcing incentives (e.g., attending treatment, 12-step meetings, avoiding stimuli).

  • Goals: Clearly defined, broken into small steps, revised as treatment progresses; contingencies occur quickly after success/failure.

Embedding Contracts in Treatment

• Contracts targeting supportive goals (e.g., vocational behavior, saving money, counseling attendance, medication adherence) are more effective.

• Example: Vouchers contingent on taking prescribed medication resulted in better outcomes than those contingent on clean urine samples (Anker & Crowley, 1982; Iguchi et al., 1997; Magura et al., 1987, 1988).

Behavioral Self-Control Training

• Substance abuser maintains primary responsibility for behavior change.

• Brief sessions to review homework and ensure client follow-through.

• Guided by self-help manuals (Miller & Munoz, 1982; Sanchez-Craig, 1995), correspondence (Sitharthan et al., 1996), or computer programs (Hester & Delaney, 1997).

Empirical Support

• McCrady (1991) highlights behavioral self-control training as promising but underutilized.

• Hester (1995) notes empirical support for achieving moderate, non-problematic drinking.

• Outcomes: Comparable long-term outcomes with moderation or abstinence goals.

• Application: Primarily used for alcohol problems but also for other substances like opiates (van Bilsen & Whitehead, 1994).

Application of Behavioral Techniques

• Delivered using manuals but adaptable to individual clients.

• Used by therapists in cognitive-behavioral therapy.

Initial Session

• Explore reasons for seeking treatment, motivation (intrinsic vs. external), concerns about substance abuse, situations of excessive use, and consequences (positive/negative, proximal/removed).

• Abbreviated functional analysis.

Counselor's Role

• Determine antecedents and reinforcers.

• Formulate a treatment plan targeting specific behaviors, using effective interventions, and reinforcing incompatible behaviors.

• Prioritize salient problems and assess readiness to change.

• Develop initial behavioral goals collaboratively, including substance use reduction/cessation and improved daily functioning (e.g., stress reduction).

Factors Maintaining Behavior in Behavioral and Cognitive Models

Figure 4-7

• Antecedents (A): Activating situations or life events with strong feelings.

• Cognitions (C): Opinions, thoughts, or attitudes filtering perception of antecedents.

• Behavior (B): Observable actions and emotional reactions resulting from beliefs and emotions.

Cognitive Theory (A.T. Beck)

• Developed to understand/treat depression, applied to substance abuse disorders.

• Depressed clients hold negative views of themselves, the world, and their future.

• Psychological difficulties stem from automatic thoughts, dysfunctional assumptions, and negative self-statements.

• Automatic thoughts: Precede emotions, occur rapidly with little awareness.

• Example: Depressed people blame themselves for everything.

Cognitive Errors (Figure 4-8)

• Common in individuals with emotional and behavioral problems, including substance abuse disorders.

Distorted Thinking in Substance Abuse (Figure 4-9)

• Automatic, overlearned, rigid, inflexible, overgeneralized, illogical, dichotomous, and not based on fact (Ellis et al., 1988).

• Reflect reliance on substances as a means of coping.

Treatment

• Directed at changing distorted/maladaptive thoughts and related behavioral dysfunction.

• Cognitive restructuring: Changing the client's thought patterns.

Irrational Beliefs vs. Rational Alternatives (Figure 4-10)

• Irrational Belief: "Drinking is never a problem for me."

  • Rational Alternative: "Losing control can be the first sign of a problem."

• Irrational Belief: "I need to use drugs to relax."

  • Rational Alternative: "I want to use drugs but don't have to."

Challenging Faulty Thoughts

• Therapist challenges the client to consider alternative perspectives.

• Homework assignments to test the truth of cognitions.

• Example: Verifying whether the boss's treatment is unique or generalized.

Thoughts, Feelings, and Behaviors (Figure 4-11)

• Modify maladaptive thoughts to avoid consequent behavior.

Cognitive Therapy (Beck et al., 1993; Beck & Liese, 1998)

• Therapist takes a more active role, depending on the stage of treatment, severity of substance abuse, and cognitive capability.

Rational-Emotive Therapy (Ellis et al., 1988)

• Therapist informs the client of the irrationality of certain beliefs.

Differences Between Therapies

• Rational-emotive therapy: More challenging and confrontational.

• Cognitive therapy: Supportive Socratic method, enlisting the client in examining the accuracy of beliefs.

Therapeutic Work

• Focuses on specific problems in the client's present life.

• Understanding the connection between the origins of cognitions and current behavior.

• Promotes development of a plan of action to reverse dysfunctional thought processes, emotions, and behavior.

• Clients are enlisted as coinvestigators who study their own thought patterns and consequences.

Usefulness of Cognitive Therapy

• Negative emotions, behaviors, and substance abuse can result from distorted thinking.

• Specific cognitive therapy techniques are appropriate based on the phase of treatment.

• Cognitive interventions can be introduced at any point.

• Periods without sessions provide time to practice new skills.

• Therapist builds on previous sessions, reinforcing the process of catching negative automatic thoughts.

• Therapist moves from topic to topic, adhering to the theme that thoughts determine feelings and actions.

Success as Brief Therapy (Carroll, 1996a)

• Short-term approach.

• Focuses on immediate problems.

• Flexible and individualized.

Cognitive-Behavioral Theory

Evolution

• Early theories focused on observable behaviors.

• Cognitive factors included over time, attributing a role to individual differences (beliefs, values, perceptions, expectations).

Definition

• Cognitive factors mediate interactions between the individual, situational demands, and coping attempts.

Integration

• Integrates principles from behavioral and cognitive theories.

• Provides a comprehensive approach to treating substance abuse disorders.

Broader Range of Cognitions

• Includes attributions, appraisals, self-efficacy expectancies, and substance-related effect expectancies.

• Common elements of brief cognitive-behavioral therapy (Figure 4-13).

Attributions

• An individual's explanation of why an event occurred.

• Individuals develop attributional styles (Abramson et al., 1978).

Attributional Dimensions

• Internal/External.

• Stable/Unstable.

• Global/Specific.

• Attributional Styles (Figure 4-14)

Role of Attributional Styles

• Considerable bearing on perception of the substance abuse problem and approach to recovery.

• An alcohol-dependent client may believe they drank because they were weak or surrounded by people encouraging them to have a beer.
  Global beliefs about failure to maintain sobriety, weak person, inability to succeed at anything.

Appraisals

• The process of determining the significance or meaning of an event (Lazarus & Folkman, 1984).

Coping Behaviors

Definition

• "What an individual does or thinks in a relapse crisis situation so as to handle the risk for renewed substance use" (Moser and Annis, 1996, p. 1101).
  Deficiency: Substance users have shown inability to cope with interpersonal, social, emotional, and personal problems.

Framework

• Observation: Family members and peers' responses to similar situations and from their own experimentation with alcohol and drugs helps with how to cope.

• Coping: The individual uses substances in response to problematic situations as an attempt to cope in the absence of more appropriate behavioral, cognitive, and emotional coping skills.
  Substance abuse: A learned behavior for the individual.

Coping Dimensions

• Focus: Affective, behavioral, and cognitive domains.

• Categories: Negative and positive thinking.

Sequence Types

• Behavioral strategies initially.

• Reliance on cognitive methods of coping for greater abstinence.

Strategies

• Emotion-focused, problem-focused, or avoidant.

• General coping strategies vs. coping with urges, craving, and temptation.

• General coping with urges, craving, and temptation to use in settings associated with past substance abuse.

Dimensions

• Anticipatory coping: "What can I do if…"

• Coping Strategies: "What can I do now…"

• Restorative Coping. To be employed if one fails to cope and finds himself using in the situation.

Self-Efficacy Expectancies

Overview

An individual's belief that they can execute behaviors required to produce outcomes (Bandura, 1977).

Dimensions

• Performance accomplishments, vicarious experience, verbal persuasion, and emotional arousal.

• Low or compromised with substance abuse.

• Increased by successful experiences.

Effect Expectation of High Self-Efficacy

• A protective factor. (Marlatt and Gordon, 1985).

Substance Related Effect Expectancies

Overview

• Beliefs about the cognitive, affective, and behavioral consequences of using substances.

• Positive: Enhanced abilities, amplified positive emotions, global positive effects, generalized arousal, euphoria, enhanced abilities, and relaxation and tension reduction (Jaffe and Kilbey, 1994; Schafer and Brown, 1991).

• Negative: Negative outcomes that individuals have about substances. (behavioural impairment, risk and aggression, and negative self-perception (Fromme et al., 1993). Depression and Paranoia (Jaffe and Kilbey, 1994; Schafer and Brown, 1991).

• Impact: Positive serves as an incentive/motivation for use. Negative serves as a disincentive.

Actions

• Research supports the actions of the expectations.

• Positive associations: Greater likelihood of relapse. (Brown et al., 1998; Rounds-Bryant et al., 1997).

• Negative Associations: Decrease likelihood of relapse. (Jones and McMahon, 1994a; McMahon and Jones, 1996).

High-Risk Situations

• People, places, feelings, activities can condition cues for strong craving (Chaney et al., 1982; Cummings and Gordon, 1980; Marlatt and Gordon, 1980, 1985).

• High abuse is reinforced through operant learning.

Setting Characterization

• Situations in which relapse occurred following a period of substance abstinence substance use in general will be more likely to occur.

Categories of Situations

• Negative emotional states, interpersonal conflict, and social pressure.

The Cognitive-Behavioural Approach to Substance Abuse Disorders

• Meaning Model: attempt to integrate all of their theoretical details - (Mackay et al., 1991; Marlatt et al., 1988).

A Cognitive-Behavioal Model of the Relapse Process

Client confronts high-risk Situation. Experiences with decrease in self-efficacy
Expectations: Positive Outcome.
Results: Abstinence violation effect.

Assumptions

• Lacking skills (Monti et al., 1994, 1995).

• Expectancies over time.

• Positive benefits versus negative.

• Consequences are based on one's belief system.

Cognitive-Behavioural Interventions

Key Elements

Functional analysis of substance abuse
Individualized training in recognizing and coping with cravings
An examination of the client's cognitive processes related to substance abuse
Identification and debriefing of past and future high-risk situations

Goal

Help individuals reduce their drug use.
Recognizing situations, finding ways of avoiding those situations, and situations related to their substance abuse (Carroll, 1998).

Core Elements

Functional analysis
Coping skills training
Relapse prevention (Rotgers, 1996).

Functional Analysis

• Behavioral, cognitive, and cognitive-behavioral treatments with an awareness of the antecedents and consequences of substance abuse. (Carroll, 1998; Monti et al., 1994; Rotgers, 1996).

• Identifies the antecedents and consequences of substance abuse behavior.

• Antecedents of use:
  Emotional
  Social
  Cognitive
  Situational
  Physiological domains

Determines a person’s strengths and weaknesses (DeNelsky and Boat, 1986).

Assessment

Assess features in the client's emotional states and thoughts.
HIGH-RISK

• Cannot be done without a thorough assessment (Rotgers, 1996).

Intrapersonal and Interpersonal Skills Training Elements - Figure 4-19

Inter: managing thoughts about substance abuse, problem-solving, planning for emergencies
Intra: standing for the rights, giving criticism, communicating emotions
According to Carroll, teaching coping skills is the core of CBT (Carroll, 1998).

Skills Training Sessions - Figure 4-20

Therapists often give homework assignments that provide the client the opportunity to practice skills.

Components for High-Risk Situations

How to leave

Core of Relapse Prevention

Assumptions: Relapse is part of the treatment

Implementation

Identify situations + effective behavioral, cognitive, and affective coping strategies (Marlatt and Gordon, 1985).
Goal: Prevent the first use!!.

Examples: Relapse Scenarios

Client: depressed after treatment
Therapist: What do you think about using cocaine?
Client: thought it would feel good and just forget/ get out of it.
Therapist: what will you feel afterwards?
Client: Always come down and feel more depressed.
Therapist: After starting using again, why can you not stop?

Duration of Therapy and Frequency of Sessions

CBT is brief is duration. (Carroll, 1998).
CBT=8 core sessions + 4 elective topics (Kadden et al., 1992).
12 session CBT for stabilized from cocaine (Carroll, 1998).

Implementations of the Sessions for CBT

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 pre-treatment physical examination)
Those who have concurrent substance dependence disorders, with the possible exception of alcohol or marijuana dependence

Adaptation to Therapy

Easily be adapted in group settings (Monti et al., 1989).

Efficacy For Treating Substance Abuse Disorders

Effective for treating substance abuse disorders has substantial evidence.
Stronger Results: Coping skills training.

Outcomes: Support for relapse prevention.

Overall, behavioral, cognitive, and cognitive-behavioral interventions are effective and can work for multiple people.