By Kathleen M. Carroll, Ph.D.
Yale University

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.