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.