By Fred D. Wright, Aaron T. Beck, Cory F. Newman, and Bruce S. Liese

“The practical effect of a belief is the real test of its soundness.” James A. Froude

INTRODUCTION

Millions of Americans have substance abuse problems. In fact, at least 1 in 10 adult Americans has a serious alcohol problem (Institute of Medicine 1987). At least one in four adult Americans is addicted to nicotine (Centers for Disease Control 1991a ). Approximately 1 in 35 Americans over the age of 12 is an illicit drug user (Institute of Medicine 1990a).

Substance abuse results in profound social, medical, and psychological problems. For example, it has been estimated that approximately 434,000 people in this country die each year as a result of cigarette smoking (Centers for Disease Control 1991b). Many thousands also die as a result of alcoholism (Institute of Medicine 1987, 1990b) and illicit drug abuse (Institute of Medicine 1990a ).

There are many different ways of conceptualizing substance abuse (Beck et al. 1993; Blane and Leonard 1987; Brickman et al. 1982; Cox 1990). Although the disease model and 12-step programs continue to dominate the treatment literature and practice, several authors have developed social learning, or cognitive-behavioral, approaches for understanding and treating substance abuse disorders (e.g., Abrams and Niaura 1987; Annis 1986; Marlatt 1978, 1982, 1985; Marlatt and Gordon 1980, 1985).

In fact, efforts even have included rational emotive approaches to treating substance abuse (e.g., Ellis et al. 1988; Trimpey 1989).

This chapter presents the theoretical rationale for the cognitive therapy of substance abuse based on work at the Center for Cognitive Therapy, University of Pennsylvania.  The Cognitive Therapy Model Cognitive therapy is an active, collaborative, focused form of psychotherapy developed from the findings that psychological disturbances frequently involve habitual errors in thinking (Beck 1976; Beck et al. 1979).

The underlying theoretical rationale stipulates that the way an individual feels and behaves is largely determined by the way he or she construes his or her experiences. Further, the model stipulates that psychological disorders are characterized by dysfunctional thinking derived from dysfunctional beliefs.

Initial improvement results from modification of the dysfunctional thinking and durable improvement from modification of dysfunctional beliefs. The cognitive model of substance abuse asserts that certain individuals have developed a cognitive vulnerability to drug abuse.

Under particular circumstances, specific beliefs are activated that increase the likelihood of substance use (Beck et al. 1990a, 1992). Idiosyncratic beliefs such as, “I cannot socialize without getting high,” are activated in certain provocative situations, leading to increased risk of succumbing to drug use.

Definition of Beliefs

Beliefs are relatively stable, enduring cognitive processes that, once formed, are not easily modified by experience. Depressed patients tend to have global negative views about themselves, the world, and the future, which contributes to their feelings of despair, guilt, and sadness (Beck et al. 1979).

Similarly, anxious patients have specific negative beliefs about some future threat, which contributes to avoidance, anxiety, and, at times, panic attacks (Beck and Emery 1985).

Without cognitive intervention, these pernicious beliefs tend to endure in spite of objective evidence that there is hope or that the perceived threat is minimal.

There are three major categories of dysfunctional beliefs associated with the patient’s acute decision to engage in substance abuse: 1. Anticipatory, 2. Relief-oriented, and 3. Facilitative or permissive. 

Anticipatory beliefs usually involve some expectation of drug use, such as, “I feel like a superman when I use.”

Relief-oriented beliefs are those that assume that using drugs will remove some uncomfortable state: “The urges and cravings will not go away unless I use.”

Facilitative or permissive beliefs are those that consider drug use acceptable even in spite of obvious potential consequences: “I deserve it. I am a hard worker. There is nothing wrong with taking risks.”

The cognitive therapy model of substance abuse states that drug-using beliefs and desires typically are activated in specific, common, often predictable, high-risk circumstances.

These circumstances can be external or internal. Examples of external circumstances are seeing drug paraphernalia or being at a party where cocaine or other drugs are being used. Internal circumstances include uncomfortable emotional states such as depression, anxiety, or boredom.

Numerous circumstances can trigger drug-related beliefs and, consequently, drug use. It should be noted that the circumstances previously mentioned do not directly cause drug use, though they may seem to give rise to spontaneous use.

The authors have observed a sequence of events that occurs between the external/internal circumstances and the actual drug use. The sequence of conditions is as follows (see figure 1): the high-risk external/internal circumstance is followed by the activation of a basic drug-related belief, which in turn leads to associated automatic thoughts and further to craving/urges.

This in turn leads to the activation of facilitating beliefs about drug use, which directs attention to instrumental strategies for obtaining the drugs, which in turn leads to use.

At this point, drug use can serve as an additional external/intemal circumstance that triggers other drug-related beliefs (e.g., “Since I have broken my abstinence, I might as well go on a binge”), resulting in a vicious cycle (Beck et al. 1990a, 1992).

This series of conditions is illustrated in the following case. Mr. C. is a 34-year-old drug abuser who completed a 28-day residential treatment program.

The following is an example of his first lapse. The situation occurred when Mr. C. went to a bar (external) in order to socialize because he felt extremely bored (internal). This, in turn, activated a common drug-related (relief-oriented) belief: “I cannot stand the boredom.” In turn, this condition led to the associated automatic thought, “Go for it.”

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FIGURE 1. Cognitive model of substance abuse [see source article] 
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Instantly, extremely strong cravings started, as he began to have images of the last time that he used. This, in turn, activated another belief, “Urges and cravings make me use,” and the facilitating belief, “Everybody in this town uses, so why not me?”

His instrumental strategy was to look around for someone in the bar who might have some cocaine. Like a heat-seeking missile, all of his attention was focused on hitting the target-getting cocaine. He found some cocaine, used, and later felt guilty and hopeless, which started the vicious cycle anew.

Case Conceptualization

There are four main components to the cognitive conceptualization of the substance abuser: 1. Relevant childhood data, 2. Dysfunctional core beliefs, 3. Conditional assumptions, and 4. Compensatory strategies.

With regard to relevant childhood data, therapists try to ascertain the early childhood experiences that contributed to the development and maintenance of general dysfunctional core beliefs. These core beliefs are the most central beliefs about how patients view themselves, generally falling into two categories: believing that one is unlovable or incapable.

Conditional assumptions are implicit rules that patients attempt to follow in order to thrive or avoid harm. They can be in the form of a positive assumption, such as “If I gain control, then I will feel effective,” or a negative counterpart: “If I do not do things perfectly, then I am inferior.”

Compensatory strategies are those behaviors that help patients to cope (albeit temporarily and ineffectively) with the core belief (e.g., avoiding tasks that they feel they cannot do perfectly or using drugs that make them feel effective and confident).

The case of Mr. C. illustrates these concepts. Mr. C. grew up in a very unpredictable family. His father was a heavy drinker who often acted impulsively and was emotionally abusive. He often would humiliate Mr. C. in public, making comments about how stupid he was and jokingly saying his son was adopted.

The two core beliefs that the  authors hypothesize developed as a result of these early childhood experiences were, “I am inadequate and powerless” and, “I am unwanted and undesirable.”

Mr. C. developed a series of conditional assumptions that stemmed from these core beliefs, including: “If I am in control, then I will feel adequate.” “If I do things perfectly, then people will like me.” “If people show their emotions, then they are out of control, and they will be rejected by others.”

In order to cope with his core beliefs, Mr. C. developed certain compensatory strategies, one being to avoid showing others how he really felt. That is, if he realized that he was going into a situation in which he might become extremely anxious, his tendency was to avoid the situation.

He also developed an all-or-none style of handling tasks. If he could not do what he considered perfect work, he tended to procrastinate or avoid it altogether. Another compensatory strategy was to drink and use cocaine. When using cocaine and alcohol, Mr. C. tended to feel more powerful and more popular with others. He felt more in control when using and believed that everything was going perfectly and that people would like him.

Modifying Beliefs in Therapy

An important goal of cognitive therapy of substance abuse is to identify and modify drug-related dysfunctional beliefs, replacing them with more adaptive, functional beliefs. At the very least, the therapist attempts to teach the patient to build functional beliefs that become more salient than the drug-related beliefs.

The ideal result is that the patient will abstain from drug use. In order to modify drug-related beliefs, the cognitive therapist must have an accurate understanding of the role of such beliefs in the patient’s life.

Thus, a careful assessment of beliefs must be undertaken for each patient. In the assessment, the therapist collects data about the patient’s beliefs using two vehicles: therapist-patient interactions during psychotherapy sessions and belief questionnaires. 

During the therapy session, some basic tasks are important for the therapist to collect raw data and maintain a collaborative relationship with the patient. The most important of these tasks is the therapist’s use of open-ended questions and probing. This strategy facilitates an examination of the structure and content of the patient’s beliefs.

Some examples of open-ended questions are the following: “What are your thoughts about that?” “How do you explain your reactions?” “How do you interpret what happened?” “What does that mean to you?”

As the patient responds to these questions, the therapist reflects what the patient has said, with particular emphasis on beliefs expressed by the patient. At various points in the interview, the therapist provides a summary of what has been discussed, again with strong emphasis placed on the patient’s beliefs.

This technique is illustrated in the following example. Mr. C. reported that during the week he was feeling extremely angry and anxious. The therapist then asked him to describe the specific situation. He reported that while at a party he saw other people using cocaine, and he started having urges to use again.

The therapist then asked, “What thoughts were going through your mind then?” Mr. C. recalled, “They can use and I cannot. I will never be able to use again.” The therapist said, “Let us assume for the moment that these thoughts are accurate. What about them is important? What is the meaning to you?”

Mr. C. replied, “It means that I will always be this way” (angry and anxious). The therapist once again asked, “And what is the meaning of that to you? How does that impact on you?” Mr. C. replied, “I will always have these urges and feel anxious.”

The therapist asked, “And how does that impact on you?” Mr. C. replied, “It makes me feel helpless.” Two important beliefs were uncovered in this brief interchange: “I will always have these urges and feel anxious,” and, “I feel helpless about this.”

In addition to the interview process, several questionnaires are available to collect data about an individual’s beliefs. Some are designated to evaluate more general beliefs, such as the Dysfunctional Attitude Scale (Weissman and Beck 1978), while others are designed specifically to assess drug-related beliefs.

This chapter will focus on those scales that are used specifically to assess the drug-related beliefs. The following are scales that can be used in making this assessment: the Beliefs About Substance Use (figure 2), the Craving Belief 

Listed below are some common beliefs about drug use. Please read each statement and rate how much you agree or disagree with each one. 1. Life without using is boring. 2. Using is the only way to increase my creativity and productivity. 3. I cannot function without it. 4. This is the only way to cope with pain in my life. 5. I am not ready to stop using.

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FIGURE 2. Beliefs about substance abuse: Sample of Items Questionnaire-CQ (figure 3), and the Relapse Prediction Scale (figure 4).
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These instruments are given to the patient at the beginning of therapy to provide baseline information. They also are completed at subsequent visits to assess changes that may occur as therapy progresses. During the therapy process, these questionnaires help therapists to understand the patient’s beliefs as they relate to target areas for intervention.

For example, during his initial visit, Mr. C. endorsed strongly the following statements on the Beliefs About Substance Use Questionnaire: “Life without using is boring.” “My life will not get any better even if I stop using.” “The urges and cravings will not go away unless I use drugs.”

These responses give the therapist important information regarding target areas for intervention. They allow the therapist to quickly conceptualize some of the patient’s problems and to target certain beliefs that will need to be modified. On the Craving Belief Questionnaire, Mr. C. endorsed the following statements: “Since I will have cravings the rest of my life, I might as well go ahead and use cocaine.” “If the craving gets too intense, cocaine is the only way to cope with the feelings.” “The craving makes me use cocaine.”

Early in therapy, the therapist has been able to identify important drugrelated beliefs that are maintaining the patient’s drug use or making the patient vulnerable to a lapse or relapse.

On the Relapse Prediction Scale, Mr. C. endorsed items that clearly identify certain high-risk circumstances for him. For example, he stated that the likelihood of using again would be strong in the following circumstances: “I am having a drink.” “I am around people with whom I previously used cocaine and crack.” “I feel bored.”

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FIGURE 3. Craving Belief Questionnaire (CQ): Sample of Ideas

1. The craving is totally out of my control. 2. The craving is a physical reaction, therefore, I cannot do anything about it. 3. If I do not stop the cravings they will get worse. 4. Craving can drive you crazy. 5. The craving makes me use cocaine.
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FIGURE 4. Relapse Prediction Scale: Sample of Items
As you know, there are many situations that can trigger an urge to use cocaine or crack. This scale has two parts: (1) to determine how strong you think the urges will be in certain situations and (2) what is the likelihood of your using in these situations.

1. I am in a place where I used cocaine or crack before. 2. Around people with whom I have previously used cocaine or crack. 3. I just got paid. 4. I see co-workers using. 5. I am leaving work.
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