Chapter 4 Brief Cognitive-Behavioral Therapy

An approach that has gained widespread application in the treatment of substance abuse is cognitive-behavioral therapy (CBT). Its origins are in behavioral theory, focusing on both classical conditioning and operant learning; cognitive social learning theory, from which are taken ideas concerning observational learning, the influence of modeling, and the role of cognitive expectancies in determining behavior; and cognitive theory and therapy, which focus on the thoughts, cognitive schema, beliefs, attitudes, and attributions that influence one's feelings and mediate the relationship between antecedents and behavior.

Although there are a number of similarities across these three seminal perspectives (see Carroll, 1998), each has contributed unique ideas consistent with its theoretical underpinnings. However, in most substance abuse treatment settings, the prominent features of these three theoretical approaches are merged into a cognitive-behavioral model.

Before focusing more specifically on the cognitive-behavioral model, this chapter examines the behavioral and cognitive theories and therapies that serve as the foundations of and have contributed significantly to the cognitive-behavioral approach to substance abuse treatment. Both behavioral and cognitive theories have led to interventions that individually have been proven effective in treating substance abuse. Several of these are reviewed, as they have been successfully incorporated into an integrated cognitive-behavioral model of addictive behaviors and their treatment.

Behavioral Theory

In contrast to many other methods, behavioral approaches to the treatment of substance abuse have substantial research evidence in support of their effectiveness. Two recent comprehensive reviews of the treatment research literature offer strong evidence for their effectiveness (Holder et al., 1991; Miller et al., 1995).

However, some critics argue that this is because behavioral approaches have been developed under controlled conditions and that in "real" therapy there are many more variables at work than can be measured in controlled experiments. Providers should take advantage of the wide range of behavioral therapy techniques that are available. These techniques can be conducted successfully in individual, group, and family settings, among others, to help clients change their substance abuse behaviors.

Behavioral approaches assume that substance abuse disorders are developed and maintained through the general principles of learning and reinforcement. The early behavioral models of substance abuse were influenced primarily by the principles of both Pavlovian classical conditioning and Skinnerian operant learning (O'Brien and Childress, 1992; Stasiewicz and Maisto, 1993). (See Figure 4-1 for definitions of classical conditioning and operant learning.)

Today, behavioral therapy for the treatment of substance abuse disorders is based primarily, though not exclusively, on methods derived from both operant and classical theories of learning. A major tenet of behavioral therapy is that because substance abuse is a learned behavior pattern, changing the reinforcement contingencies that govern this behavior can modify it.

This goal can be achieved by focusing on either the classically conditioned craving responses or on the operant reinforcement patterns that are assessed as maintaining the substance abuse. More specifically, the classically conditioned response can be addressed either through extinction or counterconditioning procedures; the operant responses can be targeted through contingency management or coping skills training. (More information about the basic assumptions of behavioral theories concerning substance abuse disorders is contained in Figure 4-2.)

According to behavioral theory, changes in behavior come about through learning new behaviors. Because substance abuse behavior is learned, it can be changed by teaching the client more adaptive, alternative behaviors aimed at achieving the same rewards. Figure 4-3 provides an overview of some of the advantages of behavioral theories of substance abuse and dependence and their treatment.

By its very design, most behavioral therapy is brief. The aim is not to remake personality, but rather to help the client address specific, identifiable problems in such a way that the client is able to apply the basic techniques and skills learned in therapy to the real world, without the assistance of the therapist. Behavioral therapy focuses more on identifying and changing observable, measurable behaviors than other therapeutic approaches and hence lends itself to brief work. Treatment is linked to altering the behavior, and success is the change, elimination, or enhancement of particular behaviors.

Regular assessment and measurement of progress are integral to effective behavioral therapy. Decisions about the length of treatment are made on the basis of these assessments, rather than according to a formula or theoretical assumption about how long therapy should take. Each individual is approached as a unique case, albeit one to which broad principles can be applied.

Behavioral Therapy Techniques Based on Classical Conditioning Models

Extinction and Cue Exposure Procedures

A principal of classical conditioning is that if a behavior occurs repeatedly across time but is not reinforced, the strength of both the cue for the behavior and the behavior itself will diminish and the behavior will extinguish. This principal has been the foundation of behavioral treatments known as "cue exposure" (O'Brien et al., 1990; Rohsenow et al., 1991; Rohsenow and Monti, 1995).

Even after relatively long periods of abstinence from substances, being placed in situations that have physical-environmental, social, or emotional cues associated with past substance abuse will elicit strong physiological arousal reactions and reports of strong sensations of craving.

In cue exposure, a client is purposefully presented with such cues physically (e.g., by showing his personal drug paraphernalia or by accompanying him into a well-frequented bar), or visually through video depiction of a drug-using scenario or through visualization of such a scenario. However, the client is prevented from drinking or taking drugs. This extinction process, over time, leads to a decreased reactivity to such cues.

O'Brien and colleagues found that cocaine-dependent clients showed the prototypical arousal and craving responses when first presented drug-related cues that reminded them of their drug use (O'Brien et al., 1990). Clients then began the cue-extinction protocol. By the sixth 1-hour treatment session, they no longer reported either subjective highs or physiological withdrawal.

By the 15th session, all clients reported that they no longer experienced craving when presented with the drug-related cues. Clients who received the cue exposure as part of their standard outpatient treatment for cocaine use were also less likely to drop out of treatment and had more cocaine-free weeks than did clients attending the same outpatient program but who did not receive cue exposure.

Counterconditioning and Aversion Procedures

Another method used to modify behavior according to classical conditioning principles is to make behaviors that had been associated with positive outcomes less appealing by more closely associating them with negative consequences. By repeatedly pairing those cues that previously elicited a particular behavior with negative rather than positive outcomes, the cues lose their ability to elicit the original classically conditioned response; instead, they elicit a negative outcome.

This has led to the development of what have been described as aversive conditioning or counterconditioning treatment approaches (Howard et al., 1991; Rimmele et al., 1995). These procedures repeatedly pair negative outcomes with the substance-related cues previously associated with the positive consequences of substance use.

For example, the Shick-Shadel Hospital in Seattle uses aversive conditioning techniques with alcohol-dependent clients (Lemere, 1987). Before a treatment session, the client is asked to drink a warm saline solution and is given an emetic medication that will ultimately lead the client to become nauseated and to vomit. The client is then brought into "Duffy's Bar," a room filled with vivid alcohol- and drinking-related posters, a bar with bottles of a large number and wide range of alcoholic beverages, and other drinking-related cues.

The room is meant to highlight and make more salient the cues associated with drinking. The client is asked to identify her favorite type and brand of alcohol. After pouring a drink, she is asked to swirl the alcohol around in the glass, to smell the alcohol, to place the glass to her lips and taste, and then to begin to take a sip of the drink. At that point, as she is about to take a drink, the effects of the emetic drug "kick in" and the client becomes nauseated and vomits.

Over repeated sessions, which occur every other day for a 10-day period, the alcohol-related sight, smell, and taste cues not only do not elicit craving and positive feelings about drinking, but rather they now elicit conditioned nausea.

Therapies based on counterconditioning theory typically use chemically induced aversion or electric shock as negative consequences to be paired with the substance-related cues. Visual imagery can also be used in a technique called covert sensitization. In this procedure, the client is asked to imagine as vividly as possible a sequence of events that begin by seeing his favorite bar; this is typically accompanied by increased craving.

As the person proceeds further in imagining entering the bar, sitting down, ordering a drink, and so on, the initial sense of craving shifts to mild discomfort. As he visualizes beginning to take a drink and tastes the alcohol, he is then asked to imagine becoming violently sick and vomiting (Rimmele et al., 1995).

While aversive conditioning procedures have most often been used in the treatment of alcohol dependence, they have also been applied to the treatment of marijuana and cocaine use (Frawley and Smith, 1990; Smith et al., 1988). It should be noted that these aversive conditioning techniques, as well as cue exposure approaches, are best viewed as components of a more comprehensive treatment program rather than as independent, free-standing treatments (O'Brien, et al., 1990; Smith and Frawley, 1993).

In this context, Smith and colleagues reported positive outcomes for dependent users of both alcohol and cocaine who received chemical aversion procedures as part of their treatment in comparison to those who did not receive similar treatment (Frawley and Smith, 1990; Smith et al., 1997). Rimmele and colleagues also recommended covert sensitization as a highly effective and portable treatment component which, unlike chemical or electric aversion therapies, can be used at any time and in any setting as a self-control strategy (Rimmele et al., 1995).

Behavioral Therapy Techniques Based on Operant Learning Models

A number of substance abuse treatment strategies have derived from operant learning principles. While they are often incorporated into broad-spectrum cognitive-behavioral approaches, they have also been used as independent forms of treatment. Common elements of behavioral treatments based on theories of operant learning include contingency management, behavior contracting, community reinforcement, and behavioral self-control training. The following sections describe some of the elements used in brief behavioral therapies based on the operant learning model.

Contingency Management and Behavior Contracting

In contingency management approaches, an active attempt is made to change those environmental contingencies that can influence substance abuse behavior (Higgins et al., 1998). The goal is to decrease or stop substance use and to increase behaviors that are incompatible with use.

In particular, those contingencies that are found through a functional analysis (see Figure 4-4) to prompt as well as reinforce substance abuse are weakened by associating evidence of substance use (e.g., a drug-positive urine screen) with some form of negative consequence or punishment. Contingencies that prompt and reinforce behaviors that are incompatible with substance abuse and that promote abstinence are strengthened by associating them with positive reinforcers.

One recent study evaluated the effects of a voucher program in the treatment of methadone-maintained opiate addicts with a history of cocaine use (Silverman et al., 1998). Clients who provided cocaine-free urine samples received vouchers that had monetary value. The value of the vouchers increased as the number of consecutive cocaine-free urine samples increased.

Clients in the contingent voucher condition, compared to those who received vouchers on a noncontingent basis, reported decreased craving for cocaine and significantly increased cocaine abstinence. A more general positive treatment effect was also noted, with clients in the contingent voucher condition also demonstrating an increased abstinence from opiates.

Chutuape and colleagues have also shown that providing methadone take-home privileges contingent on drug-free urine samples among methadone clients with persistent multiple drug abuse resulted in marked reductions in drug use (Chutuape et al., 1999). Nearly 25 percent of clients in the take-home incentive program met the criterion for marked reduction in drug use and also were significantly more likely to achieve the criterion of having 4 consecutive weeks of drug-free urine samples.

None of the clients in a control condition (no take-home privileges) met these criteria. Whereas only 2 percent of the control group evidenced a decrease in the frequency of drug-positive urines, clients in the incentive program decreased use between 14 and 18 percent.

In addition to increasing drug abstinence, similar voucher systems have been effective in maintaining attendance of methadone clients at a job-skills training program (Silverman et al., 1996). However, in contrast to drug treatment, less evidence is available concerning the effectiveness of such contingency management approaches in the treatment of alcohol problems (Higgins et al., 1998).

Attempts to incorporate real-world contingencies into treatment programs are increasing (Higgins, 1999). Clearly, programs can build contingencies such as take-home medication privileges into the structure of their programs. Milby and colleagues provide an example of a contingency management system incorporated into treatment that is more relevant to real-life situations of users (Milby et al., 1996).

In this study, homeless substance abusers were enrolled in an intensive day treatment program. A subgroup of these clients was also involved in a contingent work therapy and housing program. As long as the clients remained substance free, they were able to remain in the work program and remain in the therapeutic housing; if they were found to be drinking or using drugs, they became ineligible for both the job training/work program and housing.

Clients involved in the abstinence-contingent program had fewer cocaine-positive urine samples, fewer days of drinking, fewer days of homelessness, and more days of employment during the followup period than those in the standard treatment.

Naturalistic contingencies may also be useful in treatment. These contingencies include threatened loss of job, spouse, or driver's license and were positively related to treatment outcome among alcohol users (Krampen, 1989). However, the prognosis was less favorable in those patients who had already experienced a loss in one of those areas because the contingency no longer existed for them.

Higgins and colleagues noted that written contracts may be used to help implement a contingency management program (Higgins et al., 1998). The contract should specify clearly, using the client's own words, the target behavior to be changed, the contingencies surrounding either changing behavior or not, and the timeframe in which the desired behavior change is to occur.

The act of composing and signing a contract is a small but potentially important ritual signifying the client's commitment to the proposed change. In the contract, the client may include contingencies, especially rewards or positive incentives that will reinforce target behaviors (e.g., attending treatment sessions, getting to 12-Step meetings, avoiding stimuli associated with substance use). Goals should be clearly defined, broken into small steps that occur frequently, and revised as treatment progresses; contingencies should occur quickly after success or failure.

Most often, behavioral contracts and contingency management procedures are embedded in a more comprehensive treatment program. Contracts targeting goals supportive of recovery (e.g., improving vocational behavior, saving money, being prompt for counseling, regularly taking medication) are generally more likely to be achieved and lead to better outcomes than those more directly related to substance use (e.g., clean urine samples) (Anker and Crowley, 1982; Iguchi et al., 1997; Magura et al., 1987, 1988).

For instance, research found that receiving vouchers contingent on completing objective, individually tailored goals related to one's overall treatment plan was more effective in reducing substance abuse than either a voucher system specifically targeting drug-free urine samples or a standard treatment without either of these contingency contracts added (Iguchi et al., 1997). The effectiveness of such contracts also appears to be linked to the severity of the consequences that might result from a broken contract (Magura et al., 1987).

Behavioral contracting and contingency management are often found as elements in a number of more comprehensive approaches such as community reinforcement and behavioral self-control training.

Community Reinforcement Approach

The community reinforcement approach (CRA) was developed as a treatment for alcohol abuse disorders (Azrin, 1976; Hunt and Azrin, 1973). After a period during which it appears to have been little used, it has received increased interest as a behavioral approach to substance abuse (Higgins et al., 1998; Meyers and Smith, 1995; Smith and Meyers, 1995).

CRA is a broad-spectrum approach based on the principles of operant learning, the goal of which is to increase the likelihood of continued abstinence from alcohol or drugs by reorganizing the client's environment. In particular, CRA attempts to weaken the influence of reinforcement received by substance abuse and its related activities by increasing the availability and frequency of reinforcement derived from alternative activities, particularly those vocational, family, social, and recreational activities that are incompatible with substance abuse (Higgins et al., 1998).

A goal of CRA is to make these alternative interpersonal and social sources of reinforcement available when the person is sober or drug-free, but to make them unavailable if the person drinks or uses. The program consists of a number of components, and it can be tailored to the specific circumstances of a client. Vocational counseling and job clubs can improve clients' basic skills as well as job-seeking skills (e.g., résumé development, application completion, job interview skills). Social and recreational counseling is provided to help clients learn about and sample a number of substance-free recreational pursuits and social activities. In some cases, social clubs have been established to provide clients with a substance-free environment where they can gather and have fun.

For those clients who are married or in a relationship, marital counseling and communication skills training are provided to enhance the quality of the relationship and reduce the stress of substance-related arguments. Couples are trained to give each other positive attention through compliments, appreciation, affection, and offers to help. A focus is placed on clarifying expectations that each partner has about the behavior of the other. For those with a problem with alcohol, medication (e.g., disulfiram [Antabuse]) monitored by the spouse may be used. The client also receives training in problemsolving and in ways to refuse requests to drink or use drugs.

CRA has been described as a promising but underutilized treatment for alcohol abuse (McCrady, 1991). A review of the alcohol treatment outcome literature identifies CRA among those interventions having the greatest empirical support (Miller et al., 1995). CRA's application to substances other than alcohol also appears to have been successful (Higgins et al., 1998). This extension is exemplified by the recent publication of a detailed CRA therapy manual for the treatment of cocaine dependence by the National Institute on Drug Abuse (Budney and Higgins, 1998).

This manual relies heavily on the early work of Higgins and colleagues in evaluating the effectiveness of combining CRA with contingency management approaches (e.g., use of vouchers for drug-free urine samples) in the treatment of cocaine dependence (Higgins et al., 1991, 1993). In comparison to standard outpatient treatment, clients in the CRA-plus-vouchers condition remained in treatment longer, had more continuous weeks of drug-free urine samples, and had greater amounts of cocaine abstinence even at a 12-month followup. A similar pattern of findings has been obtained with methadone-maintained opiate addicts (Abbott et al., 1998).

The CRA model has been modified into the Community Reinforcement and Family Training procedure (CRAFT) (Meyers et al., 1996). The client's significant others and family members, who are an integral part of this approach, receive training in behavior modification and enhancing motivation. CRAFT seeks to reduce or stop substance abuse by working through nonusing family and friends. While CRA involves family or significant others in treatment, CRAFT is more of a form of family therapy (rather than individual therapy) and therefore is discussed in Chapter 8 of this TIP.

Behavioral Self-Control Training

In contrast to CRA, which incorporates a wide array of individuals in the treatment process, the behavioral self-control training approach focuses on the substance abuser and his attempts to reduce or stop substance abuse either on his own or with the aid of a therapist (Hester, 1995; Hester and Miller, 1989). The goal of this approach is either moderation and harm reduction or abstinence. As applied to alcohol problems, the approach consists of the eight sequential steps listed below (Hester, 1995):

The client establishes an upper limit on the number of drinks per day and the peak blood alcohol level on any one drinking occasion.

The client begins to self-monitor both the number of drinks taken and the drinking setting (e.g., when, where, with whom, how he is feeling). This provides the basis of a functional analysis.

The client begins to modify the rate at which alcohol is consumed. This might be done by switching from the individual's standard alcoholic beverage to one containing less alcohol, by sipping a drink over a longer period of time, or by spacing the number of drinks consumed across time.

The client must develop and practice being able to refuse drinks assertively when offered them.

The client establishes a reinforcement system to reward the achievement of these drinking-related goals.

Through the process of self-monitoring, the client is able to determine those social, emotional, and environmental antecedents that prompt overdrinking.

The client learns new coping skills to use rather than relying on drinking as a means of coping.

The client attempts to learn ways to avoid relapsing back to heavy drinking.

Although a therapist may guide the individual in a behavioral self-control model, the substance abuser maintains primary responsibility for changing his behavior.

During the course of therapy, the client and therapist meet in brief sessions to go over homework and ensure that the client is following through. Rather than involvement with a therapist, the person may be guided instead by self-help manuals (Miller and Munoz, 1982; Sanchez-Craig, 1995), intervention via correspondence (Sitharthan et al., 1996), or even a computer program (Hester and Delaney, 1997).

McCrady also included behavioral self-control training as another promising but underutilized treatment approach (McCrady, 1991). Hester indicated that there is good empirical support for behavioral self-control training in achieving the goal of moderate, nonproblematic drinking (Hester, 1995).

In randomized clinical trials, problem drinkers assigned to behavioral self-control with a goal of either moderation or abstinence typically have comparable long-term outcomes. Although behavioral self-control approaches have been used primarily with alcohol problems, they have also been used with other substances such as opiates (van Bilsen and Whitehead, 1994).

Application of Behavioral Techniques

Behavioral therapies are often delivered using a specific manual, but they are also adaptable to the individual client. A number of the behavioral techniques described here are also used by therapists using cognitive-behavioral therapy. The following sections describe how brief behavioral therapy might be applied at different stages of treatment. Some of the techniques developed for brief behavioral therapy are also presented.

Initial session

The initial session in brief behavioral therapy involves an exploration of the reasons the client is seeking treatment at this particular time; the extent to which this motivation for treatment is intrinsic, rather than influenced by external sources; the areas of concern that the client and significant others may have about his substance abuse; the situations in which she drinks or uses excessively; and the consequences she experiences (both positive and negative, as well as proximal and removed from the actual substance abuse). This involves an abbreviated functional analysis. (See the section with that name later in this chapter.)

The information gained in the session will assist the counselor in determining the antecedents that prompt substance abuse and the reinforcers that appear to maintain it. Based on the information obtained, the counselor can begin to formulate a treatment plan with respect to the specific target behaviors to address, the behavioral interventions that address these target behaviors most effectively, and behaviors incompatible with heavy drinking that should be reinforced and targeted for an increase in frequency.

During the initial session, the therapist should note the most salient problems identified by the client and intervene with them first. The therapist also should assess the client's readiness to change and then develop initial behavioral goals in collaboration with the client. For substance abuse disorders, these goals will, of course, involve a reduction in or cessation of substance use.

In addition to targeting substance abuse as the primary focus, other goals will be developed to assist the client in improving daily functioning (e.g., by reducing stress, as described in Figure 4-5). The focus of the therapy might be to negotiate with the client to accomplish these other goals by reducing use. The therapist will continue to engage the client in a collaborative process in which they determine those problems to target, their relative priority, and ways to resolve them.

Near the end of the initial session the therapist reviews with the client the procedure for filling out the self-monitoring records. In addition, the therapist might provide the client with self-help manuals that outline the specific steps in the behavioral self-control process. Self-monitoring of substance abuse behavior is one form of written homework common in behavioral approaches; other types of homework might also be used.

Homework assignments can include such things as keeping a journal of behaviors, activities, and feelings when using substances or at risk of doing so. In the brief behavioral model designed by Phillips and Weiner, techniques such as programmed therapy and writing therapy (see Figure 4-6) make what is typically thought of as "homework" the central concern of the therapy session (Phillips and Weiner, 1966).

Later sessions

Based on a review of the information collected through self-monitoring, subsequent sessions involve negotiation about treatment goals. While many problem drinkers, for example, choose a moderation goal, across time those with more severe problems shift to a goal of abstinence (Hodgins et al., 1997). Later sessions might also consider the introduction of cue exposure training or relapse prevention targeted at substance abuse above a particular level.

These behavioral techniques have been incorporated into more comprehensive behavioral self-control approaches, even those with an abstinence goal (Larimer and Marlatt, 1990; Sitharthan et al., 1997). The decision to implement such interventions will be guided by the client's continued self-monitoring, which the client and counselor review at each session.

Brief behavioral therapy might also involve the client's spouse or significant others, who may attend several of the therapy sessions. In addition to serving as a corroborator of the client's self-reported substance use, a significant other may be involved in behavioral contracting and community reinforcement interventions.

The significant other could be taught to positively reinforce a client's reduced drinking or abstinence and not to argue with her drinking when she is intoxicated, but rather to approach her when she is sober and provide positive feedback. The client and the significant other may develop a contingency contract that will encourage reinforcement of her positive behaviors.

Cognitive Theory

Cognitive theory assumes that most psychological problems derive from faulty thinking processes (Beck and Wright, 1992; Beck et al., 1993; Beck and Liese, 1998; Ellis, 1982; Ellis et al., 1988). The diagram in Figure 4-7 illustrates the three bidirectional components of this theory: (1) cognitions or thoughts, (2) affect or feelings, and (3) behavior. While cognitive theory owes a debt to the behavioral model, the differences are apparent. Unlike behavioral models that focus primarily on observable behaviors, cognitive theory views antecedent events, cognitions, and behavior as interactive and dynamic, as indicated by the double-headed arrows (depicted in Figure 4-7).

Each of these components is capable of affecting the others, but the primary emphasis is placed on cognition. The way we act and feel is most often affected by our beliefs, attitudes, perceptions, cognitive schema, and attributions. These cognitive factors serve as a template through which events are filtered and appraised. To the extent that our thinking processes are faulty and biased, our emotional and behavioral responses to what goes on in our life will be problematic. According to this theory, changing the way a client thinks can change the way he feels and behaves.

Cognitive theory was developed by A.T. Beck as a way of understanding and treating depression but has since been applied to numerous other mental health issues including substance abuse disorders. Beck believed that depressed clients held negative views of themselves, the world, and their future, and that these negative views were the real causes of their depression.

He found that their psychological difficulties were due to automatic thoughts, dysfunctional assumptions, and negative self-statements. Automatic thoughts often precede emotions but occur quite rapidly with little awareness; consequently, individuals do not value them highly. For example, depressed people address themselves in highly critical tones, blaming themselves for everything that happens. Figure 4-8 is a list of 15 common cognitive errors found in the thinking processes of individuals with emotional and behavioral problems, including substance abuse disorders.

An overview of the nature and content of distorted thinking more specifically associated with substance abuse is provided in Figure 4-9 (Ellis et al., 1988). These thoughts are presumably automatic, overlearned, rigid and inflexible, overgeneralized and illogical, dichotomous, and not based on fact. They also tend to reflect reliance on substances as a means of coping with boredom and negative emotions, a negative view of the self as a person with a substance abuse problem, and a tendency to facilitate continued substance use.

Such negative thoughts and irrational beliefs have been found to be associated with substance abuse disorders. Problem avoidance, dwelling on negative events, holding a negative outlook on the world and on one's future, and avoidance of responsibility have been associated with the development of patterns of substance abuse and urges to drink among individuals with alcohol problems (Butterfield and Leclair, 1988; Denoff, 1988; Rohsenow et al., 1989).

Rohsenow and associates found that irrational beliefs--particularly feeling doomed about the past--were predictive of both the frequency of drinking and the average quantity of alcohol consumed following substance abuse treatment (Rohsenow et al., 1989).

Cognitive Therapy

Given the view that dysfunctional behavior, including substance abuse, is determined in large part by faulty cognitions, the role of therapy is to modify the negative or self-defeating automatic thought processes or perceptions that seem to perpetuate the symptoms of emotional disorders. Clients can be taught to notice these thoughts and to change them, but this is difficult at first.

Cognitive therapy techniques challenge the clients' understanding of themselves and their situation. The therapist helps clients become more objective about their thinking and distance themselves from it when recognizing cognitive errors or faulty logic brought about by automatic thinking.

Treatment, therefore, is directed primarily at changing distorted or maladaptive thoughts and related behavioral dysfunction. Cognitive restructuring is the general term given to the process of changing the client's thought patterns. Figure 4-10 shows a number of distorted addictive thoughts and more rational alternatives that the therapist might help develop and practice over the course of cognitive restructuring.

Once a specific faulty thought is identified, the therapist will challenge a client to look at alternative ways of seeing the same event. Whenever a client has difficulty changing a perception, the therapist can give him homework to test the truth of his cognitions. If, for example, a client insists that his boss hates him, the therapist can ask him to verify this with an assignment: "Ask your coworkers if your boss treats them the same way he treats you." Figure 4-11 gives an example of how a thought leads to a feeling and then to a behavior.

Once the maladaptive thoughts are discovered in a person's habitual, automatic thinking, it becomes possible to modify them by substituting rational, realistic ideas for the distorted ones to create a happier and healthier life without substance abuse.

The approach developed by Beck and colleagues to achieve the goal of a substance-free life is referred to as cognitive therapy (Beck et al., 1993; Beck and Liese, 1998), while Ellis' approach is known as rational-emotive therapy (Ellis et al., 1988). Generally, the therapist takes a more active role in cognitive therapy than in other types of therapy, depending on the stage of treatment, severity of the substance abuse, and degree of the client's cognitive capability.

While Ellis and Beck have similar views about the prominent role that cognitions play in the development and maintenance of substance abuse disorders, their theories differ in considering how the therapist should treat irrational or maladaptive cognitions. Rational-emotive therapy is often more challenging and confrontative, with the therapist informing the client of the irrationality of certain types of beliefs that all people are prone to.

Beck, on the other hand, believes that the cognitive therapist, using a supportive Socratic method, should enlist the client in carefully examining the accuracy of her beliefs. Thus, Beck places more importance on the client's own discovery of faulty and unproductive thinking, while Ellis believes that the client should simply be told that these exist and what they are. Nevertheless, there is substantial overlap in both the theory and practice of these two therapies. Clearly, different clients will have different responses to these qualitatively different approaches to modifying their thoughts and beliefs.

Therapeutic work in cognitive therapy is devoted primarily, although not exclusively, to addressing specific problems or issues in the client's present life, rather than global themes or long-standing issues. At times, however, it is important to understand the connection between the origins of a set of cognitions and the client's current behavior. Such an understanding of how the individual got to the present emotional and behavioral state is often essential to understanding the mechanism of change.

The client's attention to current problems is intended to promote her development of a plan of action that can reverse dysfunctional thought processes, emotions, and behavior--such as avoidance of problems or feelings of helplessness. Clients are enlisted as coinvestigators or scientists who study their own thought patterns and associated consequences.

Cognitive therapy can be useful in the treatment of substance abuse disorders in several ways. When distorted or unproductive ways of thinking about daily life events lead to negative emotional states that then promote substance use, cognitive therapy can be used to alter the sequence by targeting and modifying the client's thoughts.

When clients limit their options for coping with stress by rigid or all-or-nothing thinking (e.g., "nothing will help me deal with this problem but a drink"), cognitive therapy can help them explore alternative behaviors and attitudes that do not involve the use of substances. In addition, cognitive therapy can help the client develop healthier ways of viewing both his history of substance abuse and the meaning of a recent "slip" or relapse so that it does not inevitably lead to more substance abuse.

Initial Session

Cognitive therapy works under the assumption that a client can be educated to approach his problems rationally. Because of this emphasis on rational understanding, the cognitive therapist will typically begin therapy by explaining the nature of her approach (see Figure 4-12 for a sample opening script).

In the opening session of cognitive therapy, the therapist will assess the client's view of his problems and their causes. The therapist pays careful attention to the meaning the client assigns to significant events and how that meaning is related to subsequent feelings and unwanted behavior. In the middle to late phases of the first session, the therapist will emphasize the collaborative aspect of the therapy process and introduces the cognitive model to the client. There are three major steps in this process:

The therapist establishes rapport by listening carefully to the client, using questions and reflective listening to try to understand how the client thinks about his life circumstances and how those thoughts relate to problematic feelings and behavior. The client educates the therapist about himself and his problems.

The therapist educates the client about the cognitive model of therapy and determines if he is satisfied with the model.

The therapist asks the client to describe a recent event that has triggered some recent negative feelings, as a way of illustrating the cognitive therapy process.

Later Sessions

Cognitive therapy tends to follow a standard within-session structure to make the maximum use of time, to focus on the most important current problems, to set the tone for a working atmosphere, and to maintain continuity between sessions. Beck structures sessions into eight elements, listed below, which he describes in greater detail (Beck et al., 1993):

Setting the agenda--to focus on primary goals for treatment

Mood check--to monitor the feelings of the client, especially changes

Bridge from last session--to maintain continuity between sessions

Discussion of today's agenda--to prioritize topics, avoid irrelevant tangents, determine the best possible use of time, and solicit the client's topics for discussion

Socratic questioning--to encourage the client to contemplate, evaluate, and synthesize diverse sources of information; also known as "guided discovery"

Capsule summaries--to maintain focus and a connection to the goals of the therapy

Homework assignments--to serve as a bridge between sessions and to ensure that the client continues to work on problems by collecting information, testing beliefs, and trying new behaviors

Feedback in the therapy sessions--to ensure that the client and therapist are communicating