Brief Cognitive-Behavioral Therapy

Duration of Therapy and Frequency of Sessions

Cognitive therapy adheres to the basic goals of planned brief therapy, but treatment times can vary. It typically lasts from 12 to 20 weeks, with the client and therapist meeting once per week. (Freeman et al., 1990). However, it can be conducted in less time--for instance, once per week for six to eight sessions. The number of sessions will depend on the nature of the problem.

Because cognitive therapy is usually planned for comparatively short treatment times, there has not been much research to study the relative effectiveness of longer term cognitive therapy. However, Lyons and Woods in their meta-analysis of 70 different rational-emotive therapy studies found that increased effects correlated with longer treatment times (Lyons and Wood, 1991). More research needs to be conducted looking at the effect of treatment duration on the efficacy of these therapies.

In a brief version of this therapy, there is less time to understand and restructure all of the cognitions that may be influencing substance abuse. The therapist must use the early sessions to determine the most productive focus of the therapy, given the short timeframe. If the client used substances primarily to cope with negative mood states, then therapy may focus on understanding how the client's interpretation of events led to the negative moods.

Restructuring these thought processes may help decrease reasons for substance abuse. Alternatively, if the client drinks largely to party and have a good time with friends, a focus on expected effects may lead to the client's gaining greater awareness of negative consequences and, perhaps, a reduced association of the substance with positive experiences. If the client is returning to therapy after a period of sobriety that ended in relapse, a focus on the circumstances leading to relapse and other resulting consequences may shape the therapy.

A number of specific cognitive therapy techniques may be appropriate for use, depending on the phase of treatment and the issues raised by the client. Cognitive interventions can be introduced at any point throughout the treatment process, whenever the therapist feels it is important to examine a client's inaccurate or unproductive thinking that may lead to the risk of substance abuse. They also can be used episodically with clients who leave and then return to treatment or during aftercare or continuing care following a more intensive treatment episode.

Periods without therapy sessions allow clients time to practice the new skills of identifying and challenging unproductive thinking on their own. However, it is easy to fall back into old, automatic ways of thinking that may require a return to therapy. The therapist can productively build on what was learned in previous sessions, help the client see how she slipped into old patterns, and further reinforce the process of catching oneself in the process of thinking negative automatic thoughts. The therapist must be prepared to move from topic to topic while always adhering to the major theme--that how the client thinks determines how the client feels and acts, including whether the client abuses substances.

Cognitive therapy can be quite successful as an option for brief therapy for several other reasons (Carroll, 1996a):

It is designed to be a short-term approach suited to the resource capabilities of many delivery systems.

It focuses on immediate problems and is structured and goal oriented.

It is a flexible, individualized approach that can be adapted to a wide range of clients, settings (both inpatient and outpatient), and formats, including groups.

Cognitive-Behavioral Theory

Early behavioral theories of substance abuse were nonmediational in nature (Donovan and Marlatt, 1993). They focused almost exclusively on overt, observable behaviors, and it was believed that understanding the antecedents and reinforcement contingencies was sufficient to explain behavior and to modify it. Over time, however, these behavioral theories began to incorporate cognitive factors into their conceptualizations of substance abuse disorders.

These more recent models are mediational in nature; that is, a greater role is attributed to the interaction among a variety of individual difference variables such as beliefs, values, perceptions, expectations, and attributional processes in mediating the development and continuation of substance abuse disorders (Abrams and Niaura, 1987; Mackay and Donovan, 1991; Marlatt et al., 1988; Marlatt and Donovan, 1981). This expanded, mediational model has been described as cognitive social learning or cognitive-behavioral theory. This theory postulates that cognitive factors mediate all interactions between the individual, situational demands, and the person's attempts to cope effectively.

Cognitive-behavioral theory represents the integration of principles derived from both behavioral and cognitive theories, and it provides the basis for a more inclusive and comprehensive approach to treating substance abuse disorders. However, a broader range of cognitions is included in cognitive-behavioral theory than had been involved in earlier versions of cognitive theory. These include attributions, appraisals, self-efficacy expectancies, and substance-related effect expectancies. Each of these will be reviewed briefly below. Common elements of brief cognitive-behavioral therapy are listed in Figure 4-13.

Attributions

An attribution is an individual's explanation of why an event occurred. Abramson and colleagues proposed that individuals develop attributional styles (i.e., individual ways of explaining events in their lives that can play a role in the development of emotional problems and dysfunctional behaviors) (Abramson et al., 1978).

The basic attributional dimensions are internal/external, stable/unstable, and global/specific. For instance, clinically depressed persons tend to blame themselves for adverse life events (internal), believe that the causes of negative situations will last indefinitely (stable), and overgeneralize the causes of discrete occurrences (global).

Healthier individuals, on the other hand, view negative events as due to external forces (fate, luck, environment), as having isolated meaning (limited only to specific events), and as being transient or changeable (lasting only a short time). Figure 4-14 lists and further defines the three dimensions of attribution that make up an "attributional style."

Attributional styles play a major role in the cognitive-behavioral theory of substance abuse disorders (Davies, 1992; Marlatt and Gordon, 1985). The nature of substance abusers' attributional styles is thought to have considerable bearing on their perception of their substance abuse problem and their approach to recovery.

An alcohol-dependent client, for instance, may believe that he drank because he was weak (an internal attribution) or because he was surrounded by people encouraging him to have a beer (an external attribution). He may believe that his failure to maintain abstinence shows that he is a weak person who can never succeed at anything (a global attribution) or that a drinking episode does not represent a general weakness, but was instead due to the specific circumstances of the moment (a specific attribution).

He may believe that the cause of his slip is something he cannot change (a stable attribution) or that the next time, he will catch himself and exert better coping responses (an unstable attribution). Whereas the internal, global, and stable attribution for the use of alcohol is likely to lead to feelings of hopelessness and a return to drinking, the external, specific, unstable attribution is likely to lead to greater efforts to cope with similar situations in the future.

Marlatt and Gordon described a negative attributional process that can occur after a slip (the first use of a substance after a period of abstinence) and that may lead to continued use in a full-blown relapse (Marlatt and Gordon, 1985). This process, known as the abstinence violation effect (AVE), involves the attribution of the cause of an initial slip to internal, stable, and global factors. These clients may believe that they are hopeless addicts and failures, that they will never be able to achieve and maintain sobriety, and that there is no use in trying to change because they think that they cannot succeed.

AVE also has an emotional component associated with it. Substance abusers who have slipped and have internal, stable, and generalized attributions will feel depressed, worthless, helpless, and hopeless. This attributional style tends to be associated with a form of "learned helplessness" that is perpetuated by the substance users' distorted perceptions. Together, the sense of helplessness and the negative emotional state increase the likelihood that the initial lapse will develop into a full-blown relapse.

Research with individuals dependent on alcohol, marijuana, opiates, and other illicit drugs, provides empirical support for the attributional style hypothesized to mediate the AVE (Birke et al., 1990; Bradley et al., 1992; Reich and Gutierres, 1987; Stephens et al., 1994; Walton et al., 1994).

Cognitive Appraisal

For the cognitive-behavioral therapist, an individual's appraisal of stressful situations and his ability to cope with the demands of these situations are important influences on the initiation and maintenance of substance abuse, as well as relapse after cessation of use (Hawkins, 1992; Marlatt and Gordon, 1985; Shiffman, 1987, 1989; Wills and Hirky, 1996).

Folkman and Lazarus described two different levels of cognitive appraisal (Folkman and Lazarus, 1988, 1991). The first level is a primary appraisal. This represents the individual's perception of a situation and an estimation of the potential level of stress, personal challenge, or threat involved with the situation. Secondary appraisal represents the individual's evaluation of her ability to meet the challenges and demands specific to the situation. This secondary appraisal, which will be influenced by the extent, nature, and availability of the individual's coping skills, further mediates the individual's perception of stress and the person's emotional response.

To the extent that the individual senses that she has the necessary behavioral, cognitive, or emotional coping skills to meet the challenges of the situation, it will be appraised as less threatening or stressful. Conversely, if the person judges that the necessary coping skills are lacking, the situation is viewed as more threatening and stressful, and the person is likely to be frightened, anxious, depressed, or helpless. The results of Smith and colleagues suggest that such cognitive appraisals may play a more prominent role than attributions in mediating emotional responses to potentially threatening situations (Smith et al., 1993).

Coping behaviors

In substance use-related situations, coping "refers to 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). Cognitive-behavioral theory posits that substance users are deficient in their ability to cope with interpersonal, social, emotional, and personal problems. In the absence of these skills, such problems are viewed as threatening, stressful, and potentially unsolvable.

Based on the individual's observation of both family members' and peers' responses to similar situations and from their own initial experimental use of alcohol or drugs, the individual uses substances as a means of trying to deal with these problems and the emotional reactions they create. From this perspective, substance abuse is viewed as a learned behavior having functional utility for the individual--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.

A number of dimensions are involved in the coping process as it relates to substance abuse (Donovan, 1996; Hawkins, 1992; Lazarus, 1993; Shiffman, 1987; Wills and Hirky, 1996). The first is the general domain in which the coping response occurs. Coping responses can occur within the affective, behavioral, and cognitive domains.

Litman identified a number of behavioral and cognitive strategies that are protective against relapse (Litman, 1986). There are two behavioral classes of coping behavior: (1) basic avoidance of situations that have been previously associated with substance abuse and (2) seeking social support when confronted with the temptation to drink or use drugs.

The cognitive domain also includes two general categories of coping: (1) negative thinking, or thinking about all the negative consequences that have resulted from substance abuse and a desire to no longer experience these, and (2) positive thinking, or thinking about all the benefits that are accrued by being clean and sober and not wanting to lose these.

Litman suggests that these coping strategies operate in a somewhat sequential manner (Litman, 1986). Initially, when clients are attempting to initiate and stabilize abstinence from substances, they appear to rely more heavily on the behavioral strategies. As the period of abstinence increases, there appears to be a transition from predominantly behavioral strategies toward a greater reliance on cognitive methods of coping.

Coping strategies have a number of other dimensions. They can be emotion focused, problem focused, or avoidant. A distinction is also made between those that are general coping strategies and those that are expressly attempting to cope with urges, craving, and temptation to use in settings associated with past substance abuse. Another important dimension of coping strategies is the stage at which they are used in response to a potentially difficult substance-related situation (Shiffman, 1989).

Anticipatory coping is employed as one anticipates and attempts to plan how to deal with upcoming situations. They take the form of "What can I do if..." There are also coping strategies that are employed in the moment that one is having to deal with the difficult substance-related situations. They take the form of "What can I do now..." Finally, there are restorative coping strategies that can be employed if one fails to cope and finds himself using in the situation. These take the form of "What can I do now that I've..." It is these restorative coping strategies that play a role in determining whether an initial drink or use of drugs will escalate into a full-blown relapse.

Research on coping behavior as it relates to substance abuse disorders has generally supported the basic tenet of cognitive-behavioral approaches, namely that these clients are deficient in their coping skills, that these deficiencies contribute to their continued substance abuse, and that those whose deficits are not remedied are at a greater risk of relapse than those who increase their coping through treatment (Wills and Hirky, 1996).

Another study found that the number of coping attempts and the type of coping will influence both relapse and the return to abstinence (Moser and Annis, 1996). Attempting to cope with a relapse crisis led to higher rates of abstinence than not trying to cope, and the greater the number of coping strategies employed, the less likely the person was to use. If one coping response was performed, the probability of abstinence was 40 percent; the probability rose to 80 percent if two coping attempts were made. Similarly, the greater the number of coping strategies used by an individual following a relapse, the greater the likelihood of returning to abstinence.

Exclusive use of active coping strategies (e.g., engaging in alternative activities that are incompatible with drinking, problemsolving, seeking support from others, thinking of consequences of using, using positive/negative self-talk) was associated with maintaining abstinence in contrast to exclusive reliance on avoidant strategies (e.g., ignoring the situation, dealing with it indirectly by eating, or relying on willpower).

Neidigh and colleagues investigated the strategies employed to cope with stress and the temptation to drink among individuals attempting to control their drinking (Neidigh et al., 1988). They found that both cognitive and behavioral coping strategies were effective in resisting a drink. Two other important findings were obtained. First, there appears to be a considerable degree of situational specificity in the coping process.

That is, different types of substance-related situations seem to require different types of coping responses rather than a general coping strategy's being equally effective across situations. Second, strategies used to cope with nonspecific stress appear to be somewhat different from those used to cope with temptation.

These findings suggest that treatment not only should rectify deficiencies in coping abilities, but that it may be necessary to focus on skills to deal with both general stress and substance-related temptation. Furthermore, it may be necessary to develop coping skills specific to several possible situations in which the client may use substances.

Self-Efficacy Expectancies

The apparent lack of coping skills among substance users is an important contributor to another key construct in cognitive-behavioral approaches, namely self-efficacy expectancies (Bandura, 1977). These expectancies refer to an individual's beliefs about his ability to successfully execute an appropriate response in order to cope with a given situation.

Self-efficacy expectancies are determined in part by the individual's repertoire of coping skills and an appraisal of their relative effectiveness in relation to the specific demands of the situation. Bandura has hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated or not, the amount of effort that will be expended in attempting to cope, and how long a coping attempt will continue in the face of obstacles and aversive experiences (Bandura, 1977).

He also suggested that self-efficacy exerts an influence on the individual's behavior through cognitive, motivational, and emotional systems (Bandura, 1977). If a person has low self-efficacy due to a lack of necessary coping skills, she might be expected to have negative or distorted thoughts and beliefs about herself and her situation, have reduced motivation to even try to cope, and may be depressed and perceive herself as helpless.

Cognitive-behavioral approaches to substance abuse disorders postulate that low levels of self-efficacy are related to substance use and an increased likelihood of relapse after having achieved abstinence (Annis and Davis, 1988b, 1989b; DiClemente and Fairhurst, 1995; Marlatt and Gordon, 1985). A model of relapse that is based on the role of self-efficacy and coping is depicted in Figure 4-15.

Self-efficacy has been thought of as both the degree of a client's temptation to use in substance-related settings and his degree of confidence in his ability to refrain from using in those settings (Annis and Davis, 1988b; DiClemente et al., 1994; Sklar et al., 1997).

The role of self-efficacy has been examined for alcohol (Evans and Dunn, 1995; Solomon and Annis, 1990), cocaine (Coon et al., 1998; Rounds-Bryant et al., 1997), marijuana (Stephens et al., 1993), opiates (Reilly et al., 1995), and across all of these substances of abuse (Sklar et al., 1997). This research generally supports the hypothesis that those with lower levels of self-efficacy are more likely to abuse substances.

Substance-Related Effect Expectancies

As substance use is reinforced by the positive effects of the substance being taken, it is also likely that the individual will develop a set of cognitive expectancies about these anticipated effects on her feelings and behavior. They represent the individual's expectation that certain effects will predictably result from substance use.

Although there has been more research on alcohol-related effect expectancies (Goldman, 1994), there has been an increased interest in drug-related expectancies (Brown, 1993). Given that drugs have differing effects, it has been necessary to develop measures specific to the effects anticipated from these different drugs, such as marijuana (Schafer and Brown, 1991) and cocaine (Jaffe and Kilbey, 1994; Schafer and Brown, 1991).

The initial focus in studying alcohol-related expectancies was on the positive effects that individuals anticipated from alcohol (Goldman and Brown, 1987). Drinkers anticipated that alcohol would serve as a global elixir, having positive effects on mood, social and interpersonal behavior, sexual behavior, assertiveness, and tension reduction.

Positive effect expectancies for marijuana include relaxation and tension reduction, social and sexual facilitation, and perceptual and cognitive enhancement (Schafer and Brown, 1991). Positive cocaine-related expectancies include global positive effects, generalized arousal, euphoria, enhanced abilities, and relaxation and tension reduction (Jaffe and Kilbey, 1994; Schafer and Brown, 1991).

More recently, there has been an increased interest in the expectations of negative outcomes that individuals hold about substances. Negative expectancies about alcohol include cognitive and behavioral impairment, risk and aggression, and negative self-perception (Fromme et al., 1993).

Negative consequences expected from cocaine include global negative effects, anxiety, depression, and paranoia (Jaffe and Kilbey, 1994; Schafer and Brown, 1991). It is thought that the anticipated positive effects of substances serve as an incentive or motivation to use. Conversely, negative expectancies are thought to act as a disincentive and contribute to reduced drinking or drug use (McMahon and Jones, 1993; Michalec et al., 1996).

Research supports these hypothesized actions of positive and negative expectancies (Jaffe and Kilbey, 1994; Jones and McMahon, 1994b; Rounds-Bryant et al., 1997). Positive alcohol- and cocaine-related expectancies are associated with a greater likelihood of relapse and poorer substance-related outcomes (Brown et al., 1998; Rounds-Bryant et al., 1997), whereas negative alcohol effect expectancies are related to decreased likelihood of relapse and less alcohol consumption (Jones and McMahon, 1994a; McMahon and Jones, 1996).

Research also indicates that alcohol-related effect expectancies were negatively correlated with clients' ratings of self-efficacy at the beginning of treatment (Brown et al., 1998); that is, the lower the perceived self-efficacy, the greater the level of anticipated positive effects of alcohol. Both these sets of expectancies changed over the 4-week course of treatment, with self-efficacy increasing and alcohol effect expectancies decreasing.

Lower self-efficacy judgments, positive alcohol expectancies, and reliance on avoidant, emotion-focused coping strategies were significantly associated with increased alcohol consumption and alcohol-related problems among heavy drinking college students (Evans and Dunn, 1995).

High-Risk Situations

Over time, with repeated exposure, aspects of a situational context (e.g., the people, places, feelings, activities) can come to serve as conditioned cues that can elicit a strong craving or desire to use. To the extent that substance abuse allows the individual to avoid or escape such problem situations or their resultant emotional reactions, the use of substances will be reinforced through operant learning. Thus the likelihood is increased that substances will be abused and will come to be relied on in the future when the individual encounters similar situations.

Marlatt and colleagues have characterized a number of situations in which substances are abused (Chaney et al., 1982; Cummings and Gordon, 1980; Marlatt and Gordon, 1980, 1985). While the original taxonomy of these situations focused on settings in which relapse occurred following a period of abstinence from a substance, the settings appear to represent situations in which substance use in general will be more likely to occur (Annis and Davis, 1988a; Marlatt, 1996). The situations as originally categorized are found in Figure 4-16.

These situations have been classified into categories. At the broadest level, they are considered either interpersonal (i.e., involving a present or recent interaction with someone else) or intrapersonal-environmental (i.e., factors that are either internal to the individual or reactions to nonpersonal environmental events). There are a number of more specific situations within each of these broader categories.

These situations include many emotional, interpersonal, and environmental settings in which people commonly abuse substances and where they are likely to relapse. Therefore, these are called "high-risk" situations. These situations also serve as the foundation from which a number of measures of substance-related self-efficacy have been developed (Annis and Davis, 1988b; DiClemente et al., 1994; Sklar et al., 1997).

While there appears to be considerable overlap in high-risk situations across substances (Cummings and Gordon, 1980), there are also a number of substance-specific patterns. Emotional and situational risk factors have been examined among a clinical sample of individuals who were primary abusers of alcohol, cocaine, marijuana, sedatives and tranquilizers, or heroin/opiates. They found that positive social experiences and negative emotional states were important risk factors for patients who were dependent on alcohol or cocaine.

Positive emotional and situational factors were most important for those using marijuana. Individuals dependent on sedatives and tranquilizers or heroin/opiates reported that negative physical states and interpersonal conflict were the most important risk factors. Again, it is the individual's appraisal of such situations, in terms of its threat to maintaining abstinence relative to their available coping abilities, that determines the situational risk for the individual (Myers et al., 1996).

The Cognitive-Behavioral Approach to Substance Abuse Disorders

The cognitive-behavioral approach attempts to integrate all of these theoretical details into a meaningful model of substance abuse disorders (Mackay et al., 1991; Marlatt et al., 1988). Figure 4-17 presents a flowchart that depicts this model of substance abuse and dependence.

The cognitive-behavioral model assumes that substance abusers are deficient in coping skills, choose not to use those they have, or are inhibited from doing so (Monti et al., 1994, 1995). It also assumes that over the course of time, substance abusers develop a particular set of effect expectancies based on their observations of peers and significant others abusing substances to try to cope with difficult situations and through their own experiences of the positive effects of substances. They have come to believe that substances have positive benefits that are more immediate and prominent than their negative consequences. They also come to rely on substances as a means of trying to cope with these situations.

To the extent that the individual is lacking in the coping skills necessary to deal with the demands of high-risk substance abuse or relapse situations, his sense of self-efficacy decreases. As personal efficacy decreases, the anticipated positive effects of substance abuse increase and become more salient (Brown et al., 1998).

Under such conditions, the individual is likely to use (Moser and Annis, 1996). When confronted by similar situations in the future, the likelihood of using continues to be quite high, unless new coping skills have been learned. Given the interaction of self-efficacy, substance-related effects expectancies, and high-risk situations, "the decision to drink or exercise restraint (self-control) is ultimately determined by self-efficacy and outcome expectations formulated around a current situational context" (Abrams and Niaura, 1987, p. 152).

Attributional processes and emotional responses also play a role in an individual's decision to use (Marlatt and Gordon, 1985). Should the client attribute her substance abuse to internal, stable, and global characteristics (e.g., "I'm nothing but an addict; there's nothing that I can do to stop using"), then it is likely that she will feel angry, depressed, hopeless, and helpless.

These reactions are less likely to occur and to be less pronounced for individuals who are more firmly committed to the goal of abstinence or moderation and for those who have maintained such goals longer. These negative emotions represent yet another high-risk situation. If the individual does not have the necessary restorative coping skills to deal with them and to counteract the impact of a negative attributional style, it is more likely that an initial slip