At this week’s CBT for Substance Use Disorders workshop, we had the pleasure of welcoming Katherin Torres back to Beck Institute.
She and her colleagues from Pathways in San Diego recently attended the CBT for Schizophrenia workshop in April, and now she returned solo to learn more about using CBT with her substance abusing clients.
A pre-licensed MFT intern at Pathways in San Diego, Katherin is a first episode of psychosis specialist, working in the Kickstart program which provides confidential assessment and early assistance for young people between the ages of 10 and 25 who are at risk for mental illness in San Diego County.
First episode of psychosis clients often have comorbidity, and this workshop taught Katherin new ways to treat substance use disorders, address issues with open communication, and provide support to her high-risk clients.
Katherin has a long time affection for CBT, “It’s my therapeutic style: collaborative.”
At the workshop, she enjoyed watching the videos of the instructor, Dr. Cory Newman, in therapy sessions and completing roleplays with fellow participants to put new skills into practice.
This workshop will help her to structure her sessions, remember to set goals, and better understand her clients with substance use disorders. She is most excited to bring what she has learned back to the staff in the Kickstart program.
If you plan to treat patients suffering from substance misuse disorders, I have good news and bad news. First, the bad news. When people habitually misuse a psychoactive chemical – whether it is alcohol, marijuana, benzodiazepines, stimulants, opioids, hallucinogens, or any other – they typically receive significant, immediate positive reinforcement (e.g., a sense of “high”) as well as powerful, immediate negative reinforcement (e.g., relief from negative emotions and/or withdrawal symptoms). Even when people are motivated to change, these experiences are formidable opponents to healthier, more stable, more meaningful sources of gratification, such as the pride one feels in having the ability to say “no” to urges, the satisfaction of having spent a productive day, and the trust of caring others, including therapists. Thus, effective treatment is at once an uphill climb.
Now, here is the good news. In order for people to overcome a substance misuse disorder, they need psychological tools, and cognitive therapy provides this very well. In a nutshell, this includes skills in self-awareness (e.g., of the onset of cravings and urges), self-instruction, planning, problem-solving, well-practiced behavioral strategies to reduce risk and to increase enjoyable sober activities, and methods of responding effectively to dysfunctional beliefs (about drugs, oneself, and one’s “relationship” to drugs). A chief text for the cognitive therapy of substance abuse (Beck, Wright, Newman, & Liese, 1993) describes seven main areas of potential psychological vulnerability, each of which represents a factor that contributes to the patient’s risk of alcohol and other substance misuse, and each of which suggests a potential area for therapeutic intervention. These include:
- High-risk situations, both external (e.g., people, places, and things) and internal (e.g., problematic mood states).
- Dysfunctional beliefs about drugs, oneself, and about one’s “relationship” with drugs.
- Automatic thoughts that increase arousal and the intention to drink and/or use.
- Physiological cravings and urges to use alcohol and other drugs.
- “Permission-giving beliefs” that patients hold to “justify” their drug use.
- Rituals and general behavioral strategies linked to the using of substances.
- Adverse psychological reactions to a lapse or relapse that lead to a vicious cycle.
An overarching benefit that cognitive therapy brings to the treatment of substance use disorders is its emphasis on long-term maintenance. As misusers of alcohol and other drugs are often subject to relapse episodes, therapists need to teach patients a new set of attitudes and skills on which to rely for the long run. These attitudes and skills not only improve patients’ sense of self-efficacy, they also lead to a reduction in life stressors that might otherwise increase the risk of relapse. A short (non-exhaustive) list of some of the attitudes and skills that patients learn in cognitive therapy includes:
- Learning how to delay and distract in response to cravings, by engaging in constructive activities, writing (e.g., journaling), communicating with supportive others, going to meetings, and other positive means by which to ride out the wave of craving until it subsides.
- Identifying dysfunctional ways of thinking (e.g., “permission-giving beliefs”) and getting into the habit of thinking and writing effective responses. For example, a patient learns to spot the thought, “I haven’t used in 90 days, so I deserve a little ‘holiday’ from my sobriety,” and to replace it with a thought such as, “What I really deserve is to keep my sobriety streak alive, to support my recovery one day at a time, including today, and to stop trying to fool myself with drug-seeking thoughts.”
- Developing and practicing a repertoire of appropriately assertive comments with which to politely turn down offers of a drink (or other substance) from someone (e.g., “Thanks, but I’ll just have a ginger ale, doctor’s orders!”).
- Learning how to solve problems directly and effectively, rather than trying to drown out a problem by getting impaired, which only serves to worsen the problem.
- Becoming conversant in the “pros and cons” of using alcohol and other drugs, versus the pros and cons of being sober, and being able to address distortions in thinking along the way.
- Practicing the behaviors and attitudes of self-respect, including counteracting beliefs that otherwise undermine oneself and lead to helplessness and hopelessness (e.g., “I’m a bad person anyway, so I might as well mess up my life by using.”).
- Utilizing healthy social support, such as 12-step fellowship (12SF) meetings, friends and family who support sobriety, and staying away from those who would undermine therapeutic goals.
- Making lifestyle changes that support sobriety and self-efficacy, including having a healthy daily routine, refraining from cursing and raging, engaging in meaningful hobbies, and doing things that promote spirituality and serenity (e.g., yoga).
To provide accurate empathy to patients, and to ascertain the optimal combination of validation for the status quo versus action toward change, it is important for therapists to assess the patient’s “stage of change.” Some patients are quite committed to giving up their addictive behaviors, and thus are at a high level of readiness for change. Others are more ambivalent, and may waver in their willingness to take part in treatment. Similarly, patients who are uncertain about giving up drinking and drugging may present for treatment with the goal of “cutting back” on alcohol and other drugs. Such patients may disagree that they will need to eliminate their use of psychoactive chemicals, and may decide to leave therapy if the therapist insists that the goal must be abstinence. Of course, there are some patients who are remanded for treatment who otherwise would not seek treatment on their own. They may deny that they have a problem with alcohol and other drugs, and not truly engage in the therapy process at all. The therapist’s understanding of the patient’s stage of change will be vital in helping them know just how directive to be, without going too far for a particular patient to tolerate at a given time in treatment. This sort of sensitivity may allow therapists to get the maximum out of treatment with patients who are most motivated, while retaining less motivated patients in treatment until such time as they begin to feel more a sense of ambition in dealing with their problem.
Cognitive therapy can be used in conjunction with supplemental treatments. For example, cognitive therapy can be woven into a comprehensive program in which patients (for example) take suboxone, and also attend 12SF meetings. Similar to advancements in the treatment of bipolar disorder and schizophrenia, where promise has been shown in combining cognitive therapy with pharmacotherapy, the study of best practices for alcohol and substance use disorders will probably involve more instances of coordinated care. For example, the strength of medication-based treatments that diminish the patients’ subjective desire for their drug(s) of choice can be paired with the strengths of cognitive therapy in modifying faulty beliefs and maximizing skill-building.
Empirical evidence indicates that cognitive therapy has the potential to be an efficacious treatment for alcohol and other substance use disorders, especially with adult patients who present with comorbid mood disorders, and with adolescents. However, improvements in the treatment approach still can be made, most notably via alliance-enhancement strategies that may improve retention in treatment, and more routine incorporation of the “stages of change” model.
Anton, R. F., Moak, D. H., Latham, P. K., Waid, R., Malcolm, R. J., Dias, J. K., & Roberts, J. S. (2001). Posttreatment results of combining naltrexone with cognitive- behavioral therapy for the treatment of alcoholism. Journal of Clinical Psychopharmacology, 21(1), 72-77.
Baker, A., Boggs, T. G., & Lewin, T. J. (2001). Randomized controlled trial of brief cognitive-behavioral interventions among regular users of amphetamine. Addiction, 96(9), 1279-1287.
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.
Deas, D., & Thomas, S. E. (2001). An overview of controlled studies of adolescent substance abuse treatment. American Journal on Addictions, 10(2), 178-189.
Maude-Griffin, P. M., Hohenstein, J. M., Humfleet, G. L., Reilly, P. M., Tusel, D .J., & Hall, S. M. (1998). Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: Main and matching effects. Journal of Consulting and Clinical Psychology, 66(5), 832-837.
Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.
Nishith, P., Mueser, K. T., Srsic, C. S., & Beck, A. T. (1997). Differential response to cognitive therapy in parolees with primary and secondary substance use disorders. The Journal of Nervous and Mental Disease, 185(12), 763-766.
Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-Step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, 65, 230-240.
Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 303-313). New York: Oxford University Press.
Waldron, H.B., & Kaminer, Y. (2004). On the learning curve: The emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction, 99, 93-105.
This study examined the efficacy of a group-based cognitive-behavioral treatment (CBT) for Japanese alcoholic outpatients. Participants (N = 169) were assigned either to a CBT-based relapse prevention group or a TAU (treatment as usual) group. The CBT group received 12-session CBT treatment with a structured treatment workbook once a week. The TAU group received usual daycare treatment including 12-step meeting, vocational training and leisure activities. Participants in the CBT group demonstrated a significantly low relapse rate at the end of treatment. Moreover, coping skills of the CBT group participants were significantly improved than those of the TAU group at the 6-month follow-up period. However, at the 6-month follow-up, the difference in relapse rates diminished. The effectiveness of CBT for alcoholics was well documented in Western countries but few studies were conducted outside of the West. The results provide support for the use of CBT for Japanese alcoholics.
Harada, T., Yamamura, K., Koshiba, A., Ohishi, H., & Ohishi, M. (2014). Evaluation of
Nihon Arukoru Yakubutsu Igakkai Zasshi. 49(5), 249-258
Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.
Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.
Jessica Marie Russell, MA, LPC, LAC traveled from Colorado Springs for the Beck Institute Workshop on CBT for Substance Abuse. She works as a program supervisor at Spanish Peaks Behavioral Health Centers in Colorado. She primarily sees substance abuse clients and wanted to learn to help her clients with their cognitive distortions. Her organization is focused on ensuring that teams have access to the best tools they need to provide excellent care to their clients, which brought her and 5 co-workers to Beck Institute.
The best part of attending the training? “I saw my textbooks come alive. I saw Dr. Aaron Beck walking around!” She enjoyed seeing Dr. Aaron Beck’s role play with a participant who was overly optimistic, and she was able to better learn how to motivate clients who have a habit of “painting everything wonderful”.
She and her co-workers also were able to make the most of their travel by exploring the city, “Philadelphia is amazing. So much history and so much to experience”
The status of mental health care in regard to substance abuse has shifted in recent years as Colorado has legalized the use of marijuana. As the first state in the US legalizing marijuana, Colorado has seen an “epidemic” of clients who move into Colorado from other states and countries, without a home or employment. This has caused a drain on the health care system, and subsidized housing is overflowing with applications. This influx of clients has been difficult on clinicians, especially those who do not specialize in treating substance abuse. However, to attempt to combat the negative impacts, the state has been able to use tax money from the sale of marijuana toward mental health and substance abuse prevention, which includes providing education to clinicians and counselors, and that is how Jessica was able to travel to Beck Institute.
This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.
Kalapatapu, R. K., Ho, J., Cai, X., Vinogradov, S., Batki, S. L., & Mohr, D. C. (2014). Cognitive-Behavioral Therapy in Depressed Primary Care Patients with Co-Occurring Problematic Alcohol Use: Effect of Telephone-Administered vs. Face-to-Face Treatment-A Secondary Analysis. Journal of Psychoactive Drugs, 46, 2, 85-92.
OBJECTIVE: A previous pilot trial evaluating computer-based training for cognitive-behavioral therapy (CBT4CBT) in 77 heterogeneous substance users (alcohol, marijuana, cocaine, and opioids) demonstrated preliminary support for its efficacy in the context of a community-based outpatient clinic. The authors conducted a more definitive trial in a larger, more homogeneous sample.
METHOD: In this randomized clinical trial, 101 cocaine-dependent individuals maintained on methadone were randomly assigned to standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT, with seven modules delivered within an 8-week trial.
RESULTS: Treatment retention and data availability were high and comparable across the treatment conditions. Participants assigned to the CBT4CBT condition were significantly more likely to attain 3 or more consecutive weeks of abstinence from cocaine (36% compared with 17%; p<0.05, odds ratio=0.36). The group assigned to CBT4CBT also had better outcomes on most dimensions, including urine specimens negative for all drugs, but these reached statistical significance only for individuals completing the 8-week trial (N=69). Follow-up data collected 6 months after treatment termination were available for 93% of the randomized sample; these data indicate continued improvement for those assigned to the CBT4CBT group, replicating previous findings regarding its durability.
CONCLUSIONS: This trial replicates earlier findings indicating that CBT4CBT is an effective adjunct to addiction treatment with durable effects. CBT4CBT is an easily disseminable strategy for broadening the availability of CBT, even in challenging populations such as cocaine-dependent individuals enrolled in methadone maintenance programs.
Carroll, K. M., Kiluk, B. D., Nich, C., Gordon, M. A., Portnoy, G. A., Marino, D. R., & Ball, S. A. (April 01, 2014). Computer-assisted delivery of cognitive-behavioral therapy: Efficacy and durability of cbt4cbt among cocaine-dependent individuals maintained on methadone. American Journal of Psychiatry, 171, 4, 436-444.
Early maladaptive schemas are cognitive and behavioral patterns that cause considerable distress and are theorized to underlie mental health problems. Research suggests that early maladaptive schemas may underlie substance abuse and that the intensity of early maladaptive schemas may decrease after brief periods of abstinence. The current study examined changes in early maladaptive schemas after a 4-week residential substance use treatment program. Preexisting records of a sample of male alcohol- and opioid-dependent treatment seeking adults (N = 97; mean age = 42.55) were reviewed for the current study. Pre-post analyses demonstrated that 8 of the early maladaptive schemas significantly decreased by the end of the 4-week treatment. Findings indicate that early maladaptive schemas can be modified during brief substance use treatment and may be an important component of substance use intervention programs. Implications of these findings for substance use treatment are discussed.
Shorey, R. C., Stuart, G. L., Anderson, S., & Strong, D. R. (September 01, 2013). Changes in Early Maladaptive Schemas After Residential Treatment for Substance Use. Journal of Clinical Psychology, 69(9), 912-922.
A recent study in the Journal of Consulting and Clinical Psychology suggests that cognitive behavioral therapy for adherence and depression (CBT-AD) can be an effective treatment for decreasing depression and increasing adherence to medication in HIV-infected injection drug users. The present study examined the effects of time-limited CBT-AD on participants with HIV and depression, and currently receiving treatment for their injection drug use. Participants (n=89) ranged from age 18 to 65 and were randomly assigned to receive either CBT-AD (n=44) or enhanced treatment as usual (ETAU) (n=45). Participants in the intervention group received 9 treatment sessions over a period of 3 months, involving 11 informational, problem-solving, and cognitive behavioral steps. At each step, the participants and the therapist collaboratively defined the problem, generated alternative solutions, made decisions about the solutions, and developed a plan for implementing them.
At post-treatment, the intervention group showed significant improvements. The Beck Depression Inventory showed a significant reduction in symptoms of depression in the CBT-AD group (M=5.1 points) compared to the ETAU group (M= <1 point). A 40% decrease in symptoms of depression was shown from baseline to post treatment with CBT-AD. These clinically significant improvements were maintained at the 12 month follow up. The Medication Event Monitoring System (MEMS) showed that during the CBT-AD intervention, adherence improved 11.8% from baseline and 11.3% more than the ETAU condition. However adherence gains were not maintained at follow-up. It is proposed that continued adherence counseling may be necessary to maintain adherence gains, even when depression symptoms improve.
Depression and substance abuse are the most comorbid disorders associated with HIV-infection, and it is suggested that even a small change in adherence can result in improved outcomes for HIV patients. The results of this study suggest that the integration of CBT-AD into substance abuse counseling may be useful for decreasing depression and improving adherence to medication (with continued sessions) in HIV-infected patients with a history of injection drug use.
Safren, S.A., O’Cleirigh, C.M., Bullis, J.R., Otto, M.W., Stein, M.D., & Pollack, M.H. (2012) Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in HIV-Infected Injection Drug Users: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 80(3), 404-415.
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