Cognitive Therapy of Substance Abuse

354 Pages·1993·2.79 MB·English

by  Aaron T. Beck MD

C O G N I T I VE
T H E R A PY OF
S U B S T A N CE
A B U SE
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A A R ON T. B E CK
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F R ED D. W R I G HT
C O RY F. N E W H AN
B R U CE S. L I E SE
COGNITIVE THERAPY OF SUBSTANCE ABUSE

C o g n i t i ve T h e r a py
of S u b s t a n ce A b u se
Aaron T. Beck, M.D.
Fred D. Wright, Ed.D.
Cory F. Newman, Ph.D.
Bruce S. Liese, Ph.D.
THE GUILFORD PRESS
New York London
©1993 The Guilford Press
A Division of Guilford PubHcations, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical,
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Printed in the United States of America.
This book is printed on acid-free paper.
Last digit is print number: 9
Library of Congress Cataloging-in-Publication Data
Cognitive therapy of substance abuse / Aaron T. Beck . . [et al.].
p. cm.
Includes bibliographical references and index.
ISBN 0-89862-115-1 (he.) ISBN 1-57230-659-9 (pbk.)
1. Substance Abuse—Treatment. 2. Cognitive therapy. I. Beck,
Aaron T.
[DNLM: 1. Cognitive therapy—methods. 2. Substance Abuse—
therapy. WM 270 C6765 1993]
RC564.C623 1993
616.86'0651—dc20
DNLM/DLC
for Library of Congress 93-5208
CIP
To Phyllis, Gwen, Jane, and Ziana

P r e f a ce
s
L-#ubstance abuse is widely recognized as a serious
social and legal problem. In fact, the use of illegal drugs may be
responsible for more than 25% of property crimes and 15% of violent
crimes. Financial losses related to these crimes have been estimated
at $1.7 billion per year. Homicides are also strongly linked to drug
dealing. Approximately 14% of homicides per year are causally related
to drugs. The costs for criminal justice activities directed against drug
trafficking on the federal level were approximately $2.5 billion in
1988, compared to $1.76 billion spent in 1986.
There are also many health problems caused by these drugs.
Alcohol can damage almost every body organ, including the heart,
brain, liver, and stomach. Illegal drugs such as cocaine can have a
serious effect on the neurological, cardiovascular, and respiratory
systems. Cigarettes can cause cancer, heart disease, and more. The most
widely used and abused drug in the world is alcohol. In the United
States, two-thirds of the population drink alcohol. About ten out of a
hundred people have problems with alcohol so serious that they can
be considered "alcoholic" or "alcohol-dependent." (Interestingly, this
10% of Americans buys and drinks more than half of the alcoholic
beverages!)
At least 14 million Americans take illegal drugs every month. Dur
ing "peak months" this number climbs to more than 25 million users.
Some experts have estimated that approximately 2.3% of Americans
over 12 years of age have a problem with illegal drugs serious enough
to warrant drug treatment.
To a large degree, we have tried to put a halt to drug abuse by
making drugs illegal. For example, heroin and cocaine are presently
illegal in the United States. Cigarette smoking is becoming increas
ingly proscribed. At one time we tried to stop alcoholism by legal
Vll
via Preface
mechanisms (i.e., prohibition). Obviously, these methods will never
make substances completely unavailable.
Not all people who use drugs become addicted to them, although
many people have asked themselves, "Am I [or is someone else] an
alcoholic [or a substance abuser]?" The American Psychiatric Associ
ation has defined the addictions very specifically. In fact, the official
term for an addiction is "substance dependence." There are some
specific signs of substance dependence, including (1) heavy use of the
substance, (2) continued use even though it may cause problems to
the person, (3) tolerance, and (4) withdrawal symptoms.
Cultural and historical factors are implicated in substance use and
abuse. The patterns and consequences of drug use have been influ
enced by historical developments, which have had positive and neg
ative effects. Two centuries ago, the extraction of pure chemicals from
plant materials created more powerful medicinal agents. The inven
tion of the hypodermic needle in the middle of the nineteenth cen
tury was also a medical boon, which, on the other hand, allowed drug
users to circumvent the body's natural biological controls consisting
of bitter taste and slow absorption through the digestive tract. Many
synthetic drugs developed in the twentieth century had medical appli
cation but created further opportunities for abuse and addiction. In
short, any activity that affects the reward mechanisms of the brain
may lead to compulsive, self-defeating behavior.
Social, environmental, and personality factors have affected sub
stance use and abuse in ways that go far beyond the simple pharma
cological properties of these agents. Alcoholism, for example, is preva
lent among certain ethnic groups and practically absent among others,
such as the Mormons, who require abstinence for group acceptance.
On the other hand, other social subgroups may condition group accep
tance on using or drinking. The social milieu may influence using.
Soldiers used illegal drugs extensively in Vietnam but, for the most
part, relinquished heavy drug use after returning home. Impoverished
environments have been shown in both animal experiments and
human studies to lead to addiction. As pointed out by Peele, the com
mon denominator is the lack of other opportunities for satisfaction.
Finally, our clinical experiences have indicated that addicted indi
viduals have certain clusters of addictive attitudes that make them
abusers rather than users.
Successful treatment depends on clinicians' effectiveness in deal
ing with these addictive potentials. And what form will this care take?
As pointed out by Marc Galanter, president of the American Academy
of Psychiatrists in Alcoholism and Addiction, the long-term efficacy
of new pharmacological treatments is open to question. "Tricyclics,
Preface ix
dopaminergic agents, and carbamazapine for cocaine abusers have yet
to be substantiated as a vehicle for continuing care. For opiates,
naltrexone and buprenorphine offer only a modest niche in the do
main that was traditionally occupied by methadone maintenance.
Intervention in GABAergic transmission may hold promise for alco-
hoHsm, but that promise is far from clinical application" (Galanter,
1993, pp. 1-2).
We have written this book in response to the ever-growing need
to formulate and test cost-effective treatments for substance abuse dis
orders, problems that seem to be multiplying in the population in
spite of society's best efforts at international interdiction and domes
tic control and education. We believe that cognitive therapy, a well-
documented and demonstrably efficacious treatment model, can be
a major boon to meeting this pressing need.
At one time, "drug abuse rehabilitation counseling" was regarded
as a specialty area in the field of psychotherapy—now it is apparent
that almost all who engage in clinical practice will encounter patients
who use and abuse drugs. Therefore, it would be desirable for all
mental health professionals to receive some sort of routine training
and education in the social and psychological phenomena that com
prise the addiction disorders. Our volume is intended to provide a
thorough, detailed set of methods that can be of immediate use to
therapists and counselors—regardless of the amount of experience they
might have had with cognitive therapy, or in the field of addictions.
Toward this end, we have strived to make our model and our proce
dures as specific and complete as possible. We certainly recommend
that those who read this book also read the many valuable sources
we have cited in the text. Nevertheless, our intention in writing Cog
nitive Therapy of Substance Abuse has been to provide a convenient,
centralized source that is comprehensive, teachable, and testable.
Although advances in the field have been made in the form of
pharmacological interventions (e.g., antabuse, methadone, and nal
trexone), 12-step support groups (e.g.. Alcoholics Anonymous, Nar
cotics Anonymous, and Cocaine Anonymous), and social-learning
models and programs (relapse prevention, rational recovery, etc.), each
of these approaches has posed problems that limit its respective poten
tial efficacy. For example, pharmacological interventions have pro
duced promising short-term data but are fraught with compliance and
long-term maintenance difficulties^atients may not take their chem
ical agonists and antagonists, and they are prone to relapse when the
medications are discontinued. Twelve-step programs provide valuable
social support and consistent guidance principles for individuals who
voluntarily join and faithfully attend the program meetings, but can-