Encyclopedia of Cognitive Behavior Therapy

452 Pages·2005·1.51 MB·English

by  Steven C. Hayes

of
E N C Y C L O P E D I A
C O G N I T I V E
B E H AV I O R
T H E R A P Y
EDITOR-IN-CHIEF
ARTHUR FREEMAN
EDITORS
STEPHANIE H. FELGOISE, ARTHUR M. NEZU,
CHRISTINE M. NEZU, AND MARK A. REINECKE
2 Acceptance and Commitment Therapy
through the transformation of function, the feelings that been, and if (as is most common) they have not been suc-
were present during the trauma may again be present during cessful to consider the possibility that it is that agenda itself,
the description. not the technique or method, that might be the source of
The root of several maladaptive behaviors according to their difficulty.
an ACT model can be expressed with the acronym FEAR What has not been working is gradually brought out:
(fusion, evaluation, avoidance, reasons). Cognitive fusion the deliberate control of private events. Many people strug-
refers to the domination of verbally derived behavioral func- gle with their unwanted thoughts and feelings by trying to
tions over other, more directly acquired functions. People control them or get rid of them. In their experience, most
become fused with their verbal depictions,evaluations,and clients have found that this ultimately leads to more
reasons. They no longer see them as their behavior, but as unwanted thoughts and feelings. Conscious,deliberate con-
objective situations and thus, if they are aversive, as events trol usually works when applied to the world outside the
to be avoided. For example, if a person is fused with the skin. When applied to private experiences,however,control
thought, “there is something deeply wrong with me,” he or usually works only temporarily. Exercises and metaphors
she will want to avoid situations that bring up that thought. are used as examples of how control does not work long
Unfortunately, such experiential avoidance often paradoxi- term, of how language engrains unworkable control
cally strengthens the avoided events because they strengthen strategies.
the verbal/evaluative processes that give rise to such events. Instead of avoidance, ACT clients are taught willing-
For example,a person avoiding the thought “there is some- ness and defusion as methods of coping with difficult psy-
thing deeply wrong with me”strengthens the apparent literal chological context. Willingness is the deliberate embrace of
truth of that thought since it confirms that something needs difficult thoughts, feelings, bodily sensations, and the like.
to change before one is acceptable—the very essence of the Exposure exercises are used to contact troublesome private
originating thought. experiences. Cognitive defusion techniques are used to
The source of cognitive fusion, and thus experiential reduce the dominance of the literal meaning of thoughts and
avoidance, is thought to be the bidirectionality of verbal instead to experience them willingly as an ongoing process
processes and their general utility in many domains. occurring in the present. In this phase,clients may be taught
Because this process is thought to be under contextual to watch their thoughts float by without trying to alter them;
control, the behavioral impact of thoughts and feelings is they may be asked to repeat thoughts until they lose all
dependent on context. Therefore, ACT holds that thoughts meaning; or they may be asked to think of thoughts as exter-
and feelings are not mechanical causes of behavior,and that nal objects and will be asked a variety of perceptual/sensory
the impact of thoughts and feelings can be most readily questions about them (e.g.,What color are they?). Cognitive
influenced through a change in the context of verbal behav- defusion undermines evaluation and teaches healthy dis-
ior. ACT has several techniques for doing so. tancing and nonjudgmental awareness. When this phase is
successful the client will seem to notice reactions from the
level of an observer and will take a more willing stance
ACT COMPONENTS toward unwanted thoughts.
Much of the time people identify themselves by psy-
ACT uses metaphors, logical paradox, and experiential chological content. They are the content of their thoughts.
exercises throughout its different components. The main rea- As cognitive content is defused,more emphasis is placed in
son for their use is that they are ways of undermining exces- ACT on self as context. The self as context is the observing
sive literal language,basing action instead on experience. self. It is the experience of an “I” that does not change or
The components in ACT are not a fixed or rigid set of judge, but just experiences. Meditation and mindfulness
techniques that occur in a definite order. In accordance with exercises are used to help the client experience conscious-
functional contextualism, they are a functional set of com- ness itself as the context for private experiences, not as the
ponents that can be changed and rearranged to meet the content of those experiences. Self as context work provides
client’s needs. Nevertheless, what is present below is a a safe psychological place from which acceptance,willing-
typical sequence. ness,and defusion are possible.
An ACT therapist first gathers information about all the When clients are no longer running from experience,
different ways a client has tried to change his or her suffer- direction in life is supplied by the client’s values. Values are
ing and how these attempts have worked or not worked. The desired qualities of ongoing behavioral events that can only
domination and workability of experiential avoidance is a be instantiated, never obtained as an object. For example,
primary focus. In this phase of treatment clients are asked to a person who values being loving toward others can work to
examine directly how successful their efforts to avoid have maintain those qualities in his or her human interactions,but
Acceptance and Commitment Therapy 3
this process will never be finished or obtained,as one might ACT differs from traditional CBT approaches in sev-
obtain a degree or buy a car. All ACT techniques are in the eral ways as well. Perhaps the central theme of traditional
service of helping the client live life in accordance with his CBT is the attempt to test and change the content of
or her values. The exercises and metaphors in the values thought—an effort that ACT assiduously avoids. ACT relies
phase are geared toward helping clients identify what they on a functional contextual theory of cognition,and because of
want to stand for in their lives in a variety of domains that emphasizes context over content. Its antimechanistic
(relationships, health, citizenship, and so on). Once values and explicitly contextualistic qualities differ from traditional
are identified, specific goals that fit with these values are CBT. Also,although some elements of acceptance and defu-
identified along with behaviors that might produce these sion are found in mainstream CBT, ACT dramatically
concrete goals. Finally the barriers to those actions are increases the emphasis on these elements and disconnects
identified and dealt with through other ACT methods (e.g., them from their possible use as indirect change methods
defusion,acceptance,and willingness). still focused on the content of private events. Finally, the
The final phase of ACT, the commitment phase, strong emphasis on values and self-as-context is unlike
involves working with the client to apply what he or she has traditional CBT.
received in therapy to living life in accord with one’s chosen
values even if it involves experiencing psychological pain.
This phase focuses on the client’s willingness to experience FUTURE DIRECTIONS
whatever may come up and helps the client commit to act-
ing in accordance with his or her values. Commitment is At the present time there are 11 published randomized
presented as an ongoing, never-ending process of valuing controlled trials of ACT,but there are many more outcome
and recommitting. It assumes that the old change agenda has and process studies under way or under review which allow
been abandoned,that some willingness has been contacted, us to assess the future direction of ACT research. ACT
and a valued life direction has been identified. The commit- seems to be a broadly applicable technology and future
ment stage looks the most like traditional behavior therapy, research seems likely to broaden the range of application
as the client passes through cycles of values,goals,actions, even further. ACT is one of a family of new behavioral
barriers,and dissolution of barriers. When this phase is com- and cognitive therapies that are focusing on contextual
pleted, therapy is terminated. However, often with ACT, change methods, including mindfulness, acceptance, and
clients will come in for “tune-up”sessions after termination. the like, and ACT studies are increasingly focused on
the theoretical understanding of processes of this kind.
More ACT research will be done in combination with
REVIEW OF RELEVANT LITERATURE other technologies, and more will be done to link ACT
toRFT.
There is a growing amount of research that supports
both ACT outcomes (see Hayes,Masuda,Bissett,Luoma,&
Guerrero,2004,for a review) and ACT processes. For exam- SUMMARY
ple,controlled trials have shown ACT to be effective in sev-
eral different areas including stress reduction (Bond & ACT is a therapy that is based philosophically in
Bunce,2000) and coping with psychotic symptoms (Bach & clinical behavior analysis. Functional contextualism is the
Hayes, 2002) among others. In addition to the efficacy world view that underlies ACT. Theoretically ACT is based
research available,ACT has been shown to improve clinical on RFT, which offers an account of how language creates
outcomes in an effectiveness study (Strosahl et al.,1998). pain and useless methods of dealing with it,and which sug-
gests alternative contextual approaches to these domains.
ACT uses metaphors, experiential exercises, and logical
COMPARISON TO TRADITIONAL CBT paradox to get around the literal content of language and to
produce more contact with the ongoing flow of experience
ACT is part of the behavioral tradition and is similar in the moment. The primary ACT components are chal-
in some ways to different forms of CBT. ACT shares the lenging the control agenda,cognitive defusion,willingness,
focus on cognition, emotion, and behavior. It incorporates self as context,values,and commitment. ACT is part of the
traditional behavioral components like many forms of CBT. CBT tradition, although it has notable differences from
Some elements of acceptance and defusion can be found traditional CBT. The main purpose of ACT is to relieve
in mainstream CBT approaches, for example in Ellis’s human suffering through helping clients live a vital,
inclusion of acceptance of self or Beck’s idea of distancing. valued life.
4 Acceptance and Commitment Therapy
REFERENCES
Addictive Behavior—Nonsubstance
Bach,P.,& Hayes,S. C. (2002). The use of acceptance and commitment Abuse
therapy to prevent the rehospitalization of psychotic patients:A ran-
domized controlled trial. Journal of Consulting and Clinical
Psychology,70,1129–1139.
Frederick Rotgers and Ray W. Christner
Bond,F. W.,& Bunce,D. (2000). Mediators of change in emotion-focused
and problem-focused worksite stress management interventions.
Journal of Occupational Health Psychology,5,156–163. Keywords: addiction,process addiction,gambling,sexual addiction,
Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. Internet addiction
(2004). DBT,FAP,and ACT:How empirically oriented are the new
behavior therapy technologies? Behavior Therapy,35,35–54.
Strosahl,K. D.,Hayes,S. C.,Bergan,J.,& Romano,P. (1998). Assessing
When one thinks of addictive behavior, there is often
the field effectiveness of Acceptance and Commitment Therapy:
An example of the manipulated training research method. Behavior reference to the use and/or abuse of chemical substances.
Therapy,29,35–64. However,in recent years theorists and clinicians have begun
to include other excessive behaviors including eating,gam-
bling, exercise, and sex under the umbrella of “addictions”
GLOSSARY
(Greenfield,1999; Koski-Jannes,1999). Several researchers
have classified problematic Internet use as an “addiction”
Experiential avoidance:Any behavior that functions to avoid or escape (Bingham & Piotrowski, 1996; Young, Pistner, O’Mara, &
from unwanted experiences despite psychological costs for doing so
Buchanan,1999). Common to all the aforementioned behav-
Acceptance:An open and noncontrolling stance toward all experiences
iors are characteristics of preoccupation, impaired control,
Choice:A section among alternative that is not based on verbal formulations
of pros and cons concealment of performing the behavior, and performance
Cognitive defusion: Reductions in the behavioral regulatory functions of the act despite being adverse to daily functioning
of verbal events, particularly thoughts, based on a reduction in the (American Psychiatric Association, 2000; Greenfield, 1999;
dominance of the literal content of those events as compared to
Ladouceur, Sylvain, Letarte, Giroux, & Jacques, 1998;
the ongoing processes of formulating them
Toneatto, 2002). The consequences of ongoing involvement
Values:Ways of living life that a person cares about deeply
Willingness:Openness to experiences that may be contacted in the process in these behaviors include family discord, financial debt,
of living a valued life employment loss,legal issues,and social difficulty.
Self as context:Also called the observer self; a psychological context from Complicating the conceptualization and treatment of
which thoughts,emotions,sensations,judgments,evaluations,and so
addictive behaviors is the incongruence in the terms and def-
on are observed as what they are and not what they say they are
initions of addictive behaviors. While the Diagnostic and
Statistical Manual of Mental Disorders—Fourth Edition—
RECOMMENDED READINGS Text Revision (DSM-IV-TR; American Psychiatric Asso-
ciation,2000) classifies pathological gambling as a disorder
of impulse control,some question whether it is best classified
Hayes,S. C.,Barnes-Holmes,D.,& Roche,B. (2001). Relational Frame
Theory:A post-Skinnerian account of human language and cognition. in this manner or as an addiction or obsession (Moreyra,
New York:Kluwer Academic/Plenum. Ibanez,Liebowitz,Saiz-Ruiz,& Blanco,2002). This debate
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and also extends to Internet use (Greenfield, 1999) and sexual
Commitment Therapy:An experiential approach to behavior change.
behaviors (Harnell,1995; Swisher,1995). Further complicat-
New York:Guilford Press.
ing the nosological picture is a failure among theorists to
Hayes,S. C.,Wilson,K. W.,Gifford,E. V.,Follette,V. M.,& Strosahl,K.
(1996). Emotional avoidance and behavioral disorders:A functional agree on what specific factors must be present in order to
dimensional approach to diagnosis and treatment. Journal of define an excessive behavior as “addiction” (e.g., cognitive
Consulting and Clinical Psychology,64,1152–1168. distortions,behavioral reinforcement,physiological factors).
Finally,there is great debate as to the appropriate treatments
for these excessive behaviors (e.g., cognitive–behavioral,
multimodal,self-help). We adopt the term “addictive behav-
iors” to summarize these nonsubstance use excessive
behaviors (sex,gambling,Internet use,eating,exercise). We
recognize that this is an arbitrary use of the term “addictive,”
and do so only for ease of communication.
To date, much of the understanding of addictive
behaviors stems from research on pathological gambling.
Addictive Behavior—Nonsubstance Abuse 5
Studies regarding other addictive behaviors are emerging, Silove (1995) indicated that gamblers also selectively recall
yet there continues to be much that is unknown. Research on wins over losses, they anticipate a win following a “near
cognitive and behavioral underpinnings and interventions miss,”or they await the end of the losing streak.
with addictive behaviors is relatively young compared to In addition to gambling,cognitive factors play a role in
other disorders (e.g.,anxiety,depression). other addictive behaviors as well,although the research with
other addictive behaviors is scant. Neidigh (1991) applied
the relapse prevention model of Marlatt and Gordon (1985)
THEORETICAL FOUNDATIONS to the treatment of sexual offenders/addicts. Consistent with
the relapse prevention model,Neidigh (1991) noted that sex
Although the impact addictive behavior has on one’s offenders often engage in distorted cognitions that place
daily functioning (e.g.,family problems,employment difficul- them in situations in which relapse is probable. Others have
ties) is often clear, there is less knowledge of the underlying described the sex addict as having an “illusion of self-con-
processes contributing to the onset,maintenance,and relapse trol” (Harnell, 1995). This illusion of self-control leads sex
of these behaviors. The basic tenets of CBT suggest a rela- offenders/addicts to place themselves in high-risk situations.
tionship exists between cognitive, behavioral, and emotional For instance, an individual with sexual impulses toward
factors in human functioning. The cognitive–behavioral con- children may frequent a grocery store across from a school
ceptualization of addictive behaviors, therefore, focuses on or playground. Cognitive distortion used by sex
the specific interaction between cognitive and behavioral offenders/addicts may serve as a means to justify their sex-
processes resulting in maladaptive behavior. Subsequently, ual desires or behaviors (Neidigh, 1991). For instance, a
changing maladaptive or dysfunctional thought patterns will child offender may make erroneous statements such as “she
ultimately lead to behavioral change. looked mature for her age”or “it’s okay to have sex with her
As mentioned earlier,much of the research with addic- if she agrees.”
tive behaviors concentrates on pathological gambling. Internet use is another addictive behavior in which
Ladouceur and colleagues (1998) noted the importance of cognitive explanations are useful. While there is still little
understanding the primary motivation to gamble—the research in this very new area, there is some consensus
acquisition of wealth. What differentiates “professional” regarding the function of maladaptive cognitions in patho-
from potentially addicted gamblers is the cognitive restric- logical Internet use (Davis, 2001; Hall & Parsons, 2001).
tion that limits the amounts wagered. Nonprofessional The maladaptive cognitions exhibited by those involved in
gamblers who become “addicted” often lack this pathological Internet use can be broken down into thoughts
cognitive structure (among others). Thus, cognitive factors of self and thoughts of the world (Davis,2001). Specifically,
may explain the unrelenting play in the face of the odds,as these individuals hold cognitive distortions including self-
the gamblers expect to win (e.g., “I will win this time”). doubt, negative self-appraisal, and a lack of self-efficacy.
Langer (1975) described this as the “illusion of control,”in Thus, they may have the core belief that “I am a better
which the gambler thinks his or her probability of winning a person on the Internet than I am in reality.”Thoughts about
“game of chance” is greater than that dictated by random the world may be generalized and have an all-or-nothing
chance. This is consistent with findings of Ladouceur and quality. For example, one may believe, “I can only make
colleagues (Gaboury & Ladouceur, 1989; Ladouceur & friends on the Internet.”
Walker,1996) who demonstrated cognitive biases and erro- While researchers have categorized addictive behaviors
neous beliefs about gambling among problem gamblers. into distinctly different problems—gambling, sex, and
They found that problem gamblers engage in inaccurate ver- Internet—it is important to emphasize the complexity
balizations or thoughts (e.g., predicting outcomes, explain- and interrelationship that may exist between them. With the
ing losses, and attributing causal significance) during increased amount of information available on the Internet,
episodes of gambling,and the gamblers believe their “skill” these specific addictive behaviors can occur in the confines
or employment of various strategies and/or rituals improves of one’s home. Technological advances provide access to
the odds of winning. gambling, shopping, pornography, and so on with a simple
Many studies highlight the importance of cognitive “click of a button.”Because of this,Davis (2001) proposed
factors in the onset and maintenance of gambling behaviors. specific pathological Internet use in which the individual’s
The cognitive perspective of gambling suggests that dis- overuse of the Internet serves a specific purpose (e.g.,
torted cognitive factors (e.g.,automatic thoughts,schemata, pornography, gambling) rather than general Internet use.
core beliefs) lead gamblers to maintain an inaccurate per- Some have suggested a possible evolution from online
ception that they have a greater level of skill or control, sexual behavior toward actual sexual contact (Greenfield,
which influences the gambling outcome. Blaszczynski and 1999). While these interactions are only now becoming
6 Addictive Behavior—Nonsubstance Abuse
more apparent, common to all addictive behaviors appears replacement behaviors, and changing the relationships
to be the vicious cycle of cognitive distortions or maladap- between cognitive distortions and physiological arousal and
tive thinking,which ultimately results in negative behaviors. gambling. The investigators used relaxation training,imaginal
and in vivo exposure,and cognitive restructuring as primary
modalities. Following treatment the client showed a signifi-
CBT TREATMENT STRATEGIES FOR cant decrease in frequency and intensity of gambling
ADDICTIVE BEHAVIORS impulses. With the exception of placing a single bet, the
client did not gamble for 10 months. Additionally,the client
Individuals seeking treatment for addictive behaviors reported a decrease in anxiety based on the Beck Anxiety
may experience serious financial, social, and interpersonal Inventory.
losses,as well as possible legal problems. There may be an In an experimental design,Bujold,Ladouceur,Sylvain,
initial motivation for these individuals to avoid engaging in and Boisvert (1994) evaluated the effectiveness of a treat-
the addictive behavior in order to prevent further psycho- ment program consisting of cognitive correction, problem
social implications. Thus, the use of cognitive–behavioral solving training, social skills training, and relapse preven-
treatment for addictive behaviors may play a more vital role tion with three male pathological gamblers. Individual
in the long-term maintenance of behavioral change or in intervention occurred once per week until the subjects main-
relapse prevention (Neidigh,1991; Toneatto,2002). tained a high perception of control. Following treatment,the
For example, Toneatto (2002) noted that if gamblers subjects terminated gambling behaviors, increased their
continue to believe in their abilities to predict outcomes or perceptions of self-control, and reported ensuing problems
to control the situation,then they are more likely to relapse as less severe. The subjects sustained the results at the
and reengage in excessive gambling once the difficulties 9-month follow-up.
leading them to treatment subside. Similarly,when working Sylvain et al. (1997) assessed a treatment program con-
with sex offenders/addicts, it is necessary to become aware sisting of the four components described above by Bujold
of cognitive distortions leading to them placing themselves et al. (1994)—cognitive correction, problem solving train-
in high-risk situations (Neidigh,1991). ing, social skills training, and relapse prevention. The sam-
Strategies used for addictive behaviors vary depending ple consisted of 29 individuals seeking help for gambling
on the case conceptualization of the client and the specific problems. The results demonstrated that CBT interventions
addiction presented. However, there are commonalities in significantly improve pathological gambling. Following
the use of CBT across the treatment of addictive behaviors. treatment,86% of the subjects no longer met the criteria for
Stress reduction techniques, social skills training, problem pathological gambling according to DSM-III-R. The inves-
solving skills, and cognitive restructuring have been useful tigators reported prolongation of the therapeutic gains at
in the treatment of pathological Internet use (Bingham & both 6- and 12-month follow-up.
Piotrowski, 1996; Davis, 2001; Hall & Parsons, 2001), Ladouceur et al. (1998) conducted a study evaluating
sexual addictions (Neidigh, 1991), and pathological the efficacy of cognitive interventions exclusively. The inves-
gambling (Sharpe & Tarrier, 1992; Sylvain, Ladouceur, & tigation involved the treatment of five pathological gamblers
Boisvert,1997). and used a single case experimental design across subjects.
Cognitive intervention targeted the subjects’ inaccurate
perceptions of randomness and consisted of explaining the
EMPIRICAL SUPPORT OF CBT FOR concept of randomness,offering an understanding of the illu-
ADDICTIVE BEHAVIORS sion of control, increasing awareness of inaccurate percep-
tions, and correcting maladaptive verbalization and beliefs.
While clinicians are presently using CBT interventions Subsequent to the intervention,four of the participants less-
for the treatment of addictive behaviors,few treatment pro- ened their urge to engage in gambling behavior and increased
grams exist and controlled studies are scarce. This is partic- their perception of control, thus no longer meeting the
ularly true of sexual addictions and pathological Internet DSM-IV criteria for pathological gambling. The subjects
use, as no controlled studies were available as of this writ- maintained these outcomes 6 months after treatment.
ing. Despite the lack of literature on a number of addictive In a recent randomized controlled study, cognitive
behaviors,research on pathological gambling is emerging. interventions targeting the erroneous perceptions of ran-
Sharpe and Tarrier (1992) offered a case study of a domness reported by gamblers were evaluated (Ladouceur
23-year-old self-referred gambler. The treatment program et al., 2001). The strategies involved cognitive correction
focused on increasing awareness of the cognitive errors (as described above in Ladouceur et al., 1998) and relapse
associated with gambling,teaching self-control,identifying prevention. Posttest outcomes indicated significant changes
Addictive Behavior—Nonsubstance Abuse 7
in the treatment group on measures of greater perception of standard assessment criteria, the determination of similari-
control and increased self-efficacy. Additionally,86% of the ties between various addictive behaviors, and perpetuate a
participants in the control group no longer met the criteria consistent conceptualization to facilitate treatment. While
for pathological gambling. Participants retained improve- recent studies are beginning to develop a knowledge base for
ment 6 and 12 months after treatment. gambling (e.g.,Ladouceur et al.,1998; Toneatto,2002) and
The studies reviewed demonstrate the growing empiri- Internet use (Davis, 2001; Greenfield, 1999), literature
cal basis for the use of CBT with addictive behaviors, addressing the factors composing other addictive behaviors
particularly gambling. While the use of CBT has been remains sparse.
reported with sex addictions (Neidigh,1991) and patholog- There is also a dearth of investigative efforts into
ical Internet use (Davis,2001; Hall & Parsons,2001; Young effective treatments for nonsubstance addictive behaviors.
etal.,1999),there is no empirical research demonstrating its The current literature consists of a few controlled studies for
efficacy and effectiveness with these populations. The gambling problems, but none addressing treatment of other
nature of CBT lends itself well to the treatment of various nonsubstance addictive behaviors. Studies are needed to
addictive behaviors; however, there is a need for controlled evaluate both the short- and long-term efficacy of treatments
studies to provide a firmer empirical base for its use with for addictive behaviors. The use of CBT with nonsubstance
these disorders. addictive behaviors is promising,though continued research
efforts and efficacy studies are needed.
CRITICISMS OF CBT FOR ADDICTIVE BEHAVIOR See also:Addictive behaviour—substance abuse,Relapse prevention
The use of CBT in the treatment of addictive behaviors
is a recent phenomenon, and published critiques have not
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mal, the use of CBT is promising and research outcomes American Psychiatric Association. (2000). Diagnostic and statistical manual
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Blaszczynski,A.,& Silove,D. (1995). Cognitive and behavioral therapies
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In addition to the necessity for empirical treatment, 195–220.
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nonsubstance addictive behaviors,though this is not unique of pathological gamblers: An experimental study. Journal of
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Internet use:A preliminary analysis. CyberPsychology and Behavior,
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8 Addictive Behavior—Nonsubstance Abuse
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As treatment has become more empirically based and
Compulsivity,2(1),31–39.
Sylvain,C.,Ladouceur,R.,& Boisvert,J. M. (1997). Cognitive and behav- sophisticated, it is understood that just as one does not
ioral treatment of pathological gambling:A controlled study. Journal expect a single antibiotic to be effective for every infection
of Consulting and Clinical Psychology,65(5),727–732. in every patient, it is unrealistic to think that only one type
Toneatto, T. (2002). Cognitive therapy for problem gambling. Cognitive
of treatment will be effective for everyone who suffers
Therapy for Problem Gambling,9,191–199.
from SUDs. More and more, cognitive behavior therapies,
Young, K., Pistner, M., O’Mara, J., & Buchanan, J. (1999). Cyber dis-
orders: The mental health concern for the new millennium. Cyber the 12-step programs, and, more recently, pharmacological
Psychology and Behavior,2(5),475–479. treatments are being used jointly to better meet the needs of
the individual (Beck, Wright, Newman, & Liese, 1993).
While widely used in the treatment of other disorders (most
notably depression, but also numerous other Axis I disor-
ders),CBT is not yet widely used for substance disorders—
except in relapse prevention—although this is changing.
The goal of CBT in the treatment of SUDs is to help
Addictive Behavior—Substance Abuse
patients identify maladaptive thoughts,feelings,and behav-
iors that maintain or exacerbate their substance use, and to
increase coping skills with regard to substance use and
Frederick Rotgers and Beth Arburn Davis
life problems in general. The method has several basics:
collaboration between patient and therapist throughout treat-
Keywords:alcoholism,drug abuse,drug addiction
ment, agenda setting, homework assignments, and Socratic
questioning. The latter is often referred to as “guided
discovery”and
Cognitive behavior therapy (CBT) in the treatment of
substance abuse disorders (SUDs) has its roots in social is a powerful technique to use while discussing the various
learning theory and cognitive therapy and includes the agenda items. [The] therapist asks questions in such a way
as to help patients to examine their thinking,to reflect on
groundbreaking work of Aaron Beck, Albert Ellis, and
erroneous conclusions,and,at times,to come up with better
Albert Bandura. The work of these researchers is based on
solutions to problems. This often leads to the patient’s ques-
the notion that individuals’ thoughts and feelings have a tioning,and thereby gaining greater objectivity from,their
strong and directive impact on their behavior,and that much own thoughts,motives,and behaviors. Also,Socratic ques-
behavior is learned and can therefore be unlearned. tioning establishes a nonjudgmental atmosphere and thus
facilitates collaboration between patients and therapists.
Thoughts, feelings, and behaviors are amenable to adaptive
This can help patients come to their own conclusions about
modification via a collaborative alliance between patient
the seriousness of their drug abuse problem. (Beck et al.,
and therapist, and the utilization of empirically supported 1993)
techniques that developed from learning theory,behaviorism,
In a National Institute on Drug Abuse (NIDA) treat-
and cognitive therapy.
ment manual on the use of CBT in the treatment of cocaine
addiction,Carroll (1998) states that there are two main com-
THEORETICAL FOUNDATIONS AND CONCEPTS ponents of CBT in the treatment of substance use:functional
analysis and skills training. Functional analysis identifies
CBT in the treatment of SUDs has drawn primarily “the patient’s feelings, and circumstances before and after
from social learning theory and behaviorism,both of which the cocaine use. Early in treatment, the functional analysis
Addictive Behavior—Substance Abuse 9
plays a critical role in helping the therapist assess the deter- Identified as “cognitive behavioral coping skills training”
minants, or high-risk situations, that are likely to lead to (CBST), the treatment is “aimed at improving the patients’
cocaine use and provides insights into some reasons why the cognitive and behavioral skills for changing their drinking
individual may be using cocaine.” Skills training “can be behavior. This type of treatment is considered to be broad
thought of as a highly individualized training program that spectrum in that it focuses not only on the patient’s problem
helps cocaine abusers unlearn old habits … and learn or drinking,but “addressed other life areas that often are func-
relearn healthier skills and habits.” tioning related to drinking and relapse. For example,if anger
can provoke a patient to drink, the focus of CBST will be
on those circumstances that arouse anger in the patient,
CBT TECHNIQUE the thought and behavioral processes that occur between the
onset of the anger and the patient’s drinking, and on the
CBT, whether for SUDs or other disorders, is usually events occurring after the patient drinks.”
short-term (8 to 20 sessions, though it may be longer) and There are also several CBT manuals available that
structured. Given that therapy time is limited, structure is detail the delivery of CBT treatment in group format.
critical to make certain that important topics are covered, Most prominent among these are the coping skills manual
and to model the idea that for patients who are suffering developed by Monti and colleagues (Monti, Kadden,
from disorders that often produce chaos, structure is posi- Rohsenow, Cooney, & Abrams, 2002), and a manual based
tive, reassuring, and can help them meet their goals. Beck on Prochaska and DiClemente’s (Prochaska,DiClemente,&
et al. (1993) state that structure is important for four reasons: Norcross, 1992) stages of change (Velasquez, Maurer,
(1) There is usually a large amount of material to cover and Crouch,& DiClemente,2001).
limited time to do so; (2) structuring helps maintain focus on
what topics are most important to cover; (3) structure sets
a “working atmosphere”; and (4) structure helps limit
CBT IN THE TREATMENT SPECTRUM
“therapy drift,” in which continuity from session to session
can be lost.
Though one of the most widely researched treatments
The structure of a session may differ somewhat from
for numerous Axis II and other Axis I disorders,CBT is not
therapist to therapist,but generally,there are seven elements
currently the most widely used in the treatment of SUDs,
(Beck et al.,1993):setting the agenda,doing a check on the
particularly alcohol. Fuller and Hiller-Sturmhofel (1999)
patient’s current mood state, recalling what was covered in
reported that the 12-step programs, such as Alcoholics
the last session (“session bridging”), discussing the day’s
Anonymous, are most commonly used to treat alcoholism,
agenda items (which probably will include reviewing the
with CBT a distant second,and pharmacological treatments
homework assignment from the previous session), periodic
such as disulfiram (Antabuse),acamprosate (Campral),and
summaries by the therapist of what has been discussed
naltrexone (Revia) an even more distant third. In the field
(which fosters the therapeutic alliance), assigning new
of substance abuse treatment,CBT is more commonly used
homework, and feedback about the therapy session.
in relapse prevention, and in academic and VA hospitals
Underscoring all parts of the session is the use of Socratic
(Longabaugh & Morgenstern,1999).
questioning.
Carroll (1998) identified five critical tasks in CBT for
cocaine addiction which can be generalized to treatment of
other SUDs as well:fostering the motivation for abstinence, RESEARCH ON CBT
teaching coping skills, changing reinforcement contin-
gencies, fostering the management of painful feelings, Cognitive behavior therapies are among the most empir-
and improving the social support system and social skills. ically supported of psychotherapies. Research is ongoing
Specific interventions include functional analyses,recogniz- in the use of CBT in numerous disorders including substance
ing and coping with cravings, understanding and managing use (Carroll, 1999). In a review of research into cognitive
thoughts about the substance use,problem solving,identify- behavior therapies as stand-alone treatments for alcohol
ing and modifying maladaptive thoughts with regard to abuse, Longabaugh and Morgenstern (1999) found that
substance use,identifying high-risk situations and develop- CBST “delivered as a stand-alone treatment does not differ in
ing ways to avoid or cope with them, encouragement, effectiveness from these other treatment approaches.” This
reviewing newly learned skills and practicing them in the also was true when CBST was used for aftercare; however,
session. patients who received CBST as part of a comprehensive pro-
These interventions are similar to those in the treatment gram were “likely to have better drinking-related outcomes
of alcohol dependence (Longabaugh & Morgenstern,1999). than patients”who did not receive CBST. They conclude that
10 Addictive Behavior—Substance Abuse
“CBST is but one theoretically coherent treatment that can complement other treatments (Longabaugh & Morgenstern,
improve the outcome of alcohol-dependent patients” and 1999). Van Horn and Frank (1998) suggest that,at least in the
may still be “possibly superior to other approaches under area of cocaine addiction treatment, there should be greater
certain circumstances” such as certain treatment phases, in efforts to “bridge the gap”between clinicians and researchers
high-risk situations,or with certain patients. “both to evaluate existing programs and to disseminate new
In another extensive meta-analytic review of effective approaches.” Carroll (1999) concluded that cognitive behav-
treatments for alcohol problems, Miller and colleagues ioral therapies are “well-defined approaches [that] should be a
(Miller, Wilbourne, & Hettema, 2003) found that 2 of the part of any clinician’s repertoire.”
10 treatment approaches with the greatest research support
for their efficacy were ones that are part of CBT:behavioral See also: Addictive behavior—nonsubstance abuse, Couples
self-control training and behavioral contracting. Cognitive therapy—substance abuse, Motivational interviewing, Relapse
therapy as a stand-alone treatment was 13th in the strength prevention
of evidence for its efficacy on their list of 48 well-researched
treatment approaches.
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