Chapter 24 Cognitive-Behavioral Therapies

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DOI: 10.1176/appi.books.9781585623440.353022

Textbook of Substance Abuse Treatment >

Chapter 24. Cognitive-Behavioral Therapies

COGNITIVE-BEHAVIORAL THERAPIES: INTRODUCTION

Cognitive-behavioral treatments are among the most well-defined and rigorously studied

psychotherapeutic interventions for substance use disorders. In contrast to the previous edition of

this textbook (Galanter and Kleber 2004), behavioral, cognitive-behavioral, and motivational

approaches are now covered in separate chapters, reflecting the increasing use of these strategies

in clinical practice as well as their accumulating levels of empirical support. Thus, while this

chapter will focus almost primarily on cognitive-behavioral approaches, it should be noted that

cognitive-behavioral therapy (CBT) shares several features with these other empirically supported

behavioral approaches. First, cognitive, behavioral, and motivational therapies are applicable

across a broad range of substance use disorders; that is, well-controlled trials have supported their

efficacy across alcohol-, stimulant-, marijuana-, and opioid-dependent populations. Second, these

approaches were developed from well-founded theoretical traditions with established theories and

principles of human behavior. Third, these approaches are highly flexible and can be implemented

in a wide range of clinical modalities and settings. Moreover, they are compatible with a variety of

pharmacotherapies and, in many cases, foster compliance and enhance the effects of

pharmacotherapies, including methadone, naltrexone, and disulfiram treatment. Finally, these

approaches are relatively short-term and highly focused approaches that emphasize rapid, targeted

change in substance use and related problems. In this manner, they are very compatible in a health

care environment that is increasingly influenced by managed care, best clinical practice models,

and professional accountability.

Support was provided by National Institute on Drug Abuse grants P50 DA09241, U10 DA13038 and

K05-DA00457.

THEORETICAL BASIS

Cognitive-behavioral treatments have their roots in classical behavioral theory and the pioneering

work of Pavlov, Watson, Skinner, and Bandura (see reviews by Craighead et al. 1995; Rotgers

1996). Pavlov’s work on classical conditioning demonstrated that a previously neutral stimulus

could elicit a conditioned response after being paired repeatedly with an unconditioned stimulus.

Furthermore, repeated exposure to the conditioned stimulus without the unconditioned stimulus

would eventually lead to extinction of the conditioned response. The power of classical conditioning

was demonstrated in drug abuse by Wikler (1973), who confirmed that opioid addicts exhibited

conditioned withdrawal symptoms upon exposure to drug paraphernalia. Today, classical

conditioning theory is the basis of several behavioral approaches to substance use treatment, such

as cue exposure (Childress et al. 1999; Monti et al. 1993) and stimulus avoidance as an early

component of many addiction counseling approaches.

Skinner’s work on operant conditioning demonstrated that behaviors that are positively reinforced

are likely to be exhibited more frequently. The field of behavioral pharmacology, which has

convincingly demonstrated the reinforcing properties of abused substances in both humans and

animals (Aigner and Balster 1978; Bigelow et al. 1984; Thompson and Pickens 1971), is grounded

in operant conditioning theory and principles. Behavior therapies assume that drug use and related

behaviors are learned through their association with the positively reinforcing properties of the

drugs themselves as well as their secondary association with other environmental stimuli. CBT

attempts to disrupt this learned association between drug-related cues or stimuli and drug craving

or use by understanding and changing these behavior patterns. A wide range of behavioral

interventions, including those that seek to provide alternate reinforcers to drug use or reducePrint: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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reinforcing aspects of abused substances, also are based on operant conditioning theory. Examples

include the Community Reinforcement Approach (CRA) (Azrin 1976), the work of Stitzer et al.

(1993), which has demonstrated that opioid-addicted individuals receiving methadone maintenance

treatment will reduce illicit drug use when incentives such as take-home methadone are offered for

abstinence, as well as contingency management voucher incentive systems (Budney and Higgins

1998; Higgins et al. 1991).

CBT conceives substance abuse as a complex, multidetermined behavior, with a number of

influences playing a role in the development or perpetuation of the disorder. These may include

family history and genetic factors; the presence of comorbid psychopathology; personality traits

such as sensation seeking or sociopathy; and a host of environmental factors, including substance

availability and lack of countervailing influences and rewards. Though CBT primarily emphasizes

the reinforcing properties of substances as central to the acquisition and maintenance of substance

abuse and dependence, these etiological influences are seen as heightening risk for or vulnerability

to the development of substance use problems. For example, some individuals may find substances

unusually highly rewarding secondary to genetic vulnerability, comorbid depression, a high need

for sensation seeking, and modeling of family and friends who use substances or environments

devoid of alternative reinforcers (Carroll 1999).

Cognitive-behavioral treatments also reflect the pioneering work of Ellis and Beck that emphasizes

the importance of an individual’s thoughts and feelings as determinants of behavior. CBT evolved in

part from dissatisfaction with the extreme positions of radical behaviorism (i.e., emphasis on overt

behaviors) and classical psychoanalysis (i.e., emphasis on unconscious conflicts or

representations). CBT emphasizes how the individual perceives and interprets life events as

important determinants of behavior (Meichenbaum 1995). An individual’s conscious thoughts,

feelings, and expectancies mediate his or her response to the environment. A key concept in CBT is

reciprocal determinism, which emphasizes the interdependence of cognitive, affective, and

behavioral processes. CBT also seeks to help patients become aware of maladaptive cognitions and

“teach them how to notice, catch, monitor, and interrupt the cognitive-affective-behavioral chains

and to produce more adaptive coping responses” (Meichenbaum 1995, p. 147).

EMPIRICAL SUPPORT

CBT has been shown to be effective across a wide range of substance use disorders (Carroll 1996;

Irvin et al. 1999), including alcohol dependence (Miller and Wilbourne 2002; Morgenstern and

Longabaugh 2000), marijuana dependence (MTP Research Group 2004; Stephens et al. 2000),

cocaine dependence (Carroll et al. 1994a; Carroll et al. 1998; McKay et al. 1997; Rohsenow et al.

2000), and nicotine dependence (Fiore et al. 1994; Hall et al. 1998; Patten et al. 1998). CBT has

also been shown to be compatible with a number of other treatment approaches, including

pharmacotherapy (Anton et al. 1999; O’Malley et al. 1992) and traditional counseling approaches

(Morgenstern et al. 2001), and thus can be implemented in a wide range of settings. These findings

are consistent with evidence supporting the effectiveness of CBT across a number of other

psychiatric disorders as well, including depression, anxiety disorders, and eating disorders

(DeRubeis and Crits-Christoph 1998; Roth and Fonagy 2005).

For the past 15 years, my group at Yale has been involved in a programmatic series of studies on

the effectiveness of CBT alone and in combination with pharmacotherapy. As our understanding of

CBT has deepened over time, this series of studies has been marked by progressively larger effect

sizes for CBT than for the control conditions. We believe this suggests that as our experience grows

with this approach, we are developing a more potent form of CBT. For example, in our first

randomized trial, we conducted a direct comparison of CBT with another active therapy,

interpersonal psychotherapy (IPT; Rounsaville et al. 1985), adapted for cocaine users. Although

CBT was not found to have a main effect over IPT in that trial, it was significantly more effective

among the more severely dependent cocaine abusers (Carroll et al. 1991), suggesting that the

higher levels of structure and emphasis on skills may have been particularly helpful for the more

severely impaired cocaine users.Print: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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Severity of cocaine dependence as a moderator of CBT effects was also replicated in our next study

(Carroll et al. 1994a), which used a two-by-two factorial design, in which desipramine was

compared with placebo and CBT was compared to supportive clinical management, a supportive

psychotherapy control condition. This study was also the first to describe the “sleeper effect”

phenomenon: after the study treatments were terminated, those who had been assigned to CBT

continued to reduce the frequency of their cocaine use throughout the following year (Carroll et al.

1994b). Evidence of continued improvement associated with CBT in turn led to increasing interest

in mechanisms that might underlie this effect, with skills training and behavioral practice through

homework assignments as prime candidates, as described in more detail in later sections of this

chapter.

In our next study, which was the first to report a significant main effect for CBT over supportive

clinical management (Carroll et al. 1998) and which replicated the sleeper effect for CBT over a

1-year follow-up (Carroll et al. 2000a), we evaluated the acquisition of coping skills in CBT and

their relationship to outcome. We developed and validated a role-play task for assessing the

acquisition of coping skills in CBT (Carroll et al. 1999) that involved the patient listening to a series

of audiotaped high-risk situations (e.g., “What would you do if you found yourself at a party where

you didn’t think cocaine would be available, and then noticed a lot of people going in and out of a

back room?” “What would you do if you started feeling really intense craving?”). The patient’s

responses were audiotaped and then rated for quality of response, type of coping response, and

number of responses generated using a rating method demonstrated to be highly reliable. In this

study, evaluation of the role-play task demonstrated the following: 1) coping skills increased

significantly after CBT; 2) patients demonstrated increases in coping skills that were parallel to

those taught in the treatment to which they had been assigned (i.e., differential acquisition of

specific behavioral and cognitive coping strategies in CBT with respect to alternative behavioral

therapies); and finally 3) greater acquisition of CBT-specific behavioral and cognitive coping skills

was associated with significantly less cocaine use over the 1-year follow-up (Carroll et al. 2000a).

In our most recently completed trial (Carroll et al. 2004), 121 cocaine-dependent individuals were

randomized to one of four conditions in a two-by-two factorial design: 250 mg/day of disulfiram

plus CBT; disulfiram plus IPT; placebo plus CBT; and placebo plus IPT. Across outcome measures

and for the full intention-to-treat sample (as well as across all subsamples including treatment

initiators and treatment completers), patients assigned to CBT reduced their cocaine use

significantly more than those assigned to IPT, and patients assigned to disulfiram reduced their

cocaine use significantly more than those assigned to placebo. Effects of CBT plus placebo were

comparable to those of the CBT-disulfiram combination. This was our first trial to identify a

significant main effect for CBT over another active behavioral therapy (IPT). Furthermore, although

retention was a significant predictor of better drug use outcomes, the CBT by time effect remained

statistically significant after controlling for retention.

This series of trials has demonstrated increasingly strong effects for CBT over time, and our

follow-up studies have consistently indicated high durability of CBT compared with other

approaches. Similar results have been found by other research groups evaluating CBT across a

range of substance use disorders; these will be briefly reviewed in the sections that follow.

Cocaine Dependence

Maude-Griffin et al. (1998) randomized 128 cocaine users to either CBT or 12-step facilitation

(TSF), a manualized disease model counseling approach (Nowinski et al. 1992), in order to test

several a priori matching hypotheses. Treatment was delivered in both group and individual

sessions and results suggested that CBT was more effective than TSF overall. In addition, several

matching hypotheses were supported; for example, CBT was differentially effective for individuals

with a history of depression, while TSF was more effective for participants with low levels of

abstract reasoning skills.

Monti et al. (1997) evaluated the effectiveness of adding individual sessions of coping skills

training to treatment for 128 cocaine users who were enrolled in an inpatient program or anPrint: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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intensive partial hospitalization program. Compared with an attention placebo control condition

(manualized meditation relaxation training), CBT was more effective in reducing the frequency of

cocaine use and length of relapse episodes (when they occurred) through a 3-month follow-up. A

9-month follow-up study indicated that treatment effects on cocaine use were sustained through 6

months.

McKay et al. (1997) evaluated the effectiveness of individualized relapse prevention as continuing

care following completion of an intensive outpatient program. Ninety-eight cocaine-dependent

patients were randomly assigned to either standard group counseling or relapse prevention. At the

end of the 6-month trial, rates of complete abstinence were higher in the standard counseling

condition than in relapse prevention, but for those who relapsed, the relapse prevention condition

was associated with less severe relapses, particularly during the earlier months of the intervention.

McKay et al. (1997) also evaluated a series of matching hypotheses with this group, and found that

relapse prevention was associated with better outcomes for those individuals who did not maintain

stable abstinence during the initial intensive outpatient program as well as for those individuals

whose initial treatment goal was total abstinence. The latter effect was sustained through a 2-year

follow-up (McKay et al. 1999).

Another particularly exciting development in the field of treatment of drug dependence has been

the very strong empirical support for contingency management (CM) approaches, in which

participants receive incentives (e.g., vouchers redeemable for goods and services, chances to draw

prizes from a bowl) that are contingent on demonstrating acquisition of treatment goals (e.g.,

submitting drug-free urine specimens, attending treatment sessions) (Higgins et al. 1991, 1994,

2003; Petry and Martin 2002; Silverman et al. 1996). Given that CM has strong immediate effects

that tend to weaken after the contingencies are terminated, whereas CBT tends to have more

modest effects initially but is comparatively durable, several investigators have begun to evaluate

various combinations of CBT and CM, reasoning that the relative strengths and weaknesses of these

may be offset by combining them. For example, Rawson et al. (2002) recently compared group CBT,

voucher CM, and a CBT-CM combination in conjunction with standard methadone maintenance

treatment for cocaine-using methadone maintenance patients. During the acute phase of

treatment, the group assigned to CM had significantly better cocaine use outcomes. However,

during the follow-up period, a CBT sleeper effect emerged again, where the group assigned to CBT

essentially caught up to the other groups by the 52-week follow-up. Similar results were found for

a parallel study conducted among a large sample (N = 171) of stimulant-dependent individuals

treated as outpatients (Rawson et al. 2006), in which CM was associated with better retention and

substance use outcomes during treatment, but outcomes for CBT and CM were comparable at 1

year.

Epstein et al. (2003) conducted a similar study, again in the context of intensive methadone

maintenance, in which participants were offered CM, group CBT, or a combination of the two, in

addition to standard individual counseling. Results were largely parallel to the Rawson study in that

the investigators reported large initial effects for CM, with a drop-off after the termination of the

contingencies, and best 1-year outcomes for the CBT-CM combination.

Alcohol Dependence

There is a very extensive and strong literature on the efficacy of CBT with alcohol use disorders

(Irvin et al. 1999; Marlatt and Donovan 2005; Miller and Wilbourne 2002; Miller et al. 1995;

Morgenstern and Longabaugh 2000) and hence the review below will be rather selective,

highlighting just a few of the landmark studies in this area. In one of the earliest studies of CBT,

Chaney et al. (1978) evaluated a CBT skills training approach as compared with a discussion control

and no treatment condition for 40 alcohol-dependent inpatients. The CBT approach was associated

with significant treatment effects for several, but not all, alcohol outcomes evaluated at a 1-year

follow-up. Significant differences in acquisition of coping skills were seen posttreatment for groups

receiving CBT versus the control group and groups receiving no treatment, with some degradation

of skills seen at follow-up.Print: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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Once the efficacy of CBT was established, several investigators began to evaluate what type of

individual might have better or poorer response to CBT as compared with other treatments. Kadden

et al. (1989) compared a cognitive-behavioral coping skills approach with an interactional approach

for 96 alcohol aftercare patients. This was explicitly a matching study, rather than a main effects

“horse race” study. Thus, no main effects of study treatments were seen, but several of the

investigators’ a priori matching hypotheses were confirmed. That is, participants higher in

sociopathy had better outcome (as measured by abstinent days or heavy drinking days) when

treated with CBT, and patients lower in sociopathy had better outcome when treated with the

interactional approach. For patients higher in psychopathology, CBT was superior. For patients

higher in neuropsychological impairment, the interactional therapy was superior. A 2-year

follow-up showed the matching effects were durable (Cooney et al. 1991).

CBT was also evaluated in Project MATCH, a very large multisite trial that sought to identify

patient–treatment matches for three individual therapies in a large sample of alcohol-dependent

individuals (Project MATCH Research Group 1993). Although drinking outcomes were fairly good

and sustained across all conditions, CBT was not associated with improved drinking outcomes with

respect to the two treatments to which it was compared, TSF and motivational enhancement

therapy (MET) (Project MATCH Research Group 1998a, 1998b). Furthermore, the multiple a priori

hypotheses regarding the types of individuals who might respond better to CBT compared with TSF

and MET were largely not supported. These findings, and the very sparse literature on support for

mechanisms of action of CBT and other therapies (Morgenstern and Longabaugh 2000), have

underlined both the need for more careful study of potential active ingredients of CBT as well as

common factors associated with outcome (Longabaugh et al. 2005).

Several investigators have also evaluated CBT in combination with the newly available medications

for alcohol abuse and dependence. O’Malley et al. (1992) compared coping skills therapy, which

included CBT skills, with supportive therapy in a two-by-two factorial design that also evaluated

naltrexone versus placebo, for 97 alcohol-dependent patients. Naltrexone was found to be superior

to placebo on several drinking-related outcomes, but significant main effects for the psychotherapy

condition were not seen. However, there were significant psychotherapy–pharmacotherapy

interactions, with the highest rates of complete abstinence seen in subjects who received the

naltrexone–supportive therapy condition. However, significantly fewer drinks per day and fewer

drinks per drinking occasion were reported for subjects who received the naltrexone–coping skills

condition. A 6-month follow-up also indicated that subjects who had received the

naltrexone–coping skills treatment were least likely to relapse, and once again, participants

assigned to the CBT/placebo caught up to the other groups by the end of the follow-up in terms of

reducing alcohol use (O’Malley et al. 1996).

Marijuana Dependence

Despite increased demand for effective interventions for marijuana dependence, only a few

randomized clinical trials evaluating well-defined treatments for individuals with a primary problem

of marijuana dependence have been conducted to date, virtually all of which have included a CBT

component. Stephens et al.’s (1994) comparison of a CBT group to a social support interactional

group for 212 marijuana-dependent adults suggested that although both treatments were

associated with significant and sustained reductions in reported marijuana use, there were no

significant effects by treatment condition. The Marijuana Treatment Project, a large multisite trial,

randomized 450 adult marijuana-dependent individuals to a nine-session individual treatment that

combined motivational interviewing and CBT, a two-session motivational intervention, or a

delayed-treatment control condition. Participants assigned to the nine-session CBT intervention

reduced their frequency of marijuana use and associated consequences significantly more than

those assigned to the two-session intervention. Moreover, both interventions were associated with

significantly greater reductions in marijuana use compared with the delayed-treatment control

condition (MTP Research Group 2004; Stephens et al. 2002). Our group has also had very good

results and has again seen continuing improvement associated with CBT by combining CBT and CM

as a treatment strategy for young marijuana users involved with the criminal justice systemPrint: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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(Carroll et al. 2006).

Individual Versus Group CBT

Two trials have directly compared the delivery of relapse prevention in individual versus group

format. Schmitz et al. (1997) compared outcomes following 12 sessions of either group or

individually delivered relapse prevention as aftercare among 32 cocaine-dependent individuals

after hospitalization. No significant differences were found in outcome through a 6-month

follow-up. Given the small sample size, it should be noted that the groups were also small (3–7

members) and thus may have offered fairly substantial individual attention. In a larger study

involving 155 both alcohol- and drug-using individuals, Marques and Formigoni (2001) also found

no differences in outcome for group versus individually delivered CBT. While preliminary, these

studies suggest that CBT can be effectively implemented in either group or individual formats.

COGNITIVE-BEHAVIORAL TECHNIQUES AND STRATEGIES

Specific techniques vary widely with the type of cognitive-behavioral treatment used, and there are

a variety of manuals, protocols, and training programs available that describe the techniques

associated with each approach (Annis and Davis 1989; Carroll 1998; Kadden et al. 1992; Marlatt

and Gordon 1985; Monti et al. 1989). Very simply put, however, most CBT approaches attempt to

help individuals recognize the situations in which they are most likely to use, avoid those situations

when appropriate, and cope more effectively with a range of problems and problematic behaviors

associated with substance use by implementing a range of cognitive and behavioral coping

strategies.

Defining Features of CBT

Two key defining features of most cognitive-behavioral approaches for substance use disorders are

1) an emphasis on functional analysis of drug use (that is, understanding drug use with respect to

its antecedents and consequences); and 2) emphasis on skills training. Cognitive-behavioral

approaches involve a range of skills necessary to foster or maintain abstinence. These typically

include strategies for 1) understanding the patterns that maintain drug use and developing

strategies for changing these patterns (this often involves self-monitoring of thoughts and

behaviors that take place before, during, and after high-risk situations or episodes of drug use); 2)

fostering the resolution to stop substance use through exploring positive and negative

consequences of continued use (also known as the decisional balance technique); 3) understanding

craving and craving cues and developing skills for coping with craving when it occurs (these

include a variety of affect regulation strategies, such as distraction, talking through a craving,

“urge surfing” and so on); 4) recognizing and challenging the cognitions that accompany and

maintain patterns of substance use; 5) increasing awareness of the consequences of even small

decisions (e.g., which route to take home from work) and the identification of seemingly irrelevant

decisions that can culminate in high-risk situations; 6) development of problem-solving skills and

practicing the application of those skills to substance-related and more general problems; 7)

planning for emergencies and unexpected problems and situations that can lead to high-risk

situations; and 8) developing skills for assertively refusing offers of drugs, as well as reducing

exposure to drugs and drug-related cues.

These basic skills are useful in their application to helping patients control and stop substance use,

but it is essential that therapists also point out how these same skills can be applied to a range of

other problems. For example, functional analysis can be used to understand the determinants of a

wide range of behavior patterns; skills used to cope with craving can easily be applied to other

aspects of affect control; the principles used in the sessions on seemingly irrelevant decisions can

easily be adapted to understanding a wide range of behavior chains; and substance use refusal

skills can easily be transferred to more effective and assertive responding in a number of

situations. We think it is essential that therapists who teach coping skills emphasize and

demonstrate that those skills can be applied immediately to control substance use and also can be

used as general strategies across a wide range of situations and problems the patient mayPrint: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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encounter in the future.

Broad-spectrum cognitive-behavioral approaches, such as those described by Monti et al. (1989)

and adapted for use in Project MATCH (Kadden et al. 1992), expand to include interventions

directed to other problems in the individual’s life that are seen as functionally related to substance

use. These interventions may include general problem-solving skills, assertiveness training,

strategies for coping with negative affect, awareness of anger and anger management, coping with

criticism, increasing pleasant activities, enhancing social support networks, and job-seeking skills,

among others (Carroll 1999).

In comparison to many other behavioral approaches, CBT is typically highly structured. That is, CBT

is generally brief (12–24 weeks) and organized closely around well-specified treatment goals. An

articulated agenda usually exists for each session and the clinical discussion remains focused

around issues directly related to substance use. The therapist takes an active stance throughout

treatment, and progress toward treatment goals is monitored closely and often, with frequent

testing for substance use through urine toxicology screens. Generally sessions take place within a

weekly scheduled therapy hour, and in broad-spectrum cognitive-behavioral approaches, they often

are organized roughly in thirds (the 20/20/20 rule). The first third of the session is devoted to the

assessment of the patient’s substance use and general functioning in the past week and a report of

current concerns and problems. The second third is more didactic and devoted to skills training and

practice. The final third allows time for the therapist and the patient to plan for the week ahead and

discuss how new skills will be implemented (Carroll 1998). The therapeutic relationship is seen as

principally collaborative. Thus, the role of the therapist is one of consultant, educator, and guide

who can lead the patient through a functional analysis of his or her substance use, aid in identifying

and prioritizing target behaviors, and consult in selecting and implementing strategies to foster the

desired behavioral changes.

While structured and didactic, CBT is a highly individualized and flexible treatment. That is, rather

than viewing CBT treatment as cookbook psychoeducation, the therapist carefully matches the

content, timing, and nature of presentation of the material to the individual patient. The therapist

attempts to provide skills training at the moments the patient is most in need of them. That is, the

therapist does not belabor topics such as breaking ties with cocaine suppliers with a patient who is

highly motivated and has been abstinent for several weeks. Similarly, the therapist does not race

through material in an attempt to cover all of it in a few weeks; for some patients, it may take

several weeks to master a basic skill.

Extra-Session Practice as a Possible Mediator of CBT

In CBT, therapists encourage patients to practice new skills; such practice is a central and essential

component of treatment. The degree to which the treatment is a skills training over merely a skills

exposure approach has to do with the degree to which there is opportunity to practice and

implement coping skills, making extra-session practice and homework all the more important. It is

critical that patients have opportunities to try out new skills within the supportive context of

treatment. Through first-hand experience, patients can learn what new approaches work or do not

work for them, where they have difficulty or problems, and so on. There are many opportunities for

practice within CBT, both during sessions and outside of them. During each session, there are

opportunities for patients to rehearse and review ideas, raise concerns, and get feedback from the

therapist.

As noted earlier, there has been growing interest in understanding not only which treatments work,

but how they work. Understanding the mechanisms of action of CBT and other empirically validated

therapies has heretofore received very little attention in the literature (Kraemer et al. 2002;

Morgenstern and Longabaugh 2000; Weisz et al. 2000), although it is an area of great importance.

Understanding treatment mechanisms can not only advance the development of more effective

treatment strategies but also result in more powerful, efficient, and ultimately less expensive

treatments (Kraemer et al. 2002; Wilson et al. 2002).Print: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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The converging evidence suggesting that CBT is a particularly durable approach has led to

increased focus on unique or distinctive aspects of CBT that might account for its durability.

Encouraging clients to implement and practice skills outside of sessions through homework

assignments is one possible mechanism for this effect (Beck et al. 1979; Edelman and Chambliss

1995; Primakoff et al. 1986) and emphasis on extra-session practice assignments is a unique

feature of CBT (Blagys and Hilsenroth 2002). Moreover, investigators evaluating CBT in

nonsubstance psychiatric disorders have noted the importance of homework in CBT’s effectiveness.

Some recent work suggests that homework compliance may have a causal effect on symptom

reduction in CBT for depression (Addis and Jacobson 2000; Burns and Spangler 2000) and that

ratings of the quality of the patient’s homework predict outcome in CBT for panic disorder (Schmidt

and Woolaway-Bickel 2000).

The relationship of homework compliance, skills acquisition, and outcome in CBT has received very

little attention in the substance abuse literature. Thus, in a recent trial (Carroll et al. 2005), we

evaluated homework completion in detail, collecting data on the specific type of homework

assigned and how well it was done (e.g., fully, partially, no attempt made) at every session. We

found strong relationships between homework compliance and outcome. Compared with the

participants assigned to CBT who did not do homework or who did it only rarely, the participants

who did homework consistently stayed in treatment significantly longer, had more consecutive

days of cocaine abstinence (a strong predictor of long-term outcome [Carroll et al. 1994b; Higgins

et al. 2000]), had significantly more days of abstinence, and had fewer cocaine-positive urine

screens during treatment. Similar effects were found for the subset of participants who completed

treatment in this study, suggesting that the effects of homework compliance on better substance

use outcomes were not completely accounted for by differential retention. In addition, we found

strong relationships between homework compliance and acquisition of coping skills, as well as

between homework completion and participants’ ratings of their confidence in avoiding use in a

variety of high-risk situations. Participants who completed homework had significant increases

over time in their self-reported confidence in handling a variety of high-risk situations, while scores

for the subgroup that did not do homework did not change over time. These findings have been

partially supported by other groups (Gonzalez et al. 2006).

Farabee et al. (2002) evaluated the extent to which cocaine users reported engaging in a series of

specific drug avoidance activities (e.g., avoiding drug-using friends and places where cocaine

would be available, exercising, using thought-stopping) after CBT as compared with alternative

treatments (e.g., CM and a control condition). They found that, by the end of treatment,

participants assigned to CBT reported more frequent engagement in drug avoidance activities than

participants in the comparison treatments. Furthermore, the frequency of drug avoidance activities

was strongly related to better cocaine use outcomes throughout the 1-year follow-up. Taken

together, these two studies suggest that CBT interventions that foster the patients’ engagement in

active behavioral change may play a key role in CBT’s comparative durability and should be

pursued in future research.

TRAINING AND COMPETENCE IN CBT

The growing evidence base for CBT and the increased emphasis on incorporating empirically

supported therapies into clinical practice have also led to greater focus on training and

dissemination. Although standard methods, such as intensive didactic workshop training plus

structured feedback on supervised training cases, used to train clinicians to use CBT in clinical

efficacy trials have generally been associated with high levels of treatment fidelity and

comparatively small levels of variation in treatment delivery (Carroll 1998; Crits-Christoph 1998),

these methods have not been empirically evaluated, nor are they commonly used to train clinicians

to use novel approaches (Weissman et al. 2006).

Thus, we have initiated a series of studies systematically evaluating different training strategies for

clinicians wishing to learn empirically supported therapies such as CBT by randomizing clinicians

working full-time in substance abuse treatment facilities to different training conditions. In ourPrint: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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initial study of CBT training methods (Sholomskas et al. 2005), 78 clinicians were assigned to one

of three training conditions: 1) review of the National Institute on Drug Abuse (NIDA) CBT manual

only (Carroll 1998); 2) access to a Web-based training site (which included additional frequently

asked questions, role plays, and practice exercises) plus the NIDA CBT manual; or 3) a 3-day

didactic seminar plus up to three sessions of supervision from a CBT expert trainer based on actual

session tapes submitted by the participants. Outcomes focused on clinician behavior and included

between-group comparisons of the clinicians’ ability to demonstrate key CBT techniques based on

structured role-plays administered before and after training and scores on a CBT knowledge quiz.

The videotaped role-plays were scored by independent raters, blind to the participants’ training

condition as well as time (e.g., pre- versus posttraining), and based on adherence/competence

ratings of specific CBT techniques from the Yale Adherence and Competence Scale (YACS) (Carroll

et al. 2000b). Although all groups demonstrated improved adherence and competence scores over

time, the only training condition that reached levels of skill consistent with those required of

clinicians participating in our CBT efficacy trials was the seminar-plus-supervision condition, with

intermediate ratings for the Web condition. The mean effect size for the seminar-plus-supervision

condition compared with the manual-only condition was consistent with a large effect (.69), while

the average effect size for the Web condition as compared with the manual only condition was

consistent with a medium size effect (0.30). In addition, as shown in Figure 24–1, the seminar plus

supervision condition was associated with significantly more clinicians reaching criterion levels for

adequate fidelity than those assigned to the manual-only condition (54% versus 15%).

FIGURE 24–1. Percentage of clinicians trained to criterion, by training condition.

These findings underscore the idea that merely making manuals available to clinicians has little

enduring effect on clinicians’ ability to implement new treatments. This has important implications

for current efforts to disseminate new treatments. Our findings suggest that face-to-face training

followed by direct supervision and credentialing may be essential for effective technology transfer

and may raise questions regarding whether practitioners should feel competent (from an ethical

perspective) to administer an empirically supported treatment on the basis of reading a manual

alone. Finally, the findings suggest that standard strategies used to train clinicians in clinical trials

can be effective for community-based clinicians and may be pursued as a strategy for future

dissemination trials and bridging the gap between research and practice (Carroll and Rounsaville

2007).

LIMITATIONS OF CBT

Despite CBT’s emerging empirical support, future research is needed to address its limitations. CBT

is a relatively complex approach in that it is comparatively complicated to train clinicians to use

this approach or to implement it effectively in clinical practice. Potential strategies for addressing

these issues include greater emphasis on understanding CBT’s mechanisms of action, so that

ineffective components of CBT can be removed and treatment delivery simplified and shortened,Print: Chapter 24. Cognitive-Behavioral Therapies http://www.psychiatryonline.com/popup.aspx?aID=353028&print=yes…

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and perhaps even automated via delivery by computer or other means (Carroll and Rounsaville

2007).

Another relative weakness of CBT may be the cognitive demands it places on patients, in that they

are asked to learn a range of new concepts and skills, including monitoring and remembering

cognitions and inner states, implementing new skills while in stressful situations, and so on. Recent

data suggest that substance users with higher levels of cognitive impairment may have poorer

outcome in CBT than those who are less impaired (Aharonovich et al. 2003; Kadden et al. 1989).

This suggests that clinicians should monitor the cognitive skills of their patients, and in cases

where the patients may have memory, attention, or impulse control problems, clinicians should

adapt the implementation of CBT accordingly, with slower progression through concepts, frequent

repetition of material and checking back with the patient to assess understanding, and providing

more structure on extra-session assignments.

SUMMARY

CBT is an empirically supported behavioral approach that has strong theoretical and empirical

support with a variety of substance-abusing populations. In recent years, clinical researchers have

emphasized moving these approaches more broadly into the clinical community, and thus a range

of practical resources (e.g., books, videotapes, manuals, training resources and programs) for

implementing them effectively in clinical practice are available. Moreover, these approaches can be

combined and integrated effectively with a range of other empirically supported behavioral

therapies (Barrowclough et al. 2001; Budney et al. 2000) as well as pharmacotherapies. Thus, they

should be a component of all substance abuse clinicians’ repertoire.

KEY POINTS

Cognitive-behavioral therapy (CBT) has strong empirical support across a range of different substance use

disorders as well as psychiatric syndromes that frequently co-occur with substance use disorders (e.g.,

depression, anxiety).

CBT is highly compatible with available pharmacotherapies for addiction, and recent evidence suggests it

can be delivered in a range of formats and settings.

Key components of virtually all CBT approaches include functional analyses of substance use and

individualized skills training with emphasis on cognitive and behavioral coping.

Effects of CBT appear to be comparatively durable, with several studies reporting continuing improvement

after patients leave treatment. Emphasis on skills training and practice may underlie this effect.

A variety of manuals, videotapes, and other training materials for CBT may be available. However,

specialized coaching and feedback, with structured supervision, may be needed for many clinicians to

implement CBT effectively.

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SUGGESTED READING

Marlatt GA, Donovan D: Relapse Prevention: Maintenance Strategies in the Treatment of Addictions, 2nd

Edition. New York, Guilford, 2005

Marlatt GA, Gordon JR: Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors.

New York, Guilford, 1985

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