Non-Pharmacological Treatment Approaches for Substance Abuse Part II: Behavioral and Cognitive- Behavioral Interventions

Non-Pharmacological Treatment Approaches for Substance Abuse

Part II: Behavioral and Cognitive-Behavioral Interventions

Behavioral/Cognitive-Behavioral Interventions

• This is a broad range of interventions.– Strictly behavioral, e.g. contingency

management– Extinction paradigms– Relapse prevention– Coping skills training– Community reinforcement – Purely cognitive approaches

Behavioral/Cognitive-Behavioral Interventions

• All of these models have their basis in learning principles

• Fundamental assumptions of these approaches (Rotgers, 1996):

Assumptions

1. Human behavior is largely learned.2. The same learning processes that create

problem behaviors can be used to change them.

3. Behavior is largely determined by environmental and contextual factors

4. “Covert behaviors” such as thoughts and feelings can be changed using learning principles.

Assumptions

5. Actually engaging in new behaviors in the contexts in which they are to be performed is a critical part of behavior change.

6. Each client is unique and must be assessed as an individual in a particular context.

7. The cornerstone of adequate treatment is a thorough behavioral assessment.

Behavioral/CBTEtiology of Dependence

• Operant factors play role in maintenance of abuse/dependence, through positive reinforcing aspects of the substance, plus avoidance of withdrawal symptoms (negative reinforcement).

• Classical conditioning plays role in development of conditioned craving to triggers.

• Cognitive factors, such as expectancies of substance effects, are important in maintaining dependence.

Behavioral/CBTEtiology of Dependence

• As person responds to environmental, interpersonal, and intrapersonal challenges with substance use, continued use becomes an overused, overgeneralized, and maladaptive coping strategy.

• By the time they seek treatment, person may have few other coping mechanisms left in their repertoire.

Behavioral/CBTAssessment

• Behavioral and CBT approaches based on a thorough behavioral assessment, often using a functional analysis.

• Early in treatment, functional analysis crucial in helping patient and clinician assess determinants of use, prioritize problems, set treatment goals, select type of interventions, monitor treatment progress.

Behavioral/CBTAssessment

Questions to answer in assessment:1. What are the determinants of this person’s

substance use (social, environmental, physical, emotional, cognitive)?

2. What skills or resources does the patient lack, and what concurrent problems may be obstacles to treatment?

3. What skills and strengths does the patient have?

Behavioral/CBTTreatment Goals

• In behavioral approaches– Treatment goals are highly focused and depend

on specific approach.– Example: cue exposure and extinction

approaches work primarily on reducing reactivity to specific cues and may not affect other substance-related problems.

– For instance, conditioned response to drug paraphernalia is extinguished, but what about that freeway exit sign that leads to the dealer’s house?


• In cognitive-behavioral approaches– Treatment goals tend to be broader than in

strictly behavioral approaches.– May target improved social skills, reduced

psychiatric symptoms, reduced social isolation, reentry into workforce, etc. in addition to reducing/stopping substance use.


Cognitive treatment approaches (Beck et al. 1991) focus on:

• identifying and modifying drug-related beliefs;

• reattribution of responsibility; • thought-stopping; • modifying black-and-white or catastrophic

thinking.

Behavioral/CBTStructure of Therapy Sessions

• Progress toward treatment goals is monitored closely and frequently

• Therapist is active and fairly directive• Sessions often organized by the 20/20/20 rule

(Carroll 1998) :– 20 minutes on assessment of general functioning in the

past week, report of current concerns/problems– 20 minutes on skills training and practice (fairly didactic)– 20 minutes to plan for the following week and discuss

implementation of new skills/homework

CBT Approaches

Cog-B approaches:– Develop strategies for reducing availability and

exposure to substance and related cues– Build motivation by discussing positive and

negative consequences of continued use– Self-monitoring to identify high-risk situations

and conduct functional analyses of use– Identification of seemingly irrelevant decisions

which can culminate in high-risk situations– Confronting thoughts about using

CBT Approaches

• Many cog-b approaches expand to address:– Other problems that are seen to be functionally

related to substance use– General problem-solving skills– Assertiveness training– Strategies for coping with negative affect– Awareness of anger and anger management– Coping with criticism– Increasing pleasant activities/relaxation time

Behavioral/CBTActive Ingredients

• As with any treatment approach for any disorder, what are the necessary and sufficient factors for a treatment to be effective?

• These approaches for substance abuse treatment thought to depend to a large extent on the effective use of common factors, as well as “unique” factors.

Behavioral/CBT Active Ingredients

• Common factors (Castonguay 1993)– Education about the nature of the disorder– Persuasive therapeutic rationale– Expectations of improvement– Skills of therapist– Quality of therapeutic relationship

Behavioral/CBT Active Ingredients

• Unique “active ingredients”– Cognitive-behavioral approaches – skills

acquisition and implementation– Cognitive therapies – identification and

modification of dysfunctional thoughts and beliefs

– Cue exposure therapies – active ingredient for extinction is repeated exposure to the conditioned stimulus under conditions incompatible with use.

Behavioral Interventions

• Interventions have roots in work of Pavlov, Skinner, and Bandura.– Classical conditioning– Operant conditioning– Social learning/modeling


• Behavioral pharmacology based on operant conditioning: positively/negatively reinforcing properties of abused substances

• Wide range of interventions based on operant conditioning, including contingency management, Community Reinforcement Approach, and range of interventions with methadone-maintained patients.


• Aversive counterconditioning based on classical conditioning.– Pair aversive experience (electric shock,

induced nausea, negative images) with drinking or alcohol-related stimulus. Goal to make drinking a negative experience.

– Well-controlled trials of effectiveness of aversive counterconditioning are infrequent.


• Cue exposure – develop hierarchy of cues that are triggers for use, then expose patient to them in lab or other controlled setting (very similar to systematic desensitization for anxiety disorders) where they do not have the option of using.


• Operant techniques include application of positive incentives for desired behaviors (e.g. abstinence) and negative incentives for undesired behaviors.

• One example is Contingency Management work by Steven Higgins and colleagues with cocaine abusers

Contingency Management

Higgins Contingency Management approach (Higgins et al 1991; Higgins & Budney 1993)

4 principles: 1. Drug use and abstinence must be swiftly and

accurately detected;

2. Abstinence is positively reinforced;

3. Drug use results in loss of reinforcement;

4. Emphasis on development of reinforcers that compete with reinforcers of drug use.


– Urine specimens required 3x/week– Abstinence (measured by urinalysis) reinforced

with a voucher system– Patients receive points redeemable for items

consistent with a drug-free lifestyle, such as movie tickets, grocery vouchers, sporting goods (not cash, for obvious reasons!)


– To encourage longer periods of abstinence, value of points earned increases with each consecutive clean UA, and value of points is reset to original level after a relapse or no-show to treatment.

– Often pts receive a bonus for every 3 consecutive clean urine samples.

– Approach demonstrated to be very effective with cocaine users through studies throughout the 1990’s.

Cognitive-Behavioral Interventions

• CBT grounded in work of Ellis and Beck, emphasizes importance of client’s thoughts and feelings as determinants of behavior.

• Evolved partly out of dissatisfaction with strictly behavioral approaches.

• Among most widely used treatments for mental health disorders other than substance abuse.


CBT– Thoughts, feelings, and expectancies mediate

person’s response to the environment. – Key concept is reciprocal determinism:

interdependence of cognitive, affective, and behavioral processes (Meichenbaum 1995).

– Teach pts the cognitive triad.


• Goal of tx is to teach patients how to “notice, catch, monitor, and interrupt the cognitive-affective-behavioral chains and produce more adaptive coping responses” (Meichenbaum 1995, p.147).


• CBT– Example is Relapse Prevention developed by Alan

Marlatt and colleagues (Marlatt & Gordon, 1985)

– Includes identification of high-risk situations for relapse

– Instruction and rehearsal of coping strategies

– Self-monitoring and behavioral analysis of substance use

– Strategies for recognizing and coping with cravings and thoughts about using

– Planning for emergencies and coping with lapses

Relapse Prevention Overview

• Marlatt and Gordon (1985) develop and publish Relapse Prevention approach.

• Would become one of the most widely used, adapted, and researched treatment approaches for broad range of disorders, including: eating disorders, sexual deviance, depression, schizophrenia, panic disorder, OCD, chronic pain, marital distress, social competence, and stuttering.


Goals: 1. Prevent lapse or initial return to substance use

(or whatever behavior is being addressed), so that a full-blown relapse (return to problematic use) is less likely.

2. Successful management of relapse episodes if they do occur, to prevent exacerbation or continuation of substance use.


• Marlatt & Gordon’s approach originally designed as maintenance program for pts who had gone thru intensive treatment for substance use.

• Goal was to extend and enhance therapeutic gains and reduce possibility of recycling back thru tx.


• Does not view people who lapse back to substance use as tx failures who are victims of an underlying disease process.

• Instead, views lapses as errors or temporary setbacks to be expected from someone learning new coping behaviors.

• Viewed this way, lapses may provide valuable lessons in preventing future such episodes.


• Although initially developed as a maintenance program, it is now also utilized as strategy for initiation of behavior change.

• Often combined with motivational interviewing or even disease model approaches.

Relapse Prevention Theory

• “To the extent that a substance is used to cope with unpleasant situations, experiences, or emotions, the behavior may be viewed as a learned maladaptive coping strategy.”

• Strategy may be learned thru a combination of both classical and operant conditioning processes, which may not be under the individual’s control.

Relapse Prevention Theory

• A substance’s predictable efficacy in providing temporary relief to an individual who has not developed alternative ways of handling unpleasant situations or emotions may foster continued reliance on the substance as a “primitive” coping mechanism.

• May be a perceived lack of alternative coping strategies combined with low self-efficacy.

Relapse Prevention Theory of Treatment

• Essentially a self-management approach– Model considers the individual (rather than a

higher power or a group) to be the responsible agent of change.

– Approach is empowering (consider in contrast the 12-Step approach with regard to power) and trains individuals to eventually act as their own therapists with regard to managing their addictive behaviors.

Relapse Prevention Treatment

• Focus on unlearning maladaptive behaviors and learning more adaptive behaviors often utilizes metaphors. – Problem use to non-use is a journey. Journey

involves preparation, departure, taking the journey itself.

Relapse Prevention Preparing for the Journey

• Assess motivation, commitment, and self-efficacy for change.

• Address ambivalence with a decision matrix exercise (cost-benefit analysis). Assesses costs/benefits of changing and of not changing.

• Assess client’s self-image as a drinker or drug user.


• Establish therapeutic relationship with client– Clients are regarded as consulting partners, not

“patients” and are encouraged to assume shared responsibility for treatment.

– Meetings with counselor are framed as opportunities to engage in objective discovery process rather than a confessional session.

– Break down long-term goals into series of realistic sub-goals.


• Teach clients how to self-monitor their behavior, e.g. use behavioral log. Often just doing this increases motivation greatly.

• Begin to assess relapse fantasies, e.g. scenarios they fantasize about using in.

Relapse Prevention Departure

• Set a definite quit date, or date of departure.– Should be chosen so as not to coincide with stressful

life events (stormy weather) and to allow adequate time for preparation.

• Remove cues associated with use, e.g. drug paraphernalia, etc.

• Plan healthy substitute activities • Stock up on non-harmful substances • Make sure the course of the journey is well-plotted• Might set up a departure ceremony

Relapse Prevention The Journey

• Relapse rates are particularly high during 1st 3 months.– Must plan for difficult situations (flat tires,

engine problems, bad weather, etc)

• First few days are very risky for giving in to cravings or urges. – Cravings and urges are mediated by positive

outcome expectancies of the immediate effects of the substance.


• Need to assess positive outcome expectancies early in treatment.– Clients may have come to rely on a substance

to modulate mood or behavior due to their beliefs about the effects of that subject e.g. drinking to mediate social anxiety.

– Reliance on substance due to beliefs about effects rather than the actual pharmacological effects represents part of psychological dependency.


• Many clients perceive cravings to be physiologically based. – If we frame them as being a cognitively-based

desire for immediate gratification, we can then help them to find other, healthier means of gratification.

– Also teach clients to externalize their urges to use (“I’m experiencing a craving for a hit”, rather than “I need a hit”).

– Detachment allows more objectivity and more successful use of cognitive and behavioral coping strategies.


• Teach clients that cravings, like an ocean wave, will build in intensity, peak, and then subside.

• Challenge for them is to learn how to “surf” these waves without wiping out (“urge surfing”).

Relapse Prevention Lapse

• Initial lapse yields abstinence violation effect, composed of:– Cognitive dissonance: behaviors are

incongruent with self-image or core beliefs. Generates guilt.

– Negative self-attribution effect: “I’m a failure. I’ll never be able to quit.” Leads to decreased self-efficacy.

Relapse PreventionLapse

• High-risk situation: any situation that poses a threat for resumed or excessive substance use. May be:– Intrapersonal

– Interpersonal

• In analysis of >300 initial lapses to cigarettes, alcohol, heroin use, gambling, or overeating, 3 primary situations classified over 70% of episodes (Cummings et al 1980):

Relapse Prevention Lapse

• Negative emotional states (intrapersonal) such as anger, boredom, anxiety, frustration, depression accounted for 35% of relapses.

• Social pressure (direct or indirect verbal pressure) accounted for 20%.

• Interpersonal conflict (ongoing conflictual relationships or recent conflict) accounted for 16%.

Relapse Prevention Relapse

• Other lapses were due to: – Urges and temptations (8%)– Testing personal control (5%)– Positive emotional states (4%)– Negative physical states (3%)

Relapse Prevention Dealing with a Lapse

• Need to have developed a concrete, pre-planned course of action to follow in the event of a lapse. – Leave the situation, engage in another activity

as soon as possible, call particular person for help.

– Try to remain calm and not give in to feelings of guilt/self-blame. Normalize these feelings as part of the process, rather than an excuse for continuing to drink/use.


• Lapse should be debriefed/analyzed with counselor ASAP.

• Reframe lapse as a mistake but a valuable learning opportunity, rather than a failure.

• Assess attributions and cognitive distortions such as catastrophizing about the lapse.

• Stress the riskiness of the situation and inadequate coping ability rather than inadequate effort.


• Encourage client to renew commitment to the target goal.

• Explore the events leading up to the decision to use (relapse analysis). Sometimes an analysis allows recognition of a series of “minidecisions” that led up to the lapse. – These “seemingly irrelevant decisions” are usually

discounted by clients, but often represent a covert, usually unconscious setup to use.

Behavioral/CBT

Overall, contingency management and CBT have highest levels of empirical support for treatment of opioid and cocaine dependence of any treatment approaches.

Behavioral/CBT Overall Strengths/weaknesses

• Strengths:– Flexibility in meeting individual needs– Acceptability to a wide range of substance-

abusing individuals seen in clinical settings– Solid grounding in established theory– Emphasis on linking science to treatment– Well-specified tx goals and guidelines for

evaluating progress– Emphasis on building self-efficacy– Relatively strong level of empirical support


• Strengths– Many approaches are manualized and can be

applied in wide variety of settings– Can be applied with different substances– Compatible with other tx approaches such as

family therapy and pharmacotherapy


• Disadvantages– Lack of emphasis in research on importance of

isolating and evaluating the specific active ingredients associated with behavior change.

– Relative underutilization of these approaches outside academic and research settings.

– Lack of emphasis on patient motivation and specific procedures for addressing patient’s readiness to change.

– Lack of data on specific patient characteristics associated with positive treatment response.

Documents

Non-Pharmacological Treatment Approaches for Substance Abuse Part II: Behavioral and Cognitive- Behavioral Interventions