Cognitive-behavioral coping skills treatment (CBT) is a short-term, focused approach to helping substance dependent individuals become abstinent from alcohol and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of drug and alcohol abuse and dependence. These same learning processes can be used to help individuals reduce their drug use.

Very simply put, CBT attempts to help clients recognize, avoid, and cope. That is, RECOGNIZE the situations in which they are most likely to use drug and alcohol, AVOID these situations when appropriate and COPE more effectively with a range of problems and problematic behaviors associated with substance abuse.

Why CBT?

Several important features of CBT make it particularly affective as a treatment for drug and alcohol abuse and dependence:

• CBT is a short-term, comparatively brief approach.

• CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support as treatment for drug and alcohol abuse.

• CBT is structured, goal-oriented and focused on the immediate problems faced by drug and alcohol abusers who are struggling to control their drug and alcohol use.

• CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inclient, outclient) and formats (group, individual).

• CBT is compatible with a range of other treatments.

• CBT's broad approach encompasses several important common tasks of successful substance abuse treatment.

Components of CBT

CBT has two critical components:

• Functional analysis

• Skills training

Functional Analysis

For each instance of drug and alcohol use, the therapist and client do a functional analysis; that is, they identify the client's thoughts, feelings, and circumstances before and after the drug and alcohol use. Early in treatment, the functional analysis plays a critical role in helping the client and therapist assess the determinants, or high-risk situations, that are likely to lead to drug and alcohol use and provides insights into some of the reasons the individual may be using drug and alcohol (e.g., to cope with interpersonal difficulties, to experience risk or euphoria not otherwise available in the client's life). Later in treatment, functional analyses of episodes of drug and alcohol use may identify those situations or states in which the individual still has difficulty coping.

Skills Training

CBT can be thought of as a highly individualized training programme that helps drug and alcohol abusers unlearn old habits associated with drug and alcohol abuse and learn or relearn healthier skills and habits. By the time the level of substance use is severe enough to warrant treatment, clients are likely to be using drug and alcohol as their single means of coping with a wide range of interpersonal and intrapersonal problems. This may occur for several reasons:

• The individual may have never learned effective strategies to cope with the challenges and problems of adult life, as when substance use begins during early adolescence.

• Although the individual may have acquired effective strategies at one time, these skills may have decayed through repeated reliance on substance use as a primary means of coping. These clients have essentially forgotten effective strategies because of chronic involvement in a drug-using lifestyle in which the bulk of their time is spent in acquiring, using, and then recovering from the effects of drugs.

• The individual's ability to use effective coping strategies may be weakened by other problems, such as drug and alcohol abuse with concurrent psychiatric disorders. Because drug and alcohol abusers are a heterogeneous group and typically come to treatment with a wide range of problems, skills training in CBT is made as broad as possible. The first few sessions focus on skills related to initial control of drug and alcohol use (e.g., identification of high-risk situations, coping with thoughts about drug and alcohol use). Once these basic skills are mastered, training is broadened to include a range of other problems with which the individual may have difficulty coping (e.g., social isolation, employment). In addition, to strengthen and broaden the individual's range of coping styles, skills training focuses on both intrapersonal (e.g., coping with craving) and interpersonal (e.g., refusing offers of drug and alcohol) skills. Clients are taught these skills as both specific strategies (applicable in the here and now to control drug and alcohol use) and general strategies that can be applied to a variety of other problems. Thus, CBT is not only geared to helping each client reduce and eliminate substance use while in treatment, but also to imparting skills that can benefit the client long after treatment.

Critical Tasks

CBT addresses several critical tasks that are essential to successful substance abuse treatment (Rounsaville and Carroll 1992).

• Foster the motivation for abstinence. An important technique used to enhance the client's motivation to stop drug and alcohol use is to do a decisional analysis which clarifies what the individual stands to lose or gain by continued drug and alcohol use.

• Teach coping skills. This is the core of CBT - to help clients recognize the high-risk situations in which they are most likely to use substances and to develop other, more effective means of coping with them.

• Change reinforcement contingencies. By the time treatment is sought, many clients spend most of their time acquiring, using, and recovering from drug and alcohol use to the exclusion of other experiences and rewards. In CBT, the focus is on identifying and reducing habits associated with a drug-using lifestyle by substituting more enduring, positive activities and rewards.

• Foster management of painful affects. Skills training also focuses on techniques to recognize and cope with urges to use drug and alcohol; this is an excellent model for helping clients learn to tolerate other strong affects such as depression and anger.

• Improve interpersonal functioning and enhance social supports. CBT includes training in a number of important interpersonal skills and strategies to help clients expand their social support networks and build enduring, drug-free relationships.

Parameters of CBT

Format

An individual format is often preferred for CBT because it allows for better tailoring of treatment to meet the needs of specific clients. Clients receive more attention and are generally more involved in treatment when they have the opportunity to work with and build a relationship with a single therapist over time. Also, the comparatively high rates of retention in programmes and studies may reflect, in part, particular advantages of individual treatment. This is why Channah offers you a minimum of 3 one to one sessions every week.

A number of researchers and clinicians have also emphasized the unique benefits of delivering treatment to substance users in the group formats. This generally requires the sessions to be 90 minutes to allow all group members to have an opportunity to comment on their personal experiences in trying out skills, give examples, and participate in role-playing. Treatment will also be more structured in a group format because of the need to present the key ideas and skills in a more didactic, less individualized format.

At Channah we recommend a minimum stay of 4 weeks. This includes a minimum of 3 one to one sessions per week as well as 5 group session. This comparatively brief, short-term treatment is intended to produce initial abstinence and stabilization. CBT can also be seen as preparation for longer term treatment. Further treatment is recommended directly when the client leaves at the end of the programme. The Channah programme includes 12 weeks of one to one aftercare to support the client in those crucial early months. The aftercare component of the Channah CBT programme focuses on the following:

• Identifying situations, affects, and cognitions that remain problematic for clients in their efforts to maintain abstinence.

• Maintaining gains through solidifying the more effective coping skills and strategies the subject has implemented.

• Encouraging client involvement in activities and relationships that are incompatible with drug use. Rather than introducing new material or skills, the maintenance version of CBT focuses on broadening and mastering the skills to which the client was exposed during the initial phase of treatment.

Setting

Aftercare treatment is usually delivered near the client’s home or place of work for several reasons:

• CBT focuses on understanding the determinants of substance use, and this is best done in the context of the client's day-to-day life. By understanding who the clients are, where they live, and how they spend their time, therapists can develop more elaborate functional analyses.

• Skills training is most effective when clients have an opportunity to practice new skills and approaches within the context of their daily routine, learn what does and does not work for them, and discuss new strategies with the therapist.

Clients

CBT has been evaluated with a broad range of drug and alcohol abusers. The following are generally not appropriate for CBT delivered on an out-client basis:

• Those who have psychotic or bipolar disorders and are not stabilized on medication

• Those who have no stable living arrangements

• Those who are not medically stable (as assessed by a pretreatment physical examination)

Compatibility with Adjunctive Treatments

CBT is highly compatible with a variety of other treatments designed to address a range of co-morbid problems and severities of drug and alcohol abuse:

Pharmacotherapy for drug and alcohol use and/or concurrent psychiatric disorders

Self-help groups such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA)

Family and couples therapy

Vocational counselling, parenting skill Active Ingredients of CBT

All behavioral or psychosocial treatments include both common and unique factors or "active ingredients." Common factors are those dimensions of treatment that are found in most psychotherapies - the provision of education, a convincing rationale for the treatment, enhancing expectations of improvement, provision of support and encouragement, and, in particular, the quality of the therapeutic relationship (Rozenzweig 1936; Castonguay 1993). Unique factors are those techniques and interventions that distinguish or characterize a particular psychotherapy.

CBT, like most therapies, consists of a complex combination of common and unique factors. For example, in CBT mere delivery of skills training without grounding in a positive therapeutic relationship leads to a dry, overly didactic approach that alienates or bores most clients and ultimately has the opposite effect of that intended. It is important to recognize that CBT is thought to exert its effects through this intricate interplay of common and unique factors.

A major task of the therapist is to achieve an appropriate balance between attending to the relationship and delivering skills training. For example, without a solid therapeutic alliance, it is unlikely that a client will stay in treatment, be sufficiently engaged to learn new skills, or share successes and failures in trying new approaches to old problems. Conversely, empathic delivery of skills training as tools to help clients manage their lives more effectively may form the basis of a strong working alliance.

Essential and Unique Interventions

The key active ingredients that distinguish CBT from other therapies and that must be delivered for adequate exposure to CBT include the following:

• Functional analyses of substance abuse

• Individualized training in recognizing and coping with craving, managing thoughts about substance use, problem solving, planning for emergencies, recognizing seemingly irrelevant decisions, and refusal skills

• Examination of the client's cognitive processes related to substance use

• Identification and debriefing of past and future high-risk situations

• Encouragement and review of extra-session implementation of skills

• Practice of skills within sessions

Acceptable Interventions

Four interventions are not required or strongly recommended as part of CBT but are not incompatible with this approach:

• Exploring self-help involvement as a coping skill

• Identifying means of self-reinforcement for abstinence

• Exploring discrepancies between a client's stated goals and actions

• Eliciting concerns about substance abuse and consequences

Interventions Not Part of CBT

Interventions that are distinctive of dissimilar approaches to treatment and less consistent with a cognitive-behavioral approach include those listed below.

• Extensive self-disclosure by the therapist

• Use of a confrontational style or a confrontation-of-denial approach

• Requiring the client to attend self-help groups

• Extended discussion of 12-step recovery, higher power, "Big Book" philosophy

• Use of disease model language or slogans

• Extensive exploration of interpersonal aspects of substance abuse

• Extensive discussion or interpretation of underlying conflicts or motives

• Provision of direct reinforcement for abstinence (e.g., vouchers, tokens)

• Interventions associated with Gestalt therapy, structural interventions, rational-emotive therapy, or other prescriptive treatment techniques

CBT Compared to Other Treatments

It is often easier to understand a treatment in terms of what it is not. This section discusses CBT for drug and alcohol abuse in terms of its similarities to and differences from other psychosocial treatments for substance abuse.

Similar Approaches

CBT is most similar to other cognitive and behavioral therapies, all of which understand substance abuse in terms of its antecedents and consequences. These include Beck's Cognitive Therapy (Beck et al. 1991) and the Community Reinforcement Approach (CRA) (Azrin 1976; Meyers and Smith 1995), and particularly, Marlatt's Relapse Prevention (Marlatt and Gordon 1985), from which it was adapted.

Cognitive Therapy

Cognitive therapy "is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behavior by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions" (Beck et al. 1991, p. 10).

CBT is particularly similar to cognitive therapy in its emphasis on functional analysis of substance abuse and identifying cognitions associated with substance abuse. It differs from cognitive therapy primarily in terms of emphasis on identifying, understanding, and changing underlying beliefs about the self and the self in relationship to substance abuse as a primary focus of treatment. Rather, in the initial sessions of CBT, the focus is on learning and practicing a variety of coping skills, only some of which are cognitive.

In CBT, initial strategies stress behavioral aspects of coping (e.g., avoiding or leaving the situation, distraction, and so on) rather than "thinking" one's way out of a situation. In cognitive therapy, the therapist's approach to focusing on cognitions is Socratic and based on leading the client through a series of questions; in CBT, the approach is somewhat more didactic. In cognitive therapy, the treatment is thought to reduce substance use by changing the way the client thinks; in CBT, the treatment is thought to work by changing what the client does and thinks.

Community Reinforcement Approach

The Community Reinforcement Approach (CRA) "is a broad-spectrum behavioral treatment approach for substance abuse problems...that utilizes social, recreational, familial, and vocational reinforcers to aid clients in the recovery process" (Meyers and Smith 1995, p. 1).

This approach uses a variety of reinforcers, often available in the community, to help substance users move into a drug-free lifestyle. Typical components of CRA treatment include (1) functional analysis of substance use, (2) social and recreational counseling, (3) employment counseling, (4) drug refusal training, (5) relaxation training, (6) behavioral skills training, and (7) reciprocal relationship counseling. In the very successful approach developed by Higgins and colleagues for drug and alcohol-dependent individuals (Higgins et al. 1991, 1994), a contingency management component is added that provides vouchers for staying in treatment. The vouchers are redeemable for items consistent with a drug-free lifestyle and are contingent upon the client's provision of drug-free urine toxicology specimens.

Thus, CRA and CBT share a number of common features, most importantly, the functional analysis of substance abuse and behavioral skills training. CBT differs from CRA in not typically including the direct provision of either contingency management (vouchers) for abstinence or intervening with clients outside of treatment sessions or the treatment clinic, as do community-based interventions (job or social clubs).

Motivational Enhancement Therapy

CBT has some similarities to Motivational Enhancement Therapy (MET) (Miller and Rollnick 1992). MET "is based on principles of motivational psychology and is designed to produce rapid, internally motivated change. This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client's own change resources" (Miller et al. 1992, p. 1).

CBT and MET share an exploration, early in the treatment process, of what clients stand to gain or lose through continued substance use as a strategy to build clients' motivation to change their substance abuse.

CBT and MET differ primarily in emphasis on skill training. In MET, responsibility for how clients are to go about changing their behavior is left to the clients; it is assumed that clients can use available resources to change behavior and training is not required. CBT theory maintains that learning and practice of specific substance-related coping skills foster abstinence. Thus, because they focus on different aspects of the change process (MET on why clients may go about changing their substance use, CBT on how clients might do so), these two approaches may be seen as complementary. For example, for a client with low motivation and few resources, an initial focus on motivational strategies before turning to specific coping skills (MET before CBT) may be the most productive approach.

Dissimilar Approaches

While it is important to recognize that all psychosocial treatments for drug abuse share a number of features and may overlap or closely resemble one another in several ways, some approaches differ significantly from CBT.

Twelve-Step Facilitation

CBT is dissimilar to 12-step, or disease-model approaches, in a number of ways. Twelve-Step Facilitation (TSF) (Nowinski et al. 1994) "is grounded in the concept of alcoholism as a spiritual and medical disease". The content of this intervention is consistent with the 12 Steps of Alcoholics Anonymous (AA), with primary emphasis given to Steps 1 through 5. In addition to abstinence from all psychoactive substances, a major goal of the treatment is to foster the participant's commitment to and participation in AA, Narcotics Anonymous (NA) or Cocaine Anonymous (CA) . Participants are actively encouraged to attend self-help meetings and to maintain journals of their AA/CA/NA attendance and participation" (Project MATCH Research Group 1993).

While CBT and TSF share some concepts - for example, the similarity between the disease model's "people, places, and things" and CBT's "high-risk situations" - there are a number of important differences. The disease-model approaches are grounded in a concept of addiction as a disease that can be controlled but never cured. In CBT, substance abuse is a learned behavior that can be modified. The emphasis in disease model approaches is on clients' loss of control over substance abuse and other aspects of their lives; the emphasis in CBT is on self-control strategies, that is, what clients can do to recognize the processes and habits that underlie and maintain substance use and what can be done to change them.

Similarly, the major change agent in disease-model approaches is involvement with the fellowship of AA/CA/NA and working the 12 Steps, that is, the way to cope with nearly all drug-related problems is by going to meetings or deepening involvement with fellowship activities. In CBT, coping strategies are much more individualized and based on the specific types of problems encountered by clients and their usual coping style.

While attending AA or NA meetings is not required or strongly encouraged in CBT, some clients find attending meetings very helpful in their efforts to become or remain abstinent. CBT therapists take a neutral stance to attending AA, CA or NA; they encourage clients to view going to meetings as an additional support, not the coping strategy. The CBT therapist may explore with the client the ways in which going to a meeting when faced with strong urges to use may be a very useful and important strategy to cope with craving; however, therapists will also encourage clients to think about and have ready a range of other strategies as well.

Interpersonal Psychotherapy

CBT is also different from interpersonal and short-term dynamic approaches such as Interpersonal Psychotherapy (IPT) (Rounsaville and Carroll 1993) or Supportive-Expressive Therapy (SE) (Luborsky 1984). IPT "is based on the concept that many psychiatric disorders, including drug and alcohol dependence, are intimately related to disorders in interpersonal functioning which may be associated with the genesis or perpetuation of the disorder. IPT, as adapted for drug and alcohol dependence, has four definitive characteristics: (1) adherence to a medical model of psychiatric disorders, (2) focus on clients' difficulties in current interpersonal functioning, (3) brevity and consistency of focus, and (4) use of an exploratory stance by the therapist that is similar to that of supportive and expressive therapies."

IPT differs from CBT in several ways: CBT has a structured approach, whereas IPT is more exploratory. Extensive efforts are made in CBT to teach and encourage clients to use skills to control their substance abuse, while in the more exploratory IPT approaches; substance abuse is viewed as a symptom of other difficulties and conflicts and thus may deal less directly with the substance use.