Significant cognitive theories are discussed that tend to play a major role in substance abuse treatments. Their common concepts are extracted and synthesized for the purpose of relating it to the relevant research about how they are applied to the development and treatment of addictive behavior.
Cognitive therapy is largely based on the work of Aaron T. Beck’s treatment for depression (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979; Beck, Wright, Newman, & Liese, 1993). It has been shown to be an effective form of intervention when dealing with anxiety disorders, panic disorders (Beck, Emery, & Greenberg, 1985), eating disorders, substance abuse, and dissociative disorders. A highly flexible modality, cognitive therapy has been proven successful when used in both short and long term interventions and with a variety of patients: adults, adolescents, children, couples, and groups. To be effective, cognitive forms of therapy require that the patient be active in the process, able to work with an educational type format, and willing to make changes.
Central to the therapeutic modalities associated with cognitive therapy (i.e., rational-emotive therapy, cognitive behavioral therapy, and transactional analysis) is the concept that thoughts affect feelings. This construct implies that it is the emotional tones and expectations that one learns to associate with specific events that create problems rather than the events themselves that cause distress. Therefore, the goals of such therapies consist of assisting the client in identifying maladaptive thinking that result in emotional distress. Similar to behavioristic and humanistic therapies, cognitive therapies tend to be oriented in the present rather than the past. Current patterns of thought that result in current discomfort are focused on during therapy. For these therapies to be effective, the client must be motivated and capable of working from an educational perspective.
As its name implies, the primary concern is with the cognitive abilities and skills of the client. The cognitive therapies are directed towards identifying and correcting maladaptive thinking patterns that result in self-defeating or self-destructive behaviors and feelings. The goal of therapy is to assist the client in mastering skills used to identify problems, evaluating his/her perspectives concerning the problems, and providing a more balanced perspective that is conducive to more productive behaviors. This is accomplished by approaching problem solving in a systematic manner composed of steps that the client perceives as being manageable. Cognitive therapy is usually directed towards enhancing the coping capabilities of the patient.
Problem focused strategies or emotional focused strategies are the two primary approaches used in cognitive therapies to create a shift in thinking which transforms the client’s perception of the problem. Problem focused strategies are useful in directing the client to identify a specific problem. The client is then assisted in identifying the responses that are typically used to reduce distress in the situation and to evaluate those responses for effectiveness. Alternative responses are then developed and examined from a cost-benefit perspective empowering the patient to make conscious choices about how he/she chooses to respond to stressful situations. This empowerment lends the patient a sense of control, as heretofore-unrecognized options become viable alternatives in managing distress.
Emotional focused strategies achieve the same end as the problem-focused strategies but from a different means. In this technique, the client’s perception of the distressful event is altered, thereby causing a subsequent change in level of perceived distress. By redefining the problem, the patient can hold the power to transform a crisis into an opportunity or challenge. This re-framing of the event can be accomplished by minimization, distancing, selective attention, and searching for positive value from a bad situation. Ultimately, the result is that the patient has an increased sense of control over the situation and therefore stress is reduced.
During the course of a lifetime, an individual obtains information from a wide range of sources. Early childhood is where a great deal of this information is obtained and deeply ingrained within the individual. In light of the multi-generational appearance of substance abuse, it appears likely that some of the information obtained from primary caretakers could be founded in the dynamics of substance abuse. Children raised in the home with a substance abuser will be exposed to the behaviors, values, and beliefs that have supported the addictive behaviors. As these learned addictive behaviors are incorporated into the cognitive processing of the child, they become virtually subconscious thoughts and leave the child with a distorted sense of normalcy concerning family function and a full repertoire for justifying his or her own substance abuse in the future. Those children raised in such environments may also become likely to develop behaviors that are enabling for other substance abusers. Cognitive based therapies applied to the substance abuser must address the issues of faulty beliefs and values, regardless of whether they are conscious or unconscious in nature.
Rational Emotive Therapy (RET) is an example of a cognitive based therapy that accomplishes this goal by establishing a confrontational basis which allows the therapist to call the client’s attention to irrational beliefs and the dysfunctional behaviors that result from those beliefs. Following this confrontation, the therapist then assists the client in discovering how his/her irrational beliefs and dysfunctional behaviors are generating problems for the client. Finally, the therapist and client work together to develop viable techniques that the client can use to change his/her belief structure. According to Peterson (2000), the cognitive-behavioral therapeutic approaches of Beck and others are proven methods for treating such orders as depression and anxiety states.
Eric Berne’s proposal (1961) deals with the interpretation of communication as a means of determining roles which people assume when they interact. This led to transactional analysis, a method of therapy that deals specifically with the analysis and categorizing of various types of communication. Three primary roles that come into play when transactional analysis is used: (a) parent, (b) adult, and (c) child that correspond to Freud’s psychoanalytic structures of the super-ego, ego, and id. In a therapeutic setting, the patient can learn to identify the nature of the roles and which of the roles he/she is using during interactions with others. Once the patient understands the nature of these interactions, it then becomes a matter of choosing which role to use in order to communicate more effectively with another person.
Regardless of which particular form of cognitive therapy is used, the common goal is to determine how the client cognitively interprets his/her world and how those cognitive interpretations affect his/her behavior and sense of well being. Since cognitive appraisals of a situation are generally learned, it is possible to unlearn maladaptive attributes while learning new perspectives of a given situation, resulting in less discomfort for the client. Problem focused strategies are directed towards assisting the client to develop alternative solutions and to select those solutions that result in the least amount of discomfort for the client. Emotion based strategies strive for the same ultimate goal of minimizing client distress by helping the client to adopt alternative perceptions of the problem (Lazarus, 1966).
The dynamics of substance abuse are fertile ground for the cognitive-based therapies. Frequently, a person chooses to use chemical substances as a means of modifying how they feel (self-medicating) or because of social pressures. Both of these rationales have significant cognitive foundations in forms of: (a) perception of the experience, (b) alternatives available (c) perceived level of control, and (d) the expectations others have of his/her behavior. The thoughts surrounding these issues and the feelings associated with them are what prompt the individual to use the chemical, abstain from use, or relapse following abstinence. Cognitive therapies provide a means for evaluating the reasons why an individual chooses to use substances and the affect or affects these actions can have on the individual’s overall quality of life. In addition, it also provides a means whereby thoughts, values, and beliefs relating to substance abuse can be challenged and changed in instances where the client, with the therapist’s assistance, finds a need to alter behaviors.
In order to understand why cognitive therapies are an effective intervention for dealing with addictive behaviors, one must identify some of the more common reasons of why people choose to use alcohol and drugs. There is a rich history of the use of substances to create altered states of consciousness. In some cases, this had a spiritual base and the abuse of such substances was uncommon. Perhaps this can be attributed to the fact that the social structure allowed for a certain level of use, by specific persons, in appropriate settings, and deviations from this were considered an affront to the community. In current society, the affront would be equivalent to the greater degree of shock with which one responds to child abuse by a member of the clergy than by a factory worker. Values, beliefs, and expectations of the society are deeply ingrained and include varying levels of behaviors according to the individual’s socioeconomic status, race, religions, and other parameters. These can affect perceptions of the degree of ‘wrongness’ or ‘rightness’ of behavior on an individual and a societal level.
Cultural variances concerning substance usage, particularly alcohol consumption, are particularly significant in light of the cultural diversity found in most developed nations. For example, some cultures, such as French and Italian, encourage moderate drinking while having little tolerance for abuses. Other cultures can be found where any alcohol consumption is considered inappropriate. These restrictions are frequently religiously based and in a setting where one religion holds strong dominance within the society. In America, this later perspective does not hold true. Here, there are varieties of religious factions; some of which are tolerant of moderate drinking while others exclude any form of alcohol consumption. In addition, the culture has seen fit, in some cases, to glorify cultural images of substance usage (and abuse), as exemplified in movies like “Animal House,” and television shows like “Cheers.”
This diversity of cultures has also created an accelerated rate of change within the social values as various cultures are assimilated into the whole of society. These changing social perspectives have caused shifts in the perception of substance abuse and addiction from its historical roots as a ‘weakness of character’ to the disease models that are embraced today. As such, a great deal of energy and money has been channeled into dealing with these ‘disease’ states.
Varieties of substances are used in order to reduce stress. ‘Happy Hour’ at the local bar is clear testimony to this phenomenon. Following a hard day at work, many people have developed the habit of stopping by for a drink to relax before going home. Numerous studies have indicated that people consume alcohol for what are perceived as benefits to quality of life such as relaxation, sociability, stress reduction, and greater sense of psychological well being (Pernanen, 1991; Hall, 1996; Hall et al., 1992; Cahalan, 1970; Leigh and Stacy, 1994; Makela and Mustonen, 1988; and Lowe, 1994). Substance abuse can also occur when the individual perceives a need to escape family problems and finds that the numbing effect of chemicals provides this avenue. Thus, substances that serve to lessen either physical or emotional pain, can rapidly become part of daily routine leading to substance abuse. The need to remove feelings of loneliness, anxiety, or depression can cause one to seek a chemical solution to the problem that is often easier than working on the real issues involved. In some ways, it appears that rituals, full of meanings, have been replaced with ‘meaningless’ habits or a means of avoiding feelings of discomfort. Moreover, once meaning has been lost, so, too, has the individual’s perceived sense of control over the substance usage. Self-medication, in order to avoid ‘dis-ease’ becomes a necessity in order to survive emotionally and/or physically as the source of discomfort continues to exist.
Social and peer pressures are particularly problematic for the young and the ‘upwardly mobile’. Either of these can be associated with relief of loneliness and dealing with lack of self-confidence. While Caudill and Marlatt (1975) point out that social drinking can function as a means of regulating alcohol consumption, Partanen (1991) indicates that social drinking can also be related to higher levels of intoxication. These pressures can result in patterns of substance usage that define where, when, and how much of the chemical is used. According to Heath (1995), alcohol usage has been specifically related to sociability in a variety of cultures. Associated with social settings, the use of chemical substances can lower inhibitions and result in what is perceived as closer contact with others. Unfortunately, this is part of the reason why some infectious diseases have spread dramatically and why the individual can develop the attitude that he/she is incapable of functioning socially without this chemical support.
‘third party economics’ holds a special challenge to the understanding of substance abuse. Used with legal drugs, such as alcohol and tobacco, individuals are bombarded with advertising campaigns indicating that people who are young, attractive, healthy, wealthy, and successful use these types of legal drugs. The ads that are used may indicate that these individuals are happy and have many friends. Or, that the inclusion of the substance can lead one to finding the perfect mate or escape to the ‘Islands’ far from the stressful daily world in which most of us exist. This highly seductive approach can lead the individual to develop expectations that are not based in reality. The individual’s sense of self-worth, self-esteem, social status, values, and beliefs concerning the use of these substances is the result of advertising designed to encourage consumer spending rather than consumer well being.
All of these dynamics are related to how the individual perceives oneself, others, and one’s place in society. Perceptions are largely a function of how the patient has learned to perceive the world and self. Through the application of the techniques used in cognitive therapy, the individual can begin to understand where these thoughts originated. The thoughts can be evaluated for validity, empowering the patient to choose to relinquish invalid concepts and replace them with valid ones that provide viable options for behavior. The individual’s ability to deal with stress can be greatly affected by a shift in how the patient sees the stressful situation. By developing an understanding of exactly what thoughts or behaviors result in feelings of discomfort, the patient can choose to stop self medicating and seek more appropriate measures for an intervention that deals with the underlying problems rather than a short-term distancing from the discomfort.
The chronic and relapsing condition of drug and alcohol abuse presents significant challenges for intervention. Abstinence and relapse prevention are dependent upon the client’s ability and willingness to change attitudes, behaviors, and values. Patients must be able to develop the skills necessary to be aware of what has led to the use of a substance and to identify the warning signs heralding a potential relapse. Once aware, the patient must then learn new, more effective ways of coping which allow a choice not to use the substance.
Some of the issues specific to alcohol abuse deal with the social-learning concepts which manifest, such as the degree to which the drinker believes him/her self capable of controlling his/her drinking and the belief that alcohol is an effective means of modifying moods. The fact that age, socioeconomic status, and minority status are considered predictors of problem drinking challenges the disease model concept of alcoholism and calls attention to the cognitive aspects of the process. However, this should not be considered to negate the disease model but rather exemplifies the need for holistic interventions that are inclusive of values and beliefs along with biological variables. Even where there is a known genetic basis for alcoholism, there are significant variations in the rates of alcoholism which could be attributed to social regulation (Peele, 1985).
Cognitive therapy is directed at identifying and modifying maladaptive beliefs that cause discomfort and dysfunctional behaviors. The purpose when dealing with addictive behaviors is to help the client identify and avoid stimuli which promotes the use of the substance, find the means to cope with those stimuli when they cannot be avoided, and to recognize the difference between those situations where coping skills are effective and where avoiding the situation is necessary.
The importance of cognitive processes in addiction is well argued by Ludwig (1989). In dealing with the topics of craving and relapse, cognitive distortions contribute greatly to obtaining and maintaining abstinence. The author discusses the processes used by an alcoholic in order to justify, and indeed, set up the opportunity for relapse to occur. Treatment can be directed at assisting the patient in learning how to predict the occurrence of and resist the craving for alcohol. When these methods are put into practice, the alcoholic is able to correct thinking patterns and to remain abstinent. Ludwig promotes such cognitive manipulations as ‘distraction’, ‘substitution’, ‘thought-ignoring’, and ‘thought-stopping as cognitive-behavioral methods which serve the recovering alcoholic well.
The implications for applying cognitive therapies in the treatment of substance abuse are clearly indicated by recent research on health (Taylor, Kemeny, Bower, Gruenewald, & Reed, 2000). Cognitively based concepts such as optimism, personal control, meaning in life, self worth, and others have been found to contribute positively when an individual is faced with the stress of illness. However, distortions of these concepts, such as would be found when expectations are not based in reality, did not impact the health of the individual.
In terms of the positive outcomes attributed to positive beliefs, it is held that positive beliefs may affect emotional states that then, in turn, affect physiological functioning. Taylor, et al. (2000) indicate that positive beliefs contributing to a enhanced sense of self-worth, level of control, and optimism, can encourage the individual to participate in health-promoting activities. Additionally, the positive emotional states may well contribute to enhanced social interactions and therefore affect support systems. All of these serve to provide the individual with greater resources for responding to stress.
Relapse Prevention Therapy (RPT) is a cognitive-behavioral therapy that has been used in treatment of alcohol and cocaine abuse with positive results (Marlatt & Gordon, 1985; Parks & Marlatt, 1999). Based upon the premise that maladaptive behavioral patterns are a function of the learning processes, Relapse Prevention uses several cognitive-behavioral techniques to obtain abstinence and for intervention with relapse. These methods are used to enhance the individual’s level of awareness of the costs of addictive behaviors. Additionally, the individual’s off self-control is increased by preparing the person to deal with potential problems before they become real problems.
The National Institute of Drug Abuse (NIDA) (1999) reports that cognitive therapy is an effective intervention for drug addiction treatment. Cognitive therapy is versatile enough to be applicable in long-term or short-term residential settings as well as non-residential treatment programs. This is particularly important within the current social mandates to minimize the cost of intervention without reducing the quality of care. Moreover, when in both residential settings and in non-residential programs, there can be a continuity of therapy type that provides a more comfortable transition for the client.
Cognitive based therapies can provide a variety of techniques that the patient can use to either minimize the temptation to use a substance or to choose not to use the substance. The cognitive skills needed to deal with social pressures, interpersonal conflict, and negative emotions can be developed and patients can learn to identify ‘high-risk situations’ and avoid them. This leads to the patient developing a greater sense of control and empowerment, which serve to enhance self-esteem, and well being. The evidence certainly exists to indicate cognitive therapies are effective in dealing with addictive behaviors.
Traditional 12-step groups, cognitive-behavioral therapies, and motivational interviewing have been found equally effective in the treatment of people with alcohol abuse problems (American Psychological Association, 1997). One of the greatest advantages to the cognitive-behavioral therapies is that they are also appropriate in dealing with some of the mental health issues that may have been contributing factors in the onset of substance abuse. For those who are dual diagnosed, this is particularly important because of the stigmas concerning mental illness that can be found with those involved in the 12-step programs.
Ouimette, Finney, and Moos (1997) found similar results when comparing cognitive-behavioral therapy with 12-step approaches to alcohol abuse treatment. However, the authors report that those individuals in the 12-step program were more likely to remain abstinent one year following treatment as compared to those who were involved in a cognitive-behavioral therapy treatment modality. It is interesting to note that one of the distinct differences between the two approaches is that the 12-step programs are free while most cognitive-behavioral therapies are financially driven and subject to financial constraints of state or locally funded programs, insurance companies, or health management organizations. Simple availability to resources could be a factor when apprising long-term outcomes in a non-research setting. Furthermore, the support structure provided by such programs offers a degree of immediate assistance and ease of availability that may not be available in clinical outpatient settings.
In examining the effectiveness of cognitive therapy as a component in treatment of substance abuse with and without auditory guidance, Sanders and Waldkoetter (1997) noted that cognitive behavioral therapy coupled with aspects of transactional analysis and rational behavior therapy showed a marked decrease in aggression and other negative behaviors. The authors further noted that these benefits were increased when auditory guidance was added to the treatment protocol. Since substance abuse tends to be a ‘family affair’, the reduction of aggressive and other negative behaviors can be of particular importance when the maintenance or enhancement of the family support system is desired.
Comorbid depression and alcoholism are frequently found with patients. Cognitive-behavioral therapy has been shown to be particularly effective when treating alcohol abuse with a depressive patient (Brown and Ramsey, 2000). This therapy can be initiated early in substance abuse treatment. It is a non-invasive intervention presenting little or no risk of harm to the patient. The use of cognitive-behavioral treatment of depression, when added to alcohol treatment can serve to reduce depressive symptom and improve treatment outcome.
Overall, recent research clearly portrays cognitively based therapies as providing an effective intervention for those dealing with substance abuse. The flexibility of these therapeutic modalities allow for a broad-range approach which can be easily modified to generate the greatest degree of positive change while minimizing the negative effects of altering behavior. Moreover, it allows for the inclusion of treatment for any comorbid mental health issues that may exist at the onset of treatment or arise during the therapeutic process.
Substance abuse is not a simple cause and effect relationship. Instead, it involves a myriad of factors, both internal and external to the patient, which contribute to use, abstinence, and relapse prevention. For the addicted person, all of life is affected by the need to obtain and use his/her drug of choice. Relationships with family members, coworkers, social groups, and the self can be seriously compromised. In large part, these effects are the result of subconscious or conscious thoughts that precipitate detrimental behaviors. Cognitive based therapies provide a fertile field for dealing with these issues. By enhancing the client’s awareness of the cognitions that lead to these behaviors, it becomes possible to open the way for learning new ways of thinking about situations. This effectively empowers to client to make choices about behaviors that are more conducive to the way he/she wishes to live life. Once the deeply entrenched values and beliefs have been uprooted, the client can begin to develop new ways of approaching challenges that are less costly and provide greater benefits in quality of life than the previous ones were capable of contributing.
In light of the recent trends towards managed care, cognitive therapies offer a cost-effective alternative because it can be used effectively with any age group and as a short-term intervention. It also allows for the treatment of comorbid mental health issues within the same treatment venue. Once the client has mastered the methods employed, they can be applied to a broad range of areas of life where distress occurs. Thus, the client is empowered with problem-solving techniques.
The mental health provider must maintain an awareness of the potential complications in cognitive functioning that are likely to accompany substance abuse issues. Before a period of abstinence from the chemical substance, there may be cognitive side effects that may change as usage decreases or ceases. The length of time and the degree of change that occurs can be a function of the type of substance abuse and the length of time of usage. Furthermore, it is likely that the substance abuser has developed self-care patterns that can also affect cognitive functioning. Dietary intake, poly-substance abuse, stress, and physical illnesses can all serve to reduce cognitive functioning. Some of these deficits may reverse when the behaviors causing them change. Unfortunately, there are also situations where the damage is irreversible. This clearly mandates the care provider to do an ongoing assessment of the unique individual in order to maximize the benefits of cognitively based therapeutic interventions.