Cognitive-Behavioral Therapy and Family Therapy Approaches to the Treatment of Substance Abuse Disorder
Alliant International University
This paper describes substance abuse and then examines 3 treatment approaches to substance abuse disorder. The first is Cognitive-Behavioral Therapy, the second is Family Therapy, and the third is an approach that combines the two, called Integrated Family and Cognitive- Behavioral Therapy. Multicultural issues pertinent to the treatment of substance abuse disorder are also discussed.
Cognitive-Behavioral and Family Therapy Approaches to the Treatment of Substance Abuse Disorder
Substance abuse is a complex disease with physiological, environmental, social, spiritual, and psychological components. In the United States, approximately one-third of the population abstains from alcohol and other drugs; approximately one-third uses occasionally on a social basis; about 25 percent abuses alcohol and other drugs; and the remaining 6 to 8 percent of the population has crossed the line into addiction (Tighe, 1999).
Addiction has three main characteristics: loss of control, denial, and preoccupation. When individuals experience a loss of control over alcohol and/or other drugs, they feel powerless in that they are unable to predict or control chemical use. Addicted individuals tend to minimize or deny the effect his or her dependency has on others or themselves. They may minimize or lie about the amount of their chemical use. Preoccupation involves spending a great deal of time anticipating, planning, and protecting one’s chemical use.
The Diagnostic and Statistical Manual of Mental Disorders lists the following criteria for substance abuse:
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights. (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Ed.-TR)
Cognitive-Behavioral Therapy (CBT) has been widely applied to treatment of substance abuse. CBT views substance use as functionally related to problems in the individual’s life, which are influenced by social and cognitive factors. CBT holds that a person’s belief system is the primary cause of substance abuse disorders. Thus, the intervention targets high-risk social situations as well as perceptions (Deas & Thomas, 2001). CBT pays little attention to the past, and instead, highlights present functioning and teaches the client to rethink and reverbalize in a more constructive way. CBT also emphasizes building the skills necessary to cope in situations that can lead to relapse. The goal of CBT is to help the individual recognize situations that can lead to substance use, avoid these situations if possible, and cope with problems and behaviors associated with such situations.
Cognitive and behavioral techniques, often imparted through group therapy, are increasingly popular in treating cocaine addiction and other forms of drug abuse (“Cocaine Abuse,” 1999). Patients are urged to identify and record the situations and feelings associated with the desire to use cocaine so that they can learn how to avoid the former and neutralize the latter. They are taught how to cope with the many situations that might prompt them to use cocaine, such as boredom, fatigue, anger, frustration, or depression. They are also taught how to refuse the drug when they feel under social pressure to accept it. Through the technique of imaginal exposure, they can rehearse these situations in the therapy session with the help of an experienced therapist.
Clients are urged to avoid people, places, and things associated with past cocaine use. They are also encouraged to give up other drugs, especially alcohol, that promote the desire for cocaine or reduce the capacity to resist it. Clients are advised on how to prevent temporary slips from turning into permanent relapses. They are also trained in methods of solving problems without recourse to cocaine and are urged to develop new interests and hobbies.
In cognitive therapy, the self-defeating behavior of addicts is modified by changing their beliefs about themselves, their lives, and their futures, as well as beliefs about the drug itself. Socratic questioning and other techniques are used to enhance self-awareness regarding these beliefs and the capacity to test and reject them. Clients who use language patterns that reflect helplessness and self-condemnation can learn to employ new self-statements. Addicts who tell themselves, “I won’t be able to make it through the day if I don’t have cocaine,” or “It’s okay to do a line of coke because I deserve to feel good,” learn that these are distorted thinking processes. Through the process of changing their language patterns and making new self-statements, clients come to think and behave differently. As a consequence, they also begin to feel differently (Corey, 2001).
The most common form of CBT used to treat addictions is called relapse prevention coping skills (Ball, 2003). G. Alan Marlatt, Ph.D., developed this method in the late 1980’s to treat alcoholism. It was later tested for cocaine and cannabis dependence as well. It emphasizes the identification, teaching, and mastery of coping skills as more adaptive responses that drug-taking behavior. The first step of relapse prevention coping skills (RPCS) is called a functional analysis of behavior, which breaks down drug use or craving into smaller component parts, called antecedents and consequences, in order to identify common triggers or high-risk situations that can be targeted for intervention. Self-monitoring homework assignments using functional analysis of behavior are given so that the patients continue this process between therapy sessions and practice applying it to everyday situations.
Early in treatment, clients are encouraged to use stimulus-avoidance techniques (e.g., changing relationships, living situations, phone numbers, money availability, and old routines) and then gradually develop and practice more proactive coping skills. Coping skills are categorized according to their relevance to problems such as craving, people, dysfunctional cognitions, negative emotions, and emergencies. The enactment of new skills during therapeutic role-playing and the practice of new skills in between therapy sessions are believed to be essential components of effective CBT treatment.
Research comparing CBT to other substance abuse treatment methods has revealed a significant reduction in severity of substance abuse among clients receiving CBT. Results revealed long-term gains in the areas of substance abuse, family function, and psychiatric status (Deas & Thomas, 2001).
Substance abuse problems are serious, often recurring, complex, biopsychosocial disorders that generate systems problems at many levels, from the cell and organ, to family, to schools, to workplaces, and to society at large. Carter and McGoldrick (1999, p. 468) put forth that; “Our challenge as family therapists is to remind families of the potential threat to their well-being that addiction represents, while simultaneously helping them to maintain a vision of recovery.” These editors see the family level as ideal for therapeutic intervention because it is the product of both individual and social forces, bridging and mediating between the two. Systems theory postulates that people in the family unit play a part in the way family members function in relation to each other and in the surfacing of problem behavior. A systems view allows for a new and expanded definition of intervention, moving away from the individual as the sole form of treatment and supporting the adoption of a proactive, positive stance while promoting growth-producing behavior in families and related systems. Within this conceptualization, substance abuse is viewed as maladaptive behaviors expressed by a family member(s), and is an indication of the dysfunction of the entire system. Therefore, to gain a comprehensive understanding of the dysfunction, it is important for the therapist to consider the whole family system and its relationships to other larger external systems such as the school, the workplace, and legal systems (Lambie & Rokutani, 2002).
The systems perspective views substance abuse as potentially serving a function within the family. The adolescent abusing drugs, for example, may be seen as the symptom bearer for an unbalanced family system. The adolescent drug abuser may serve as a focus of attention for the family to preserve family stability by detouring conflict away from other subsystems. For example, the adolescent’s problematic behavior can draw the family members together to focus on the substance abuse, directing attention away from other family problems such as marital conflict.
Certain biological factors and interactional patterns, which lead to substance abuse, may be passed down intergenerationally. A family therapist may discover such themes within a family if a genogram is completed.
Genetics and the family environment, structure, and processes are the primary sources for human development. Parents influence their children’s behavior by modeling actions, defining norms, controlling the youngster’s vulnerability to the influence of others, and by providing positive attachment. Family factors such as degree of parental nurturance and support, parent-child communications, and parental relationships have been found repeatedly to have a relationship to adolescent substance abuse (Lambie & Rokutani, 2002).
Specific variables of family patterns and interactions have also been identified as influences on adolescent substance abuse. Parental substance abuse has been positively related to adolescent substance use, while family bonding and parental support appears negatively related to misuse and abuse (Lambie & Rokutani, 2002). Parental support in the form of acceptance, warmth, and personal value is consistently linked to positive development in youth and negatively related to substance abuse. Families of adolescent substance abusers tend to be rigid and have difficulty adapting to change. A relationship between low bonding to family and problematic alcohol and substance use among adolescents supports Bowlby’s Attachment Theory. Other research has indicated that the parental subsystem of adolescent substance abusing families is more controlling, provides little opportunity for independence and expressiveness, promotes a high degree of conflict in the family, and produces a low degree of cohesion and closeness in the family (Lambie & Rokutani, 2002). Based on this research, adolescent substance abuse appears to have a strong relationship to family structure and interpersonal relationships within the family.
In general, interventions based on a systems approach focus on the individual, family, peers, school, and social network variables, which are linked with identified problems, as well as on the interface of these systems (Henggeler, Clingempeel, Brondino & Pickrel, 2002). One goal of treatment at the family level is to increase caregivers’ capacities to effectively monitor adolescent behavior and whereabouts. Therapists coach caregivers on how to provide positive consequences for responsible youth behavior and sanctions for irresponsible behavior. The therapist will often help caregivers develop increased family structure and identify natural reinforcers to be linked with desired behavior. The therapist assesses for possible barriers to parental effectiveness, such as parental substance abuse or parental mental health issues, and designs interventions to assist in overcoming such potential barriers. At the peer level, a frequent goal of treatment is to decrease the adolescent’s involvement with delinquent and drug-using peers and to increase his or her association with prosocial peers. Interventions with this purpose are optimally conducted by the adolescent’s caregivers, with the help of the therapist, and may consist of active support and encouragement of associations with unproblematic peers (e.g., providing transportation and increasing privileges) and substantive discouragement of involvement with deviant peers (e.g., applying significant sanctions). Likewise, under the guidance of the therapist, the caregivers develop strategies to monitor and promote the adolescent’s school activities. Typically included in this domain are strategies for opening and maintaining communication with teachers and for restructuring after-school activities to promote academic efforts. Emphasis is placed upon developing a collaborative relationship between the parents and the school personnel.
Hence the multi-systemic model views the caregivers as key to achieving desired outcomes, and interventions typically focus on the family system and its interface with significant social systems. The efficacy of Family Therapy has been demonstrated in several federally funded randomized trials in which consistent reductions in conduct problems, substance use, and association with antisocial peers were found, as well as improvements in family functioning and increased family participation in therapy (“Adolescent Substance,” 2002).
Integrated Family and Cognitive-Behavioral Therapy
Integrated Family and Cognitive-Behavioral Therapy (IFCBT) was developed in response to the National Institute on Drug Abuse Behavioral Therapies Development Program. IFCBT is an approach to substance abuse that coordinates family therapy and cognitive-behavioral modules. Within this therapeutic approach, adolescent drug abuse is viewed as a learned behavior disorder that develops within a cultural context comprised of family, peers, and social institutions that define substance use beliefs and behaviors. This viewpoint is informed by a primary tenet of ecological theory that interpersonal transactions operating across multiple systems influence human behavior across the life span (Latimer, Winters, Zurilla, & Nichols, 2003). The ecological perspective puts forth that drug treatments have the best chance at modifying human behavior when objectives, such as drug abstinence, are accomplished by targeting risk and protective behaviors operating across multiple social systems.
The development of cognitive and psychosocial skills is achieved by IFCBT through an integration of four therapeutic models. The first three are cognitive-behavioral modules delivered to adolescents in a group format, namely, Rational-Emotive Therapy, Problem-Solving Therapy, and Learning Strategy Training. The fourth is a family therapy module, Problem- Focused Family Therapy, and is delivered in an individual family format.
The Rational-Emotive Therapy sessions focus on identifying and refuting irrational beliefs that are associated with substance abuse and psychiatric distress. The goal is to promote rational beliefs that are associated with psychological well-being and drug abstinence. These sessions utilize various Rational-Emotive Therapy strategies to identify activating events for drug use, define the beliefs mediating between activating events and drug use, analyze the evidence for identified irrational beliefs, and develop alternative beliefs during homework assignments.
Once the attitudinal basis for abstinence has begun to be established via Rational-Emotive techniques, behavioral skill development is fostered through the use of Problem-Solving Therapy. Problem-Solving Therapy is used within IFCBT to promote the development of executive-function-type skills to help clients effectively manage a range of drug abuse risks, such as association with deviant peers and coping with negative emotional states. These therapy sessions address the five problem-solving steps of positive problem orientation, problem definition and formulation, generation of alternative solutions, decision making, and solution implementation and verification.
Learning Strategy Training sessions focus on academic achievement strategies. This module of IFCBT responds to the academic failure that often characterizes at risk youth by providing instruction on learning strategies that have been shown to improve school grades.
Finally, Problem-Focused Family Therapy is employed to identify and modify maladaptive behavioral patterns that characterize interactions between family members. These sessions focus on the identification of problematic interactions and then plan, enact, and evaluate novel and adaptive responses to family stress. The primary goal of this component of IFCBT is to promote abstinence by fostering adaptive family communication, age-appropriate roles, and effective parenting skills through the use of structural, strategic, and parent-training strategies. During sessions, families enact specific interactional problems in order to identify familial strengths as well as maladaptive interaction patterns. Behavioral contracts that outline specific tasks for each family member are assigned as homework.
Research findings suggest that IFCBT is a promising approach for the treatment of adolescent drug abuse. IFCBT produced significant reductions in post treatment alcohol and marijuana use frequencies as well as rates of marijuana relapse. Equally important, IFCBT produced changes in targeted cognitive-behavioral and familial risk and protective factors. Adolescents receiving IFCBT exhibited significant advances in rational problem-solving skill and school learning strategy skills. These adolescents were also significantly less likely to avoid problems. They also exhibited an increase in a sense that difficult problems were solvable and reductions in irrational beliefs. IFCBT participation also resulted in significant improvements in familial protective factors, and IFCBT parents exhibited significant improvements in their communication and involvement with family members, limit setting with their children, and improved articulation of family values and norms (Latimer et al., 2003).
Most contemporary models for prevention and treatment of substance abuse are “culturally blind” to the effects of certain cultural variables on the risk of substance abuse among racial/ethnic minority people (Castro & Alarcon, 2002). Such cultural variables include specific beliefs, values, norms, and behaviors that capture the core life experiences of racial/ethnic minority people. Inattention or superficial consideration of these cultural variables in substance abuse prevention and treatment models raise questions about the true relevance and applicability of such programs to racial/ethnic minorities. Several ethnic minority cultural variables have evolved that refer to specific aspects of interpersonal and intrapersonal relations. The cultural concepts that pertain to interpersonal styles that affect the nature and quality of relationships include: familism, individual-collectivism, personalismo, respeto, simpatia, and tiu lien (loss of face). Similarly, the cultural factors that explain interpersonal factors or personal traits that affect social relationships and the person’s place within the larger society include: level of acculturation, Afrocentricity, biculturalism, cultural flex, enculturation, ethnic affirmation, ethnic identity, ethnic pride, field independence and sensitivity, machismo, marianismo, modernism, spirituality, and traditionalism (Castro & Alarcon, 2002).
It is imperative to integrate these cultural variables into existent treatment models in order for them to properly serve racial/ethnic minority people, especially for those who are very traditional and/or low in level of acculturation. The current cultural omission from most treatment approaches calls for future health services research that explicitly examines how these and other cultural variables may enhance the cultural relevance and efficacy of prevention and treatment programs that are administered to racial/ethnic minority people.
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