Overview And Structure Of

Cognitive-behavioral treatments are typically highly structured in comparison to other approaches for substance use disorders. That is, these treatment approaches are typically comparatively brief (12-24 weeks) and organized closely around well-specified treatment goals. There is typically an articulated agenda for each session and discussion remains focused around issues directly related to substance use. Progress toward treatment goals is monitored closely and frequently, and the therapist takes an active stance throughout treatment.

Cognitive-behavioral approaches typically include a range of skills to foster or maintain abstinence and to prevent relapse. These typically include strategies for:

(1) reducing availability and exposure to the substance and related cues,

(2) fostering resolution to stop substance use through exploring positive and negative consequences of continued use,

(3) self-monitoring to identify high risk situations and to conduct functional analyses of substance use,

(4) recognition of conditioned craving and development of strategies for coping with craving,

(5) identification of seemingly irrelevant decisions which can culminate in high risk situations,

(6) preparation for emergencies and coping with a relapse to substance use,

(7) substance refusal skills, and

(8) identifying and confronting thoughts about the substance.

The techniques of teaching these coping responses include a combination of direct verbal instruction, modeling of appropriate skills through role play, and rehearsal of the skills within the therapy session (Marlatt & Gordon, 1985). Material discussed during sessions is typically supplemented with extra- session tasks (i.e., homework) intended to foster practice and mastery of coping skills.

Broad-spectrum cognitive-behavioral approaches such as that described by Monti and colleagues (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 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, job seeking skills, and so on.

There are a variety of manuals available (Monti et al.,1989; Kadden et al. 1992, Carroll, 1998) which describe key CBT strategies and techniques, as well as guidelines for its implementation with a variety of types of substance users. The classic resource in this area remains the Marlatt and Gordon's (1985) landmark book on relapse prevention.

The goals of cognitive-behavioral treatments tend to be somewhat broader than those of 'strict' behavioral approaches, and the choice of treatment goals will dictate the specific interventions implemented. For example, in broad spectrum cognitive-behavioral treatments (e.g., Azrin et al., 1976; Monti et al., 1989), the patient and therapist may select a wide range of target behaviors in addition to a treatment goal of abstinence, including improved social skills or social functioning, reduced psychiatric symptoms, and reduced social isolation, entry into the work force. Cognitive behavioral therapy also differs from cognitive therapy through greater emphasis on building specific behavioral skills (e.g., coping with craving, avoiding high risk situations, understanding behavioral patterns) and somewhat lesser emphasis on targeting and challenging maladaptive cognitions in the earlier stages of abstinence.

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