Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence
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Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence Current Status and Future Directions Richard Longabaugh, Ed.D., and Jon Morgenstern, Ph.D. Cognitive-behavioral coping-skills training (CBST) is an alcoholism treatment approach aimed at improving the patients’ cognitive and behavioral skills for changing their drinking behavior. CBST encompasses a variety of approaches that despite their core similarities differ in duration, modality, content, and treatment setting. Numerous studies and reviews have ranked CBST among the most effective approaches for treating alcoholic patients. Nevertheless, a recent analysis of nine studies failed to identify specific CBST components that could account for the treatment’s effectiveness. Furthermore, a similar analysis of 26 studies suggested that CBST’s superior effectiveness was limited to specific treatment contexts (i.e., when delivered as part of a comprehensive treatment program) and to specific patient subgroups (e.g., patients with less severe alcohol dependence). Several measures may help broaden CBST’s focus and effectiveness, such as incorporating components of other treatment approaches. KEY WORDS: cognitive therapy; behavior therapy; coping skills; AODU (alcohol and other drug use) treatment method; AOD (alcohol and other drug) use behavior; treatment outcome; patient-treatment matching; aftercare; combined modality therapy; motivational interviewing; drug therapy; literature review he term “cognitive-behavioral and by analyzing the mechanisms through coping-skills therapy” (CBST) which it works. The article also examines RICHARD LONGABAUGH, ED.D., is profes- Trefers to a family of related treat- whether CBST differs in effectiveness sor of psychiatry and human behavior ment approaches for alcohol dependence for different kinds of patients, during and associate director of the Center for and other psychiatric disorders that aims different treatment phases, or in various Alcohol and Addiction Studies, Brown to treat the patient by improving his or potential relapse situations as well as University, Providence, Rhode Island. her cognitive and behavioral skills for whether any specific CBST approaches changing problem behaviors. This article are more effective than others. Finally, JON MORGENSTERN, PH.D., is associate describes the current status of CBST the article explores the future of CBST professor of psychiatry and director of in alcoholism treatment by evaluating and suggests modifications that might Alcohol Treatment and Research Programs, CBST’s effectiveness when compared enhance the treatment’s effectiveness as Mount Sinai Medical Center, New York, with alternative treatment conditions well as improve analyses of CBST efficacy. New York. 78 Alcohol Research & Health Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence Evolution and Definition During the past 25 years, numerous ing. The discussion in this article is of CBST CBST approaches have been developed limited to CBSTs that focus exclusively to treat alcohol dependence; these on coping-skills training of the individ- CBST has its origins in a branch of approaches have differed in many aspects, ual patient, whether this training occurs academic psychology that focuses on including duration, modality, content, in group- or individual-therapy sessions. understanding how human learning and treatment setting (Miller et al. 1995). Because BMT, CRA, and BSCT include occurs. This approach views any type Despite their differences, however, all important therapeutic components of psychopathology, including alcohol CBST approaches for alcohol dependence other than individual coping-skills train- dependence, as a maladaptive learning share the following two core elements: ing, they have been excluded from this process. Accordingly, the central goal of review. These approaches may influence CBST approaches, which exist for • They espouse the principles of social- drinking behavior through mechanisms numerous psychiatric disorders, is to cognitive theory (Bandura 1986). As other than those related to coping-skills design techniques through which mal- applied to alcohol dependence (Abrams training. In addition, CRA and BMT adaptive responses can be “unlearned” and Niaura 1987), these principles both involve other people besides the and replaced with adaptive responses. postulate a central role for coping alcoholic patient in the therapeutic In the early 1970s, social learning the- skills. The guiding theory is that intervention, thereby adding another ory emerged as a theoretical basis for deficits in the ability to cope with important element to the therapy. (For designing new interventions for people life stress in general and with alco- more information on CRA, see the arti- with alcohol problems (Marlatt and hol-related stimuli (i.e., alcohol cues) cle in this issue by Miller and Meyers, pp. Gordon 1985). For example, early stud- in particular help maintain excessive 116–121.) Furthermore, in contrast to ies reported that alcoholic patients who drinking and lead to a resumption of CBST, which focuses on achieving absti- were treated with CBST could be taught drinking following aborted attempts nence, BSCT emphasizes the patient’s to reduce or eliminate their alcohol at abstinence. choice of a treatment goal (i.e., absti- consumption to a greater extent than nence or moderate drinking). Finally, could patients who were not treated • They employ some form of individ- relaxation training is excluded from with CBST (Chaney et al. 1978; Oei ual coping-skills training to address this discussion, because previous reviews and Jackson 1980). Subsequently, the patient’s deficits. For example, have concluded that it is ineffective for research on using CBST in treatment each CBST approach teaches skills alcohol-dependent patients (Miller et for alcohol problems has been guided (using a standard set of techniques) al. 1995). primarily by the book Relapse Prevention: to help the patient identify specific CBST interventions were among Maintenance Strategies in the Treatment situations in which coping inade- the first alcoholism treatment approaches of Addictive Behaviors by Marlatt and quacies typically occur. To enhance to demonstrate efficacy in reducing Gordon (1985), which focuses on relapse the client’s coping skills in those sit- drinking in randomized clinical trials1 prevention among patients with alcohol uations, all CBSTs use such teaching (Chaney et al. 1978; Oei and Jackson and other drug (AOD) abuse problems tools as instruction, modeling, role 1980). Numerous additional studies (for more information on relapse pre- play, and behavioral rehearsal. during the past 25 years have contin- vention, see the article in this issue by ued to support CBST’s effectiveness. Larimer and colleagues, pp. 151–160). CBST frequently is classified as a Moreover, several comprehensive reviews These studies generally have been con- “broad-spectrum treatment approach”— of treatments for alcohol-related prob- ducted by clinical psychologists, often that is, an approach that does not focus lems have ranked CBST approaches in Veterans Affairs (VA) hospitals. primarily on the patient’s alcohol con- among those having the most evidence Over time, CBST has become the sumption but addresses other life areas for clinical and cost effectiveness (e.g., alcoholism treatment of choice in aca- that often are functionally related to Holder et. al. 1991; Finney and Monahan demic and VA hospitals. Outside of these drinking and relapse. For example, if 1996; Miller et al. 1995). For example, settings, however, the Minnesota Model anger can provoke a patient to drink, in those reviews, social-skills training was of alcoholism treatment, which is based the focus of CBST will be on those found to be one of the two most effec- on the 12-step philosophy of Alcoholics circumstances that arouse anger in the tive treatments for alcohol dependence. Anonymous, remains the most popular patient, the thought and behavioral pro- treatment approach. The effectiveness cesses that occur between the onset of What Are CBST’s Active Ingredients? of that approach, however, has not been the anger and the patient’s drinking, and documented in well-controlled studies— on the events occurring after the patient Because numerous clinical studies had that is, in studies comparing 12-step- drinks. Several other broad-spectrum suggested that CBST was effective in treated subjects with control subjects alcoholism treatment approaches exist, receiving other types of therapy. Thus, including the community-reinforcement 1Randomized clinical trials are studies in which a disparity exists between the popularity approach (CRA), behavioral marital patients are randomly assigned to different treat- of a treatment and its demonstrated therapy (BMT), behavioral self-control ments. In this case, the participants received CBST effectiveness (Hester and Miller 1995). training (BSCT), and relaxation train- or another intervention. Vol. 23, No. 2, 1999 79 alcoholism treatment (e.g., see Finney studies, either coping skills that increased therapy and 12-step facilitation therapy and Monahan 1996; Miller et al. 1995), through CBST were unrelated to drink- (Project MATCH Research Group, Longabaugh and Morgenstern (1998) ing outcomes, or coping skills related to 1997a). In these 39 comparisons, evi- reviewed the existing literature to iden- drinking outcome were not increased to dence for CBST’s superior effectiveness tify mechanisms of action inherent to a greater extent with