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 CBST than with depended on two factors: CBST that contribute to its effectiveness. the comparison treatment. Furthermore, That is, the investigators attempted to several studies did not fully analyze the • The context in which CBST was determine which characteristics of CBST effects of individual coping skills—that compared (i.e., whether CBST was were responsible for the fact that alcoholic is, the studies did not determine whether delivered as the only treatment, as a patients treated with CBST reportedly CBST increased a particular coping skill component of a more comprehensive had better drinking outcomes than did more than did the comparison treat- treatment, or as aftercare following patients treated with various alternative ment and whether that same skill was another treatment) therapies. related to improved drinking outcome. The investigators limited the review In summary, although the review of • The expected effectiveness of the to well-controlled studies in which the the nine clinical trials indicated that treatment against which CBST was patients had voluntarily entered treat- better coping skills generally were asso- to be compared. ment and had been assigned randomly ciated with better drinking outcomes, to receive either CBST or another it allowed no conclusions regarding the treatment. Furthermore, patients had active ingredients of CBST. The studies Effectiveness of CBST as a Stand-Alone to have been either formally diagnosed demonstrated neither that CBST led Treatment. Eleven studies compared with alcohol dependence or strongly to increases in specific coping skills that the effectiveness of CBST delivered as presumed to be alcohol dependent. resulted in better drinking outcomes the only (i.e., stand-alone) treatment Finally, the researchers selected only nor that CBST’s greater effectiveness with the effectiveness of other stand- those studies that attempted to identify was attributable to better coping skills. alone therapies (e.g., supportive group the variables responsible for (i.e., the Thus, researchers do not yet know how therapy plus naltrexone [O’Malley et mediators of) CBST’s effectiveness. CBST works to improve drinking out- al. 1992]). In 10 of those comparisons, To demonstrate that a variable actually come. Similarly, recent studies that did CBST was found to be neither more mediated CBST effectiveness, the follow- not involve random assignment of nor less effective than the treatment ing three factors had to be demonstrated: patients to treatment conditions (i.e., against which it was compared. In one were conducted in naturalistic clinical study, CBST was less effective than the • At least part of the observed effective- settings) and which assessed the mecha- comparison treatment, 12-step facilitation ness of the treatment (i.e., CBST) nisms underlying treatment responses therapy, with respect to the percentage had to be attributable to an increase also indicated that the active ingredients of patients who maintained total absti- in the mediator variable (e.g., a mea- of CBST are not unique to this approach nence in the year following treatment sure of coping skills). but are shared by other therapies (e.g., (Project MATCH 1997a). These results Finney et al. 1998). indicate that CBST delivered as a • A correlation had to exist between the stand-alone treatment does not differ patient’s posttreatment status with How Effective Is CBST Compared in effectiveness from these other treat- respect to the mediator variable (e.g., With Other Treatments? ment approaches. coping skills) and drinking outcome. As mentioned previously, several general Effectiveness of CBST as Aftercare. • Statistical analyses had to demon- reviews of treatment effectiveness for CBST also has been delivered as after- strate that when the effect of the patients with alcohol problems have care—that is, following completion of mediating variable was selectively concluded that CBST is one of the most a previous, more intensive treatment eliminated, overall treatment effec- effective interventions. Nevertheless, (e.g., inpatient therapy). In this context, tiveness declined. researchers’ inability to identify the spe- seven studies compared the outcome of cific mechanisms through which CBST patients receiving CBST with the out- Nine studies fulfilled the researchers’ acts (as described in the previous section) criteria.2 The studies measured and ana- suggested a need for a more focused lyzed numerous potential mediators analysis of CBST’s effectiveness. Thus 2A complete list of references for those nine studies for CBST’s effectiveness (e.g., variables Longabaugh and Morgenstern (1998) is available from the authors of this article. measuring coping behaviors and self- identified 26 well-controlled clinical 3 3 In this context, self-efficacy refers to the patient’s efficacy ). Only one of the nine studies, studies published through July 1998; belief that he or she can successfully deal with situa- however, was able to identify a measure the reports included 39 comparisons of tions likely to lead to drinking. 4 of social skills that attained even marginal CBST with other treatment approaches. 4A complete list of the references for the studies status as an actual mediator (Hawkins For example, Project MATCH compared included in this analysis is available from the et al. 1986, 1989). In the remaining CBST with motivational enhancement authors of this article.

80 Alcohol Research & Health Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence

come of patients receiving either an Together these analyses suggest that particularly well to CBST. The results alternative treatment or no aftercare. CBST is but one theoretically coherent of this research, as follows, have been None of those studies found any signif- treatment that can improve the outcome mixed, however, and even contradictory: icant differences in effectiveness between of alcohol-dependent patients. In con- CBST and the comparison treatments trast with previous assessments, the find- • Two studies found that patients (i.e., including no aftercare). ings further indicate that CBST is more with a high degree of sociopathy or effective than other therapeutic approaches with antisocial personality disorder Effectiveness of CBST as a Component only when added as a component to an had better drinking outcomes when of a More Comprehensive Therapy. In ongoing therapy but not when delivered treated with CBST than when addition to being a stand-alone treat- as stand-alone therapy or aftercare. These treated with approaches aimed at ment, CBST has been included as a observations, coupled with the previously improving interpersonal relationships component of other treatments, such reported finding that the mechanisms (Kadden et al. 1989; Longabaugh et as inpatient AOD-abuse treatment. A underlying CBST’s effectiveness remain al. 1994). More recent studies, how- total of 21 studies have evaluated CBST unknown, indicate that less evidence ever, have failed to confirm this asso- in this context. In 15 of those studies exists for CBST’s effectiveness than pre- ciation or matching effect (Project (71 percent), CBST was found to be viously believed. MATCH 1997a,b; Kalman et al. more effective than the comparison 1996). treatment, whereas no differences in CBST and Treatment Matching. Even effectiveness existed in the remaining 6 if CBST is not generally more effective • Some researchers have hypothesized studies (29 percent). Thus, patients who than other therapies in the treatment of that patients with deficits in social receive CBST as a component of a more alcohol-dependent patients, CBST is skills would be most likely to benefit comprehensive ongoing treatment are still possibly superior to other approaches from CBST (Kadden et al. 1992). likely to have better drinking-related under certain circumstances. Thus, Studies investigating this hypothesis outcomes than patients who do not CBST may be particularly effective dur- have yielded mixed results, however, receive CBST. ing certain treatment phases, in specific and two recent studies even suggest high-risk situations, or with patients the opposite relationship. According CBST Effectiveness and Strength of with certain characteristics. Given CBST’s to those studies, patients with low Comparison Treatments. The effective- focus on relapse prevention, it would problem-solving skills (Jaffe et al. ness of CBST also can be evaluated by appear plausible that CBST could be 1996) or greater alcohol-related social assessing the presumed effectiveness, or superior to other treatments when used dysfunction (Longabaugh et al. “strength,” of the treatment with which as aftercare therapy, because patients 1999) were less likely to benefit from CBST was compared. Such analyses who receive aftercare face day-to-day CBST than from more socially sup- have demonstrated that the stronger the situations that they may not encounter portive treatment approaches. For alternative therapy was, the less likely during a more intensive prior inpatient example, Longabaugh and colleagues CBST was to be more effective than the treatment phase. For example, a patient (1999) found that patients with comparison treatment. For example, who is being trained in drink-refusal lower social-functioning skills had when patients receiving CBST were skills might be more apt to encounter better drinking outcomes when compared with patients receiving no such situations during the aftercare treated with 12-step facilitation ther- additional therapy, CBST-treated patients phase of treatment than during primary apy, a treatment aimed at involving had better drinking-related outcomes treatment. As described in the previous patients in Alcoholics Anonymous in 67 percent of the comparisons. When section, however, this assumption does (AA), a mutual self-help group, than compared with treatments that were not appear to be valid. Similarly, although when treated with CBST. likely to be ineffective, such as a general Marlatt’s classification of relapse situations discussion group, CBST was more has provided a framework for designing • Investigators also have hypothesized effective than the comparison treatment CBST approaches to improve appro- that patients with more severe psy- in 50 percent of the comparisons and priate coping skills (Marlatt and Gordon chiatric dysfunction would respond equally effective in the remaining 50 1985), little data suggest that those better to CBST than to treatments percent of the comparisons. Finally, coping skills are more effective in some that do not focus on psychiatric when CBST was compared with treat- high-risk relapse situations than in oth- impairment (Kadden et al. 1989). ments that had a solid theoretical basis ers. For example, researchers do not yet Again, the results of studies assessing (i.e., were theoretically coherent) and know whether patients might more this proposition are contradictory therefore could be expected to be effective, effectively resist drinking when they are (Kadden et al. 1989; Project MATCH CBST was more effective in one com- feeling unhappy than when a friend is 1997a,b). parison (10 percent of comparisons), offering them a drink. This issue certainly less effective in another comparison (10 warrants further investigation. • For two patient characteristics that percent), and equally effective in the Several studies have attempted to iden- have been thought to be associated remaining eight comparisons (80 percent). tify patient subgroups that may respond with lowered rates of CBST success—

Vol. 23, No. 2, 1999 81 cognitive impairment and greater use the same mechanisms of change as and applied in real-life situations before alcohol dependence—clinical studies do CBST patients (Finney et al. 1998). the therapist can conclude that the patient also have yielded equivocal results. Both patients receiving CBST and those has adequately acquired the skills. Again, For example, conflicting evidence receiving 12-step facilitation therapy, for however, such demonstrations generally exists as to whether mildly to mod- example, are less likely to spend time in have not been a component of CBST erately cognitively impaired patients settings that used to be associated with research studies. Consequently, some benefit less from CBST than from drinking. Furthermore, some researchers patients in those studies may have never alternative treatments (Jaffe et al. 1996; have incorporated CBST-based relapse- mastered the necessary skills, thereby Project MATCH 1997a,b). Similarly, prevention strategies into 12-step pro- reducing the effectiveness of CBST. The evidence suggesting that patients grams (Gorski and Miller 1982). number of treatment sessions in CBST with different severity of alcohol research studies generally averages about dependence will respond differently 12. It is possible that this number is too to various treatment approaches is low for CBST to develop its full effect. also mixed. Most recently, Project CBST assumes that MATCH found that among patients Broadening CBST’s Focus exhibiting fewer symptoms of alco- the patient already hol dependence, those treated with is motivated to Assuming, however, that the CBST CBST in an aftercare setting had approaches tested in research studies better treatment outcomes than those stop or reduce adequately reflect the treatment admin- treated with a 12-step program. istered in real-life clinical settings and Conversely, among patients exhibiting drinking and that that the reported results therefore accu- more symptoms of alcohol depen- he or she only rately represent CBST’s effectiveness, dence, those who received CBST the findings reported in this article had worse outcomes than those who needs to acquire clearly demonstrate that CBST’s effec- received 12-step-oriented therapy tiveness could be increased appreciably. (Project MATCH 1997b). the skills to do so. One approach to doing so could be to incorporate components of other effective In summary, although some evidence therapies, just as other therapies have supports the hypothesis that CBST Third, the studies that have tested broadened their focus and enhanced efficacy differs among various patient CBST’s effectiveness and mechanisms their effectiveness by including CBST subtypes, the results of relevant studies of action may not have shown complete strategies. Several possibilities exist for are mixed and the extent of any observed fidelity to the tenets of CBST’s concep- this approach. association generally is small. Con- tual framework. For example, one key First, motivational interviewing—a sequently, more studies and stronger element of CBST is a detailed analysis strategy aimed at increasing the patient’s evidence will be needed before one can of each patient’s drinking pattern to motivation for change—has been found draw the conclusion that CBST is more identify individual antecedents and to increase the effectiveness of other effective than other treatment approaches consequences of drinking. The results treatment approaches (e.g., Brown and for specific patient subgroups. of this functional analysis provide the Miller 1993). As commonly delivered, basis for developing that patient’s specific CBST assumes that the patient already treatment plan. Such a plan can indicate is motivated to stop or reduce drinking Future Directions which situations the patient should and that he or she only needs to acquire for Research avoid, how the patient should deal with the skills to do so. This assumption, those situations if they do occur, and however, may not always be correct, and Several factors may contribute to the which alternative behaviors (other than some patients may have the appropriate apparent lack of difference in effectiveness drinking) the patient should use to cope coping skills but lack the motivation to between CBST and other theoretically with problematic situations. However, use them. For those patients, the incor- coherent treatment alternatives and few research studies of CBST’s effective- poration of motivational interviewing may explain the differences in outcome ness—and none of the studies reviewed into CBST could increase skill use. compared with earlier studies. First, in the previous sections—have included Second, research has consistently alternative treatments may have improved individualized functional analyses to shown that patient involvement in self- in efficacy over time. Second, as a result guide the treatment of individual patients. help groups, such as AA, is associated of changes in other treatment approaches, Instead, therapies used in those studies with positive drinking outcomes (e.g., CBST may no longer be as distinctive have relied on teaching social skills for Tonigan et al. 1996). CBST could easily as it used to be. For example, studies of dealing with commonly occurring incorporate a referral module to increase the active ingredients of CBST have sug- problematic situations. the likelihood that patients become gested that patients receiving alterna- Another tenet of CBST is that the involved in mutual self-help groups. tive treatments (e.g., 12-step therapy) skills to be learned should be mastered The incorporation of such an element

82 Alcohol Research & Health Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence into the CBST treatment plan may (e.g., an alcoholic beverage) and taught learning theory (e.g., self-help groups potentiate CBST effectiveness, particu- skills to cope with these cues. The re- and pharmacotherapies). Given all larly if it involves self-help groups with peated exposure to alcohol cues is thought these suggestions for adding components belief systems similar to those underlying to eliminate, or extinguish, the previous to CBST and for intensifying CBST CBST (e.g., SMART Recovery [1995]). responses to those cues (i.e., craving approaches, the question arises: How In SMART, the underlying assumption, and drinking). (For more information could such extensive treatment be pro- like in CBST, is that alcohol consump- on cue-exposure therapy, see the article vided to all alcohol-dependent patients? tion is at least in part a learned mal- in this issue by Monti and Rohsenow, The answer is that most likely such an adaptive behavior that the person has pp. 107–115.) all-encompassing treatment approach within himself or herself the power to Fifth, although current CBST thera- would not be necessary for each patient, change. In contrast, an AA belief is that pies generally focus on teaching skills because most patients would not need the individual is powerless to change for coping with situations with high to be exposed to each of the treatment his or her drinking without the help risk for relapse, early studies of CBST’s components. Instead, each patient of a “higher power.” Consequently, effectiveness also frequently included could be matched to the specific treat- patients treated with CBST who are general social-skills training. This ment elements that he or she needs. referred to AA may experience difficulty approach was based on the assumption Along those lines, several matching in the shift in belief system about what that if a patient lacks general skills for studies have attempted to link specific it takes to get better. coping with life’s demands, failures in patient characteristics to different treat- Third, several studies have demon- coping may lead to general unhappiness. ment requirements. For example, in the strated the effectiveness of therapeutic Unhappy people, in turn, may not be previously mentioned Project MATCH approaches that aim to incorporate one motivated to deprive themselves of the study, patients were randomly assigned or more significant others into the treat- transient reduction in distress that may to one of three standardized and largely ment of people with alcohol problems, follow alcohol consumption. Conse- uniformly delivered treatments—CBST, such as BMT (O’Farrell 1989) and CRA quently, current CBST therapies might motivational enhancement therapy, and (Meyers and Smith 1995). Similar to be improved by refocusing, at least in 12-step facilitation therapy—in order CBST, these therapies seek to modify part, on assisting patients to learn general to identify patient characteristics that the ways in which a patient responds to skills for coping with life. would allow selection of the most appro- a stimulus to drink and the consequences Finally, in addition to incorporating priate therapy. In contrast, this article that the patient will experience depend- elements of other psychosocial therapy proposes that a single treatment be ing on whether or not he or she does approaches, CBST also might benefit developed that allows for selecting spe- take a drink. By modifying the patient’s from the addition of pharmacotherapies. cific components of one comprehensive response, the patient will be more likely For example, the medication acam- approach to match each patient’s prefer- to maintain sobriety in order to achieve prosate5 has been found to be useful in ence or need. Such a matching process well-being. In contrast with CBST, delaying relapse (Litten and Allen 1991), could be conducted by using decision however, BMT and CRA enlist signifi- and the medication naltrexone has trees that triage patients through a menu cant others from the patient’s social been shown to reduce heavy drinking of options based on their stated prefer- environment directly into the treatment; following a relapse (e.g., O’Malley et al. ences or assessed needs. For example, a thus, the quality of the patient’s rela- 1992). The addition of such pharma- patient who feels a greater need to learn tionships with those significant others ceutical agents to CBST might provide better communication skills might can be enhanced and made contingent patients with a buffer against urges to select this module instead of a module on sobriety (Longabaugh et al. 1995). reinitiate drinking or drink to excess, that focused on mood management. The incorporation of environmental thereby expanding the patient’s oppor- Two such treatment modalities are factors into CBST also may increase tunity to learn the skills that can help currently being developed for implemen- therapeutic control over the reinforcing avoid a relapse. tation with alcohol-dependent patients. factors that can help a patient maintain One of these modalities, which com- an alcohol-free lifestyle. bines pharmacotherapy with behavioral Fourth, CBST might easily incorpo- A Next-Generation, therapy, is being studied in Project rate treatment strategies based on clas- Broad-Spectrum COMBINE, a multicenter randomized sical conditioning procedures, such Behavioral Treatment clinical trial being conducted by the as cue exposure (Monti et al. 1993). National Institute on Alcohol Abuse Classical conditioning posits that stimuli As suggested in the preceding section, and Alcoholism in collaboration with or cues that repeatedly have co-occurred the focus and effectiveness of CBST 11 universities. In this study, the behav- with drinking (e.g., the sight of a bar or could be broadened by incorporating ioral therapy component combines the smell of alcohol) eventually can elicit important ingredients from other motivational interviewing, referral to craving for alcohol and precipitate drink- broad-spectrum behavioral treatments ing. During cue exposure, patients are and from therapies that have not arisen 5Acamprosate has not yet been approved for com- directly exposed to alcohol-related stimuli from, but are compatible with, social mercial use in the United States.

Vol. 23, No. 2, 1999 83 mutual self-help groups, and involvement the menu of treatment options are incor- results that can be generalized, it may of a supportive significant other, and porated into the treatment plan. Further- not be necessary to deliver the same selection of coping-skills modules more, the choice of treatment modules standard treatment to all patients but based on patient preference. With that can be reevaluated and adjusted as the to apply the same decision trees to all approach, patients first develop self- patient’s alcohol-related problems patients. If uniform decision trees are change plans based on assessments of change during treatment. used, the selection of treatment mod- the feedback they have received regard- Both the treatment delivered in ules based on those decision trees will ing the effects of their drinking on Project COMBINE and Broad be consistent, and the resulting treat- their lives. Subsequently, patients select Spectrum Therapy are, of course, not ments can be replicated and generalized the appropriate options from a menu unlike CBST delivered by many com- to everyday clinical practice. of coping-skills modules to facilitate petent therapists in everyday clinical Clinical research testing the effec- execution of their self-change plans. practice. Thus, individualized treatment tiveness of such an approach to treat- The second example of a CBST plans are developed and implemented ment will evaluate the efficacy of the approach that is driven by decision trees for many patients in response to patient underlying principles of the treatment based on assessed patient strengths and preference and therapist assessment of rather than the implementation of the deficits is called Broad Spectrum Therapy, need. In clinical research, however, specific package selected by each indi- a methodology developed by Gulliver treatment generally has been standard- vidual patient. Thus, study results would and Longabaugh (Longabaugh 1999). ized so that all patients are offered more tell researchers whether using decision In this approach, a systematic assessment or less the same treatment because of trees as a generic guiding principle of the patient’s strengths and deficits researchers’ fears that results obtained improves patient outcomes. Such stud- becomes the basis for designing an indi- with less uniform protocols cannot be ies would provide less information, vidualized treatment plan (see figure generalized outside of the research set- however, on whether specific alternatives below). Depending on the emergent ting. The authors of this article pro- chosen by patients using each of these patient profile, different modules within pose, however, that in order to obtain decision trees are helpful. Consequently,

Does the patient have a high investment in his or her social network?

Yes No

Patient’s social Patient’s social Patient’s social Patient’s social network supports network supports network supports network supports abstinence drinking abstinence drinking

No intervention 1. Decrease patient’s Increase patient’s Assess value of investment in his or investment in his social network her social network or or her social network to patient decrease network’s support for drinking

2. Involve patient in AA* and/or other mutual self-help support group

An example of a decision tree for assessing a patient’s social network. The therapist first assesses how highly invested the patient is in his or her social network (i.e., How many people are in the patient’s social network? How much time does the patient spend with them? Does the patient regard the members of his or her social network as important?). Next, the therapist evaluates whether the network supports the patient’s drinking or abstinence. Network members who support drinking frequently drink themselves, drink a lot per drinking occasion, and encourage or accept the patient’s drinking. Finally, the therapist determines the patient’s treatment based on the assessment of this information.

*AA = Alcoholics Anonymous.

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