C O G N I T T H E R A S U B S T A B U S I V P E Y A O N C F E E -^ ^'^ySi:'yf^'^''->->*' 'r ^'i-'Mt #''a^K"'-M>' • M ^ i € • ^^ M'^:: • A A R O N T B E C K •^•rf- F R E D C O R Y D F B R U C E W R I G H T N S E W H A N L I E S E COGNITIVE THERAPY OF SUBSTANCE ABUSE C o g n i t i v e o f T h e r a p y S u b s t a n c e A b u s e A a r o n T Beck, M D Fred D Wright, Ed.D C o r y F N e w m a n , Ph.D Bruce S Liese, Ph.D T H E G U I L F O R D PRESS N e w York London ©1993 The Guilford Press A Division of Guilford PubHcations, Inc 72 Spring Street, New York, N Y 10012 www.guilford.com All rights reserved No part of this book may be reproduced, stored in a retrieval s or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Printed in the United States of America This book is printed on acid-free paper Last digit is print number: Library of Congress Cataloging-in-Publication Data Cognitive therapy of substance abuse / Aaron T Beck [et al p cm Includes bibliographical references and index ISBN 0-89862-115-1 (he.) ISBN 1-57230-659-9 (pbk.) Substance Abuse—Treatment Cognitive therapy I Beck, Aaron T [DNLM: Cognitive therapy—methods Substance Abuse— therapy W M 270 C6765 1993] RC564.C623 1993 616.86'0651—dc20 DNLM/DLC for Library of Congress 93-5208 CIP To Phyllis, G w e n , Jane, a n d Ziana P r e f a c e s L-#ubstance abuse i widely recognized as a serious s social and legal problem In fact, the use of illegal drugs m a y be responsible for more than % of property crimes and % of violent crimes Financial losses related to these crimes have been estimated at $1.7 billion per year Homicides are also strongly linked to drug dealing Approximately % of homicides per year are causally related to drugs The costs for criminal justice activities directed against drug trafficking on the federal level were approximately $2.5 billion in 1988, compared to $1.76 billion spent in 1986 There are also m a n y health problems caused by these drugs Alcohol can damage almost every body organ, including the heart, brain, liver, and stomach Illegal drugs such as cocaine can have a serious effect on the neurological, cardiovascular, and respiratory systems Cigarettes can cause cancer, heart disease, and more The most widely used and abused drug in the world is alcohol In the United States, two-thirds of the population drink alcohol About ten out of a hundred people have problems with alcohol so serious that they can be considered "alcoholic" or "alcohol-dependent." (Interestingly, this % of Americans buys and drinks more than half of the alcoholic beverages!) At least 14 million Americans take illegal drugs every month During "peak months" this number climbs to more than 25 million users S o m e experts have estimated that approximately 2.3% of Americans over 12 years of age have a problem with illegal drugs serious enough to warrant drug treatment To a large degree, w e have tried to put a halt to drug abuse by making drugs illegal For example, heroin and cocaine are presently illegal in the United States Cigarette smoking is becoming increasingly proscribed At one time w e tried to stop alcoholism by legal Vl l via Preface mechanisms (i.e., prohibition) Obviously, these methods will never make substances completely unavailable Not all people w h o use drugs become addicted to them, although m a n y people have asked themselves, " A m I [or is someone else] an alcoholic [or a substance abuser]?" The American Psychiatric Association has defined the addictions very specifically In fact, the official term for an addiction is "substance dependence." There are some specific signs of substance dependence, including (1) heavy use of the substance, (2) continued use even though i m a y cause problems to t the person, (3) tolerance, and (4) withdrawal symptoms Cultural and historical factors are implicated in substance use and abuse The patterns and consequences of drug use have been influenced by historical developments, which have had positive and negative effects T w o centuries ago, the extraction of pure chemicals from plant materials created more powerful medicinal agents The invention of the hypodermic needle in the middle of the nineteenth century was also a medical boon, which, on the other hand, allowed drug users to circumvent the body's natural biological controls consisting of bitter taste and slow absorption through the digestive tract M a n y synthetic drugs developed in the twentieth century had medical application but created further opportunities for abuse and addiction In short, any activity that affects the reward mechanisms of the brain m a y lead to compulsive, self-defeating behavior Social, environmental, and personality factors have affected substance use and abuse in ways that go far beyond the simple pharmacological properties of these agents Alcoholism, for example, i prevas lent among certain ethnic groups and practically absent among others, such as the Mormons, w h o require abstinence for group acceptance O n the other hand, other social subgroups m a y condition group acceptance on using or drinking The social milieu m a y influence using Soldiers used illegal drugs extensively in Vietnam but, for the most part, relinquished heavy drug use after returning home Impoverished environments have been shown in both animal experiments and h u m a n studies to lead to addiction As pointed out by Peele, the comm o n denominator i the lack of other opportunities for satisfaction s Finally, our clinical experiences have indicated that addicted individuals have certain clusters of addictive attitudes that make them abusers rather than users Successful treatment depends on clinicians' effectiveness in dealing with these addictive potentials And what form will this care take? As pointed out by Marc Galanter, president of the American Academy of Psychiatrists in Alcoholism and Addiction, the long-term efficacy of new pharmacological treatments i open to question "Tricyclics, s Preface ix dopaminergic agents, and carbamazapine for cocaine abusers have yet to be substantiated as a vehicle for continuing care For opiates, naltrexone and buprenorphine offer only a modest niche in the domain that was traditionally occupied by methadone maintenance Intervention in GABAergic transmission m a y hold promise for alcohoHsm, but that promise is far from clinical application" (Galanter, 1993, pp 1-2) W e have written this book in response to the ever-growing need to formulate and test cost-effective treatments for substance abuse disorders, problems that seem to be multiplying in the population in spite of society's best efforts at international interdiction and domestic control and education W e believe that cognitive therapy, a welldocumented and demonstrably efficacious treatment model, can be a major boon to meeting this pressing need At one time, "drug abuse rehabilitation counseling" was regarded as a specialty area in the field of psychotherapy—now i i apparent t s that almost all w h o engage in clinical practice will encounter patients w h o use and abuse drugs Therefore, i would be desirable for all t mental health professionals to receive some sort of routine training and education in the social and psychological phenomena that comprise the addiction disorders Our volume i intended to provide a s thorough, detailed set of methods that can be of immediate use to therapists and counselors—regardless of the amount of experience they might have had with cognitive therapy, or in the field of addictions Toward this end, w e have strived to make our model and our procedures as specific and complete as possible W e certainly recommend that those w h o read this book also read the m a n y valuable sources w e have cited in the text Nevertheless, our intention in writing Cognitive Therapy of Substance Abuse has been to provide a convenient, centralized source that is comprehensive, teachable, and testable Although advances in the field have been made in the form of pharmacological interventions (e.g., antabuse, methadone, and naltrexone), 12-step support groups (e.g Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous), and social-learning models and programs (relapse prevention, rational recovery, etc.), each of these approaches has posed problems that limit i s respective potent tial efficacy For example, pharmacological interventions have produced promising short-term data but are fraught with compliance and long-term maintenance difficulties^atients m a y not take their chemical agonists and antagonists, and they are prone to relapse w h e n the medications are discontinued Twelve-step programs provide valuable social support and consistent guidance principles for individuals w h o voluntarily join and faithfully attend the program meetings, but can- 342 References ins, L.M., George, L.K., Karno, M., & Locke, B.Z (1988) One-month prevalence of mental disorders in the United States Archives of General Psychiatry, 45, 977-986 Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K (1990) Comorbidity of mental disorders with alcohol and other drag abuse: Results from the Epidemiological Catchment Area (ECA) sfady Journal of the American Medical Association, 264(19), 25112518 Robins, L.N., Davis, D.H., & Goodwin, D.W (1974) Drag use by U.S army enlisted m e n in Vietnam: A follow-up on their refarn home American Journal of Epidemiology, 99, 235-249 Ross, H.E., Glaser, F.B., & Germanson, T (1988) The prevalence of psychiatric disorders in patients with alcohol and other drag problems Archives of General Psychiatry, 45, 1023-1031 Rounsaville, B.J., Anton, S.F., Carroll, K., Budde, D., Prasoff, B.A., & Gawin, F (1991) Psychiatric diagnoses of 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(1992) Prob lem drinkers' perceptions of whether treatment goals should be selfselected or therapist selected Behavior Therapy, 23, 43-52 Spitzer, R.L., Williams, J.B.W., & Gibbon, M (1987) Instruction manual for the Stmctured Clinical Interview for the DSM-III-R (SCID) N e w York: N e w York State Psychiatric Institute Stabenau, J.R (1984) Implications of family history of alcoholism, antisocial personaUty, and sex differences in alcohol dependence American Journal of Psychiatry, 141(10), 1178-1182 Stacy, A.W., N e w c o m b , M.D., & Bentier, P.M (1991) Cognitive motivation and drag use: A 9-year longifadinal sfady Journal of Abnormal Psychology, 100(4), 501-515 Stimmel, B (1991) The facts about drug use: Coping with drugs and alcohol in your family, at work, in your community N e w York: Consumer Reports Books Stine, S.M (1992) Cocaine abuse within methadone maintenance programs In T.R Kosten & H.D Kleber (Eds.), Clinician's guide to cocaine addiction: Theory, research, and treatment (pp 359-373) N e w York: Guilford Stitzer, M.L., Grabowski, J , & Henningfield, J.E (1984) Behavioral interven tions in drug abuse treatment In J Grabowski, M.L Stitzer, & J.E Henningfield (Eds.), Behavioral techniques in drug abuse treatment (Research Monograph No 46) Rockville, M D : National Instifate on Drag Abuse Tarter, R.E., Ott, P.J., & Mezzich, A.C (1991) Psychometric assessment In R.J Frances & S.I Miller (Eds.), Clinical textbook of addictive disorders (pp 237-267) N e w York: GuUford Thomason, H.H., & Dilts, S.L (1991) Opioids In R.J Frances & S.l Miller (Eds.), Clinical textbook of addictive disorders (pp 103-120) N e w York: Guilford Tiffany, S.T (1990) A cognitive model of drag urges and drag-use behavior: Role of automatic and non-automatic processes Psychological Review, 97, 147-168 Tucker, J.A., & Sobell, L.C (1992) Influences on help-seeking for drinking problems and o n nafaral recovery without treatment Behavior Therapist, IS, 12-14 Vaillant, G.E (1983) The natural history of alcoholism: Causes, patterns, and paths to recovery Cambridge, M A : Harvard University Press Velten, E (1986) Withdrawal from heroin and methadone with rationalemotive therapy: Practice and theory British Journal of Cognitive Psychotherapy, 4, 19-24 Walfish, S., Massey, R., & Krone, A (1990) Anxiety and anger a m o n g abusers of different substances Drug and Alcohol Dependence, 25, 253-256 Washton, A.M (1988) Preventing relapse to cocaine Journal of Clinical Psychiatry, 49, 34-38 344 References Watkins, K., Metzger, D., Woody, G., & McLellan, A.T (1991, April) The sexual behaviors of intravenous drug users: Implications for the spread of HIV infection Paper presented at the University of Pennsylvania Department of Psychiatry Research Retreat, Philadelphia, PA Weiner, H., & Fox, S (1982) Cognitive-behavioral therapy with substance abusers Social Casework, 63, 564-567 Weinstein, S.P., Gottheil, E., & Steriing, R.C (1992) Cocaine users in medical practice: A five-year follow-up American Journal of Drug and Alcohol Abuse, 18, 157-166 Weiss, C.J., & MUlman, R.B (1991) Hallucinogens, phencyclidine, marijuana, inhalants In R.J Frances & S.I Miller (Eds.), Clinical textbook of addictive disorders (pp 146-170) N e w York: Guilford Weiss, R.D (1992) The role of psychopathology in the transition from drag use to abuse and dependence In M.D Glantz & R.W Pickens (Eds.), Vulnerability to d m g abuse (pp 137-148) Washington, D C : American Psychological Association Weissman, A.N., & Beck, A.T (1978) Development and validation of the Dysfunctional Attitudes Scale: A preliminary investigation Paper presented at the Annual Meeting of the American Educational Research Association, Toronto, Canada Westermeyer, J (1991) Historical and social context of psychoactive substance disorders In R.J Frances & S.I Miller (Eds.), Clinical textbook of addictive disorders (pp 23-40) N e w York: Guilford Wills, T.A., & Shiffman, S (1985) Coping and substance use: Concepfaal framework In S Shiffman & T.A Wills, (Eds.), Coping and substance use (pp 3-24) N e w York: Academic Press Wilson, G.T (1987a) Cognitive sfadies in alcoholism Journal of Consulting and Clinical Psychology, 55(3), 325-331 Wilson, G.T (1987b) Cognitive processes in addiction British Journal of Addiction, 82, 343-353 Wilson, G.T (1988) Alcohol and anxiety Behavioral Research and Therapy, 26(5), 369-381 Wolf, A.W., Schubert, D.S.P., Patterson, M.B., Grande, T.P., Brocco, K.J., & Pendleton, L (1988) Associations a m o n g major psychiatric diagnoses Journal of Consulting and Clinical Psychology, 56(2), 292-294 Woody, G.E., Luborsky L, McLellan, A.T., O'Brien, C.P., Beck, A.T., Blaine, J., Herman, I., & Hole, A (1983) Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry, 40, 1081-1086 W o o d y , G.E., McLellan, A.T., & O'Brien, C P (1990) Research on psychopathology and addiction: Treatment implications D m g and Alcohol Dependence, 25, 121-123 W o o d y , G.E., Urschel, H C IH, & Alterman, A (1992) The m a n y paths to drug dependence In M.D Glantz & R.W Pickens (Eds.), Vulnerability to d m g abuse (pp 491-507) Washington D C : American Psychological Association Young, J.E (1990) Cognitive therapy for personality disorders: A schema-focused approach Sarasota FL: Professional Resource Exchange References 345 Zanarini, M.C, Gunderson, J.G., & Frankenburg, F.R (1989) Axis I phenomenology of borderline personality disorder Comprehensive Psychiatry, 30(2), 149-156 Ziedonis, D.M (1992) Comorbid psychopathology and cocaine addiction In T.R Kosten & H.D Kleber (Eds.), Clinician's guide to cocaine addiction: Theory, research, and treatment (pp 335-358) N e w York: Guilford Zotter, D.L., & Crowther, J.H (1991) The role of cognitions in bulimia nervosa Cognitive Therapy and Research, 15, 413-426 Zung, W.W.K (1986) Prevalence of clinically significant anxiety in a family practice setting American Journal of Psychiatry, 243(11), 1471-1472 Author Index Abrams, D.B., 13 Adlaf, E.M., Alberti, R.E., 254, 264, 286 Allsop, S., 292 Alterman, A.I., 7, 51, 236, 273, 281 Amaro, H., 196, 220, 252 Ananth, J , 10 Anderson, L.R., 33 Annis, H.M., 157 Arif, A., Arnold, M., Auerbach, A.H., 109, 136, 185 Brown, G., 94 Brown, S.A., 33 Brown, V.B., 10, 268 Brownell, K.D., 11 Bunt, G., 10 Buriing, T.A., 228 Burns, D.D., 109, 117, 136, 143, 185, 327 Cabral, H., 196 Cacciola, J.S., 236, 281 Cameron, D.C, Carey, K.B., 187, 270, 272 Carroll, K.M., 30, 32, 57, 124, 152, 154, Babor, T.F., 157, 298, 299, 300, 301, 302, 307, Baker, CD., 315 Baker, T.B., 12 Castaneda, R., 10, 27, 59, 152, 158 Bandura, A., 13, 33 Chalkley, A.J., 264 Barnett, L.W., 10, U Chang, G., 206 Baumeister, R.F., 38 Chiasson, R.E., 209 Beck, A.T., 10, 14, 27, 35, 42, 48, 49, 50, Chiauzzi, E.J., 11 51, 52, 69, 82, 93, 94, 95, 100, 135, Childress, A.R., 50, 51, 52, 157, 159, 302 140, 143, 169, 173, 226, 227, 230, Clark, D.M., 264 234, 244, 252, 258, 269, 273, 276, Clayton, R.R., 5, 289, 290, 291, 327 Closser, M.H., 197, 208 Beck, J.S., 86 Cohen, S., Beeder, A.B., 257 Collner, D., 254, 264, 286 Beitman, B.D., 257 Cooper, A.M., 269 Bentler, P.M., 13 Covi, L, 7, 55, 124, 157 Bernstein, D.A., 168, 264 Crowther, J.H., 38 Blackburn, I.M., 108 Cummings, C, 308 Blane, H.T., 12 Cummings, N.A., 216, 271, 280 Bogardis, J , 16 D'Aulaire, E., Borkovec, T.D., 168, 264 Davidson, K.M., 108 Bowser, B.F., 209 Davis, C.W., 27 Branch, L.G., 10, 11 Davis, D.H., 24 Brecher, E.M., 3, 5, Davis, D.I., 10 Brocco, K.J., 268 DePhilippis, D., 50 Brodsky, A., 346 Author Index DiClemente, C.C, 15 DiGiuseppe, R., 28 Dilts, S.L., Donovan, D.M., 292 Doren, D.M., 280, 281, 285, 286 Drake, R.E., 269 D'Zurilla, T.J., 290 347 Gross, S.A., 209 Grossman, J , 203, 208 Gunderson, J.G., 269, 279 Haaga, D.A.F., 13, 285 Hall, S.M., 28, 167, 229 Haller, D.L., Hansen, K.V., EUinwood, E.H., 6, 7, 25, 31, 37, 51, 197 Harrison, R., 95 Ellis, A., 28, 242, 244, 246 Harstone, E., Emery, G., 27, 42, 327 Hatsukami, D., 27, 234 Emmons, L., 254, 264, 286 Havassy, B.E., 28, 57, 124, 167, 301 Epstein, N., 94, 95 Heath, A.W., Erbaugh, J , 93 Heatherton, T.F., 38 Estroff, T.W., Helzer, J.E., 257, 268 Evans, K., 59, 268 Henningfield, J.E., 8, 9, 126 Hermalin, J , 150, 194, 253, 254 Fingarette, H., Hess, J.M., Fiore, M.C, Hesselbrock, M.N., 10, 257, 268 Fishman, B., 209, 329 Hesselbrock, V.M., 268 Fox, S., 57, 76 Hester, R.K., 14, 17, 18, 19 Frances, R.J., 5, 23, 55, 77, 209, 301, 308 Hole, A., 50 Franco, H., 27 HoUon, S.D., 10 Frankenburg, F.R., 269 Horney, K., 244 Freeman, A., 49, 288 Horvath, A.T., 25, 31, 32, 37, 152, 157, Fried, L.E., 196 163, 166, 301 FuUilove, M.T., 209 Hudson, C.J., 257 Fullilove, R.E., 209 Hunt, W.A., 10, 11 Inn, A., 33 Isbell, P.G., 276 Galanter, M., 10, 27 Garrison, B., 94 Gaspari, J.P., 27 Jellinek, E.M., Gawin, F.H., 6, 7, 25, 30, 37, 51, 57, 197, Jennings, P.S., 25, 130 207, 246, 272, 296 Jones, R.T., Germanson, T., 10 Gibbon, M., 226 Kaplan, J , 257 Gilmore, M.M., 269 Kaplan, R.D., 269 Glantz, M., 246 Karan, L.D., 3, 6, 7, 34, 276 Glaser, F.B., 10 Keller, D.S., 30, 32, 57, 124, 152, 154, Goldfried, M.R., 290 157, 298, 299, 300, 301, 302, 307, Goldman, M.S., 33 315 Goldsmith, M.F., 209 Kenner, J J , 10, 257, 268 Gomberg, E.S.L., 192 Khantzian, E.J., 27, 152, 158, 269 Good, S.P., Kleber, H.D., 23, 25, 27, 59, 207, 246, Goodwin, D.W., 3, 24 272, 296 Gordon, J.R., 11, 12, 31, 33, 37, 47, 49, Klein, D.F., 257 293, 303, 306, 308 Koenigsberg, H.W., 269 Gorski, T.T., 12, 298 Korner, P., Gottheil, E., Kosten, T.R., 23, 59, 212, 236 Grabowski, J , 8, 126 Kovacs, M., 94 Grande, T.P., 268 Kranzler, H.R., 10, 27, 257 Grant, M., Krone, A., 27 Greenberg, J , 194 Kushner, M.G., 257, 258 Greenberg, R.L., 42 348 Author Index LaBounty, LP., 27, 257 Ung, A.R., 192 Layden, M.A., 288, 289, 290 Leo, G.I., 16 Leonard, K.E., 12 Lester, D., 94 Levin, J.D., Levine, I.S., 10 Lewis, C.E., 268 Lichtenstein, E., 11 Liebowitz, N.R., 10, 27, 257 Lifshutz, H., 10 Linehan, M.M., 290 Ling, W., 236 Lingswiler, V.M., 38 Linnoila, M.L, 257 Lyon, D., 194 Mackay, P.W., 66, 292, 293, 301, 302, 308 Marlatt, G.A., 11, 12, 13, 14, 16, 31, 33, 37, 47, 49, 66, 292, 293, 303, 306, 308 Marzuk, P.M., 216, 240 Massey, R., 27 McCann, M.J., 236 McCord, J , McDermut, W., 13 Mclnerney, J.F., 28 McLellan, A.T., 7, 18, 51, 124, 209, 236 Mendelson, M., 93 Metzger, D., 209 Meyer, R.E., 10, 257, 268 Mezzich, A.C, 247 Miller, M., 12, 298 Miller, N.S., 9, 22, 271 Miller, R.L., Miller, S.L, 5, 23, 55, 77, 209, 301, 308 Miller, W.R., 4, 14, 17, 18, 19, 124 Millman, R.B., 5, 6, 257 Mirin, S.M., 27, 29, 227, 240 Mock, J , 93 Moltzen, J.O., 228 Moorey, S., 47, SO, 64, 151, 292 Morgan, S.F., 27 Morse, S.B., 288 MuUaney, J.A., 257 Munoz, R.F., Murray, G.F., 327, 59, 269, 276 Nace, E.P., 10, Musto, D.R., 10 Nathan, P.E., Nelson, L., 27 Newcomb, M.D., 13 Newman, C.F., 65, 70, 77, 82, 109, 211, 214, 285, 288, 290 Nezu, CM., 153 Nezu, A.M., 153, 290 Niaura, R.S., 13 Nirenberg, T.D., 59 Nolen-Hoeksema, S., 109 Norcross, J.C, 15 Novotny, T.E., O'Brien, C.P., 7, 48, 51, 167, 197, 236 O'Connell, D.F., 268 O'Connor, P.G., 206, 276 Obert, J.L., 236 Ola, P., Ott, P.J., 247 Overholser, J.C, 103, 136 Patterson, M.B., 268 Peele, S., 4, 23, 24 Penick, E.C, 10, 268 Pepper, B., 10 Perez, J.F., 57 Perioff, J.M., 109 Perri, M.G., 153 Persons, J.B., 10, 80, 109, 136, 185, 237, 291 Pickens, R.W., 27, 234, 246 Pierce, J.P., Piatt, J J , 150, 194, 253, 254 Pollin, W., Prochaska, J.O., 15, 26 Prochnow, H.Z., 292 Pryzbeck, T.R., 257, 268 Quitkin, F.M., 257 Rawson, R.A., 236 Regier, D.A., 10, 22, 27, 29, 226, 257, 268 Reilly, P.M., 228 Rice, J , 268 Ridgely, M.S., 10 Rifkin, A., 257 Robins, L., 268 Robins, L.N., 24 Rollnick, S., 14, 124 Ross, H.E., 10, 258, 268 Ross, S., 254, 264, 286 RounsaviUe, B.J., 27, 30, 32, 57, 59, 124, 152, 157, 226, 298, 299, 300, 301, 302, 307, 315 Rush, A.J., 27, 327 Rush, B., Ryglewicz, H., 10 Author Index Salkovskis, P.M., 264 Saunders, B., 292 Saxon, J J , 10, 269 Schneier, F.R., 10 SchnoU, S.H., Schottenfeld, R., 208 Schubert, D.S.P., 268 Schuckit, M.A., 258, 269 Schwartz, J.L., 19, 20 Shaw, B.F., 27, 327 Shayne, V.T., 13 Sher, K.J., 257 Shi, J , 206 Shifftnan, S., 296, 301 Shore, N., 10, 269 Shulman, G.D., 51, 157, 293 Siris, S.G., 10 Skinner, W., 16 Smart, R.G., 3, 7, 197, 208 Smith, D.P., 236 Sobell, L.C., 15, 16, 59, 81 Sobell, M.B., 16, 59 Spitzer, R.L, 226, 272 Stabenau, J.R., 268, 269 Stacy, A.W., 13 Stanton, M.D., Steer, R.A., 94, 100 Stephens, M.A.P., 38 Steriing, R.C, Stimmel, B., 22, 208, 209 Stine, S.M., Stitzer, M.L, 8, 126, 168, 232 Tarter, R.E., 247 268 Sullivan, J.M., 59, Thomason, H.H., Tiffany, S.T., 13, 30, 37, 157, 166 Treece, C, 269 Trexler, L., 94 349 Trippett, C.J., 257 Tucker, J.A., IS Urschel, H.C, 273 Vaillant, G.E., 269, 292 Velten, E., 31, 51 Walfish, S., 27, 242, 258 Ward, C.H., 93 Washton, A.M., 37, 157, 163, 302 Wasserman, D.A., 28, 167 Weiner, H., 57, 76 Weinstein, S.P., Weiss, C.J., 5, Weiss, R.D., 27, 29, 227, 240, 246 Weissman, A.N., 94, 173 Westermeyer, J , 2, Wilber, C , WiUiams, J.B.W., 226 Wills, T.A., 301 Wilson, G.T., 11, 13, 258 Wolf, A.W., 268, 269 Woody, G.E., 45, 209, 226, 236, 273, 281 Wright, F.D., 82, 211, 214, 311, 312, 313 Yeager, R.J., 28 Young, J.E., 290 Zanarini, M.C, 269, 279 Ziedonis, D.M., 25, 34, 236, 240 Ziff, D.C, 228 Zotter, D.L, 38 Zuckerman, B., 196 Zung, W.W.K., 257 Subject Index Assertive training, 253, 264 Abstinence, 2, 124-125; see also Relapse Attention deficit disorder, 246 prevention Abstinence Violation Effect (AVE), 12, 13, Attribution, 250 Automatic Thoughts about Substance 303 Abuse; see Psychometric inventories Action stage; see Stages of change Automatic thoughts, 44, 48, 55, 75, 82, Active listening, 150-151 114, 159, 229, 251, 264, 294 Addictive beliefs; see Beliefs examples of, 165 Advantages-disadvantages analysis; see five basic questions, 164 Techniques Autonomous craving, 32, 40 Agenda; see Structure Autonomy, 88-89, 93 Alcohol(ism) Alcoholics Anonymous; see Models of Beck Anxiety Inventoty; see Psychometric addiction inventories crimes associated with, Beck Depression Inventoty; see Psychohistory, metric inventories medical problems associated with, 4, Beck Hopelessness Scale; see Psychometmorbidity and mortality, 4, 226 ric inventories negative social consequences, Behavioral experiments; see Techniques prevalence, 1, 4, 226 Behavioral rehearsal; see Techniques role in illicit drug-abusing patients' Belief(s), 42-53, 169-186; see also therapy, 66 Schemas treatment interventions, 17-19 addictive, 38, 43-46, 52, 116, 169-189 Alcoholics Anonymous (12-step program); anticipatoty, ^ , 48, 53, 169 see Models of addiction conditional, 82 All-or-none thinking; see Cognitive conflicting, 46, 170-171 distortions control, 170, 178-185, 299, 300 Anger, 242-267 core (basic), 28-31, 37, 40, 43-14, 51, and abusive behavior, 252-253 140, 149, 201 low frustration tolerance, 242-248 drug-related, 30, 43, 48, 51, 82, 116, toward therapist, 251-252 149, 154, 293, 300 Anticipatoty beliefs; see Beliefs dysfunctional, 25-26, 32-33, 38, 40, Antisocial; see Personality disorders 227 Anxiety (disorders), 169, 242-267; see also facilitating, 48, 294 Anger levels of, 43 case conceptualization, 259 permissive (permission-giving), 31, 35cognitive therapy of, 258 36, 38, 46, 48, 53, 169 350 management of, 259, 262-264 and substance abuse, 23, 24, 257-267 Subject Index relief-oriented, 45, 48, S3, 169 romanticized beliefs, 45 substance-using, 42 system(s), 51-115, 171 Beliefs about Substance Use inventoty; see Psychometric inventories Black and white thinking; see Cognitive distortions, all-or-none thinking Borderline; see Personality disorders Bridge from last session; see Structure of therapy session Capsule summaries, 107-108, 172; see also Structure of therapy session Case conceptualization; see Case formulation Case formulation, 80-96, 135-136 anxiety, 259 case study of, 83-85 components, 80-85 definition, 10, 27 depression, 229-230 diagram of, 86 Ulusttation of, 90-93 questions and scales for, 93-95 Case formulation profiles; see also Case formulation cognitive, 85, 87-88, 136 developmental, 85, 87, 136 integration and conceptualization of, 85, 88, 92 Catastrophizing; see Cognitive distortions Checklist for Dealing with Ambivalence and Lapses, 298, 315-317 Cigarette smoking; see Nicotine Cocaine, 5-7, 208 prevalence, 7, 197, 208 medical problems associated with, Co-dependency, 194 Cognitive blockade, 51-52 Cognitive conceptualization worksheet, 89 Cognitive dissonance, 153 Cognitive distortions, 58, 123, 231, 246 all-or-none thinking, 14, 243, 246, 303 catastrophizing, 141, 244, 246-247, 250, 256-257 overgeneralization, 77, 115, 244, 246 personalizing, 246 selective abstiaction, 246 Cognitive profile; see Profiles Cognitive therapy model of addiction (diagrams), 22-53, 174-175, 261, 293 Cognitivetiiad,140, 227 Collaboration, 68-70; see also Therapeutic relationship 351 Collusion; see Therapeutic relationship Conditional beliefs; see Beliefs Confidentiality; see Therapeutic relationship Confrontation, 77-78; see also Power struggles Contemplation stage; see Stages of Change Control beliefs; see Beliefs Coping techniques, 11, 51, 80, 126, 130 Core beliefs; see Beliefs Cost-benefits analysis (advantagesdisadvantages analysis); see Techniques Cravings, 23, 31-32, 48, 157-168; see also Urges automatic thoughts associated with, 159 Daily Record of Cravings, 323 scenario, 119 spontaneous, 49 techniques for coping with, 160-168 types of, 43, 157-159 Craving Beliefs Questionnaire; see Psychometric inventories Crisis, 211-225 definition, 211 related to substance abuse, 214-223 typical crises, 211-212 warning signs, 212-214 Daily Activity Schedule; see Techniques Daily Record of Cravings; see Cravings Daily Record of Dysfunctional Thinking; see Daily Thought Record (DTR) Daily stressors; see Life problems Daily Thought Record (DTR); see Techniques Depression, 10, 45, 226-241 automatic thoughts and beliefs, 169, 232-234 behavioral techniques for, 237-240 beliefs associated with, 227-228 case formulation, 229-230 characteristics of, 227 co-morbidity, 226 dysphoria, 34 suicide, 234-235 target symptoms of, 230-231 therapeutic approach to, 228-230 Developmental profile; see Case formulation profiles Diagnostic and Statistical Manual of Mental Disorders, (3rd ed., rev.) (DSM-III-R), 257 psychoactive substance classes, 352 Subject Index Diagnostic and Statistical Manual of Mental Disorders (continued) Structured Clinical Interview for D S M III-R Disorders (SCID), 226 substance abuse definition, substance dependence definition, Dichotomous thinking; see Cognitive distortions, all-or-none thinking Disease model of addiction; see Models of addiction Distraction, 160-161, 249, 252, 300; see also Cravings, techniques for coping with; Anger; Anxiety; Relapse Downward arrow technique; see Techniques Drug-related beliefs; see Beliefs DSM-III-R; see Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) Dual diagnosis, 10, 29, 59, 268 Dysfunctional Attitude Scale; see Psychometric inventories Dysphoria; see76-77, 135, 151 Empathy, 74, Depression Enabling, 70 Exercise; see Techniques Feedback; see Structure Flashcards; see Techniques Goal setting, 121-134 Graded task assignments; see Techniques Guided discovety (Socratic method), 29, 48, 103-107, 136, 142, 156, 177, 185, 300 opioids, 5, 8, 24 treatment, 19 Imagety, 144-147, 159, 183, 208, 252, 275; see also Techniques image mastety, 161 image refocusing, 161 image rehearsal, 161 negative image replacement, 161 positive image replacement, 161 Inductive questioning, 117 Internal reality, 112 Lapse, 13-14, 294, 302-306 Life problems, 83, 187-210 daily stressors, 200-203 legal, 203-206 marital and family, 192-197 medical, 206-209 socioeconomic, 88, 197-200 Limit-setting; see Therapeutic relationship L o w Frustration Tolerance (LFT), 24, 28, ^ , 242-248; see also Anger; Anxiety Maintenance stage; see Stages of change Models of addiction, 12-16 Alcoholics Anonymous, 12, 16, 34 cognitive-behavioral model, 12 cognitive models, 13-14 disease model, 3, 4, 12 M o o d check; see Structure Negative image replacement; see Imagety Nicotine, DSM-lIl-R, histoty, interventions, 19 morbidity and mortality, Helplessness, 40, 83, 201 prevalence, 1, 8-9 High-risk situations (HRS), 11, 13, 47, 50, as a psychoactive substance, 2, 293-294, 297-299, 302, 308; see also relation to illicit drug abuse, Stimulus situations HIV patients, cognitive therapy with, 329 Open-ended questions, 104, 144, 155, 171 Homework; see Structure of therapy Overgeneralization; see Cognitive session distortions Hopelessness, 83, 100, 201, 234, 236 Hot cognitions, 76, 159, 202, 274 Patient's Report of Therapy Session Illicit drugs, 5-8 (questionnaire); see Structure prevalence, Permissive (permission-giving) beliefs; see crimes, Beliefs deaths, Personality disorders, 10, 27, 29, 268-291 marijuana, 5-6 antisocial, 236, 268-269, 278-287 Subject Index assessment, 271-276 avoidant, 254, 270, 276 borderiine, 269-270, 287-291 c o m m o n features of, 269-270 dependent, 270, 277 histrionic, 277 narcissistic, 277 obsessive-compulsive, 254, 277 passive-aggressive, 277 prevalence, 268-269 schizoid, 278 schizotypal, 278 Personalizing; see Cognitive distortions Physiological addiction, Pleasure principle, 35 Polysubstance abuse, 6, Positive image replacement; see Imagety Positive outcome expectancies, 12-13, 33, 306 Possible Reasons for Not Doing Self-Help Assignment Checklist, 109-110, 327328 Precontemplation stage; see Stages of change Preparation stage; see Stages of change Problem solving; see Techniques Profiles; see also Case formulation cognitive, 85, 87-88 developmental, 85, 87 integration and conceptualization of, 10, 85, 88, 92 Programmed practice (covert rehearsal), 183 Psychoactive substances addictive potential, attitudes regarding, definition, DSM-III-R classes, histoty of use, 2-4 most commonly used 4-9 multiple substances (polysubstance abuse), Psychometric inventories Automatic Thoughts about Substance Abuse, 173 Beck Anxiety Inventoty, 87, 93, 94, 101, 299 Beck Depression Inventoty, 87, 93-94, 101, 173-174, 212, 226, 232, 299 Beck Hopelessness Scale, 87, 93, 94, 101, 232, 299 Beliefs about Substance Use, 93, 94, 117, 311 Craving Beliefs Questionnaire, 93, 95, 173, 312 Dysftinctional Attitude Scale, 93, 94, 173 353 Relapse Prediction Scale, 93, 95, 313314 Sociotropy-Autonomy Scale, 93, 95 Rapport; see Therapeutic relationship Rational response(s), 36, 76, 144, 155, 163, 180 Rationalizations; see Beliefs, permissive Reality principle, 35 Reattribution of responsibility; see Techniques Reframing, 130, 132, 157, 234-235 Reinforcement, 62, 126, 168 Relapse/relapse prevention, 10-12, 14, 30-31, 236, 292-309 behavioral strategies, 301-302 cognitive sttategies, 299-301 depression, 234-235 goals of, 296 models of relapse prevention, 293-297 prediction and control of, 297-308 prevalence, 10 social support network, 308 Relapse Prediction Scale; see Psychometiic inventories Relaxation training; see Techniques Relief-oriented beliefs; see Beliefs Research on the tteatment of substance abuse alcoholism, 17-19 illicit drug treatment, 19 smoking cessation interventions, 19-20 Schemas, 50,outcome goals, 16 treatment 81-82 Selective abstraction; see Cognitive distortions Self-efficacy, 13, 228 Self-medicating, 27, 151, 158, 206 Social network, 194 Socioeconomic; see Life problems Sociottopy, 88-89, 93 Sociotropy-Autonomy Scale; see Psychometric inventories Socratic method; see Guided discovety Stages of change, 15-16, 26-27 Stimulus circumstance; see Stimulus situations Stimulus control; see Techniques Stimulus generalization, 33-34 Stimulus sihiations, 47, 50, 52-53, 81-82, 191, 293, 297-302 Structure (of therapy session), 97-111 bridge from last session, 101 capsule summaries, 107-108 354 Subject Index Structure (of therapy session) (continued) discussion of agenda items, 101-103 feedback, 62, 110-111 homework, 108-110, 136, 144, 155, 185 m o o d check, 100-101 Patient's Report Of Therapy Session (questionnaire), 101, 324-326 setting the agenda, 98-100 Structured Clinical Interview for DSM-III-R Disorders (SCID), 226 Substance using beliefs; see Beliefs Suicide, 4, 100-101, 214, 227, 234, 240 Symptom exacerbation, 236 Target symptoms; see Depression Techniques (of cognitive therapy), behavioral, 147-154 behavioral experiments, 149-150, 266 behavioral rehearsal, 150-151 Daily Activity Schedule, 147-149, 167168, 238-240 exercise, 153-154 graded task assignment, 152, 239 problem solving, 152-153, 201 relaxationttaining,151-152, 168, 264 stimulus conttol, 154 Techniques (of cognitive therapy), cognitive, 137-147 advantages-disadvantages analysis, 28, 37, 126-130, 137-139, 180-182, 284, 306-307, 318-322 Daily Thought Record, 109, 143-145, 164, 180, 203-204, 265 downward arrow technique, 118, 140142, 178 flashcards, 160-168, 183 identitying and modifying drug-related beliefs, 139-140 imagety, 144-147, 159, 161-163, 166, 252, 266, 303 reattribution of responsibility, 142143 Theories of addiction; see Models of addiction Therapeutic relationship, 54-79, 135 building trust, 62-64 collaboration, 57, 68-70, 235 collusion, 70-72 confidentiality, 55, 67 credibility, 68 power struggles, 74-78 rapport, 57-62 setting limits, 64-66 Therapy drift, 97, 122-123 Trust-building; see Therapeutic relationship Urges, 31-32, 157-168; see also Cravings Vulnerable situations; see Stimulus situations Will power, 36-37 Worid Health Organization ( W H O ) , PSYCHOLOGY COGNITIVE THERAPY OF SUBSTANCE ABUSE Aaron T Beck, Fred D Wright, Cory F N e w m a n , and Bruce S Liese "I will refer to and recommend this book as a bountiful clinical guide Bolst by outcome data, this wise and hopeful book will greatly advance integration of cognitive therapy into addiction treatment programs." — C o n t e m p o r a r y Psychology "One important aspect of this cognitive format is that its techniques can be combined with other therapeutic approaches to addiction, such as the use of AA, family supports, and social network supports Practitioners of these modalities would well to adapt the cognitive approach in their work." — ^ A m e n c o n Journal of Psychiatry "[This] textbook explicates and expands on Aaron Beck's applications of cogniti therapy to the addictions with lucid, useful integration and a wide explanation of theory and practice." — G e n e r a l Hospital Psychiatry "The strength of the authors' approach is exemplified by the clarity and concisi of their writing, and by the operationalization of their constructs Constitutes a 'gold standard' for the field." —Journal of Cognitive Psychotherapy Cognitive therapy offers a well-documented and cost-effective psychosocial treatment model for working with substance abuse disorders Comprehensive and accessible, this volume clearly details the cognitive model of substance abuse, the specifics of case formulation, m a n a g e m e n t of the therapeutic relationship, and the structure of the therapy sessions I discusses h o w to educate t patients in the treatment model and procedures and m a n a g e their cravings and urges for drugs and alcohol Specific cognitive and behavioral strategies and techniques are described, as are methods for understanding and working with patients w h o present concomitant problems of depression, anxiety, low frustration tolerance, anger, and personality disorders Also addressed are such significant issues as crisis m a n a g e m e n t and relapse prevention Also available in hardcover: ISBN 0-89862-1 15-1, Cot #2/15 Cover des/gn by James Ty Cumbie ISBN The Guilford Press 72 Spring Street N e w York, N Y 0 www.guilford.com l-S723D-bST-T ... Library of Congress Cataloging-in-Publication Data Cognitive therapy of substance abuse / Aaron T Beck [et al p cm Includes bibliographical references and index ISBN 0-8 986 2-1 1 5-1 (he.) ISBN 1-5 723 0-6 5 9-9 ... ISBN 0-8 986 2-1 1 5-1 (he.) ISBN 1-5 723 0-6 5 9-9 (pbk.) Substance Abuse? ??Treatment Cognitive therapy I Beck, Aaron T [DNLM: Cognitive therapy? ??methods Substance Abuse? ?? therapy W M 270 C6765 1993] RC564.C623... stage for the cognitive therapy of substance abuse W e begin with an overview of psycho-v active substances and substance abuse, w e briefly review the history of psychoactive substance use,