College research paper by Henry Tarkington, MSW, LCSW, LCAS, CCS

Introduction

This writer has been working in and around the addictions treatment field for almost 14 years. During the first 10 years of that time, 12-Step Facilitation and the Minnesota Model were the therapy models of choice. Things began to change during the early 1990′s. The agency where this writer was employed began to admit patients with co-occurring substance dependence and mental disorders. This was a radical change from 1987 when very few patients were admitted to Wake County Alcoholism Treatment Center (ATC) if they even had a drug problem besides alcohol. Any type of diagnosis for a mental disorder disqualified them from the program.

The ATC used the Minnesota Model of substance abuse treatment, which is based on the program of Alcoholics Anonymous (AA). The goal of the Minnesota model is lifetime abstinence from alcohol and other mood altering drugs by applying the 12-steps of AA (NIDA, 2000). This was the only model used by recovering counselors at the ATC. There seemed to be an attitude that “if it worked for me, it will work for them.”

Some recovering counselors maintain this attitude even today. However, there were no outcome studies to determine the effectiveness of models used there. Treatment did not allow for patients with dual-diagnosis and different needs (such as mothers with young children) who did not respond well to the model. It was a one-size-fits all program. The only problem was it did not fit all and those it did not fit were screened out or provided treatment that did not work for them.

During the 1990′s patients with dual-diagnosis and issues such as being court mandated, Social Service referrals, and (later) Work First had become a regular part of the milieu. New models of treatment were necessary to reach the new population served. The model most often taught to staff at the ATC was Cognitive-Behavioral Therapy (CBT). Though the 12-step Facilitation and the Minnesota Models are still used extensively, they are used in conjunction with CBT and other models.

Included in this paper will be a review of the Minnesota Model, Twelve-Step Facilitation, theories of cognitive therapy, behavioral therapy, and cognitive-behavioral therapy. The 12-step Facilitation and Minnesota Models will be reviewed. A comparison of cognitive-behavioral therapy to other therapies will be discussed along with the practice of CBT in substance abuse treatment. Strengths and limitations, implications for practice and recommendations will conclude this discussion.

Twelve-Step Facilitation and Minnesota Model

Ninety-five percent of inpatient addictions programs in the U.S. incorporate Alcoholics Anonymous and Narcotics Anonymous into their treatment programs at some level (Bristow-Braitman, 1995). In her research, Bristow-Braitman found that of AA participants, 77% received psychotherapy before abstinence and 45% received psychotherapy after abstinence. The research indicated that because of relapse rates as high as 75%, clients are utilizing as many resources as possible to overcome addiction and its presenting problems.

Therapists best serve their clients by having a thorough understanding of the spiritual principles of 12-step programs in addition to the necessary cognitive-behavioral changes to maintain recovery (Bristow-Braitman, 1995). To effectively treat clients using a combination of CBT and referral to 12-Step programs, therapists must be able to reconcile some of the striking differences.

For example, the 12-step program necessitates “admitting powerlessness over one’s addiction [which] flies in the face of psychologically constructed self-efficacy as posited by social-learning theorists (p. 416). To conform to CBT principles, “the admission of powerlessness could be viewed as the first step in improving self-efficacy by preparing a person to use the 12-steps as an alternative coping strategy (p. 417). Though they do not necessarily need to be in recovery themselves, therapists must have a thorough understanding of the 12 Steps and 12 Traditions and should have attended a number of meetings to use this model effectively (NIDA, 2000).

Twelve-step Facilitation (TSF) is a brief, structured approach designed to help clients in treatment and early recovery maintain complete abstinence from alcohol and drug use. NIDA (The National Institute on Drug Abuse) states that TSF is designed to incorporate the “behavioral, spiritual, and cognitive principles that form the core of 12-step fellowships such as Alcoholics Anonymous and Narcotics Anonymous” (2000, p.95). A basic premise of the 12-steps is acceptance that willpower is not enough to achieve long-term sobriety. “Self-centeredness must be replaced by surrender to the group conscience, and long-term recovery consists of a process of spiritual renewal (p. 95).

TSF may be used in conjunction with pharmacotherapy. Antebuse and naltrexone are often used to support abstinence. It is not compatible with severely depressed patients or those with major affective disorders or psychotic disorders. It was designed to support individual therapy and active participation of the client in 12-step programs. Though designed for individual therapy, it has been adapted for use in groups.

Twelve-Step Facilitation is most similar to the Minnesota Model. This model was first described by David Anderson and implemented in AA-oriented programs such as Hazeldon Foundation, the Betty Ford Clinic, the Sierra Tucson Center , and others (NIDA, 2000). The primary goal is abstinence, which is achieved by the client changing his or her beliefs about his or her relationship to others and to self by attending meetings, by self-reflection, and by learning new coping skills, (NIDA, 2000, p. 103). Improved quality of life is another goal that is achieved by applying the principles of the 12-steps (p.103). About 80-90% of the work with clients is done in groups with this model. The ultimate goal is personality change or change in basic thinking, feeling, and acting in the world. Within this model, this change is referred to as a spiritual experience (p.103).

The Minnesota Model uses a multidisciplinary approach to treatment. A team of professionals such as counselors, nurses, doctors, psychiatrists, and social workers plan and conduct the treatment program with the client. Each member of the team meets with the client individually. The team then discusses the findings, client needs, progress, and discharge plan during team meetings. This can be done on either an inpatient or outpatient basis. Addiction is seen as a primary diagnosis and not the symptom of some other factor. It is also seen as progressive because symptoms continue to worsen as the addict continues to use his or her drug of choice (NIDA, 2000).

The 12-step Programs believe the concept of a higher power is a fundamental necessity for recovery. The higher power can be viewed as anyone or anything who is viewed as transcendent: a felt connection to others, to nature, or to the metaphysical (Bristow-Braitman, 1995, p.415). This is viewed as necessary because humans are inherently flawed and unable to achieve a life changing experience without some energy or substance beyond themselves (p.415) .A spiritual awakening is defined as the ability to think, feel, or behave differently and in a way that was not possible previously when the individual was attempting to recover without assistance (p.415).

CBT is based on a combination of Behavioral Theory and Cognitive Theory.  SAMHSA (1999, p. 51) reports, “Both cognitive and behavioral theories have led to interventions that have been proven effective in treating substance abuse.”  Behavioral therapies are based on theories of classical conditioning, operant conditioning and social learning. Classical conditioning goes back to Pavlov’s famous experiments with dogs. It is explained by paring of unconditioned stimuli with conditioned stimuli until the organism learns to respond to the conditioned stimuli” (Black & Bruce, 1989, p. 1153). Operant conditioning holds that
behavior is a function of its consequences and can be altered by the use of reinforcement and punishment (p. 1153). Modeling is the “most prominent behavioral treatment founded on social learning theory” which emphasizes that subjects may learn a behavioral repertoire through observation of others (p. 1153).

Cognitive theory assumes that most psychological problems derive from a faulty thinking process (SAMHSA, 1999, p. 61). Beck, Shaw, Rush & Emery (1979, p. 8) list several assumptions on which cognitive theory is based:

Perception and experiencing in general are active processes, which involve both inspective and introspective data. The patient’s cognitions represent a synthesis of internal and external stimuli. How a person appraises a situation is generally evident in his cognitions. These cognitions constitute the person’s ‘stream of consciousness’ or phenomenal field, which reflects a person’s
configuration of himself, his world, and his past and future. Alterations in the content of the person’s underlying cognitive structures affect his or her affective state and behavioral pattern.

SAMHSA (1999) defines Cognitive-behavioral theory as “the integration of the principles derived from both behavioral and cognitive theories, and it provides the basis for a more inclusive and comprehensive approach” to treatment (p. 69). Attribution, appraisals, self-efficacy, expectancies, and substance-related effect expectancies are “broad range cognitions” (p. 69) included in cognitive-behavioral theory. An attribution is an “individual’s explanation of why an event occurred” and plays a major role in the cognitive-behavioral theory of substance abuse disorders” (p. 69). An example of attributional styles are whether the client believes events and their cause are attributed to himself or to others. Another is whether behaviors continue to affect the future or can they change or stop.

Cognitive appraisal is an individual’s “appraisal of stressful situations and his ability to cope with the demands of these situations” (p. 70). An individual’s coping skills and coping strategies are described as secondary to the individual’s cognitive appraisal. Self-efficacy expectancies have been “thought of as both the client’s temptation to use in substance-related settings and his degree of confidence in his ability to refrain from using in those settings” (p. 73). Those with lower levels of self-efficacy are more likely to abuse substances. Substance-related effect expectancies are the individual’s “expectation that certain effects will predictably result from substance use” (p. 73). Positive expectancies usually relate to euphoria, relaxation, enhanced sexual facilitation among others. Over time, negative expectancies may develop such as aggression, risk taking, impairment, and hangovers for alcohol use. Cocaine use may cause anxiety, depression, and paranoia.

SAMHSA (1999) continues by describing a 3-way relationship among factors that maintain behaviors in cognitive and behavioral models. “Antecedents are activating events in a client’s life.” “Cognitions represent the client’s beliefs, thoughts, or attitudes that serve to filter or distort the perception” of the activating events (p. 62). The third factor is the behavior “the observable actions and emotional reactions that result from his beliefs and emotions”(p. 62).

The relationship among the antecedents, cognitions, and behavior is reciprocal. The client may experience and “antecedent such as getting paid on Friday. He believes (cognition) that since he now has money, it is okay to just spend $20. The behavior is that he buys the $20 worth of cocaine and ends up spending his whole paycheck and possibly gets into some type of trouble on top of being broke. Depending on his attributional style, he may either say that his boss was so demanding that he had no choice but to use (blaming others). Or he may say that he decided to use because he has messed his life up so badly that it does not matter anyway (blaming self, unable to change).

“Cognitive therapies have been aimed fundamentally at restructuring the belief systems assumed to be of motivational significance” (McCusker, 2001, p. 47). Grant and Haverkamp describe Cognitive Behavioral Therapy as an “umbrella term for a variety of approaches and interventions aimed at changing a person’s internal experience by changing cognitions and behavior” (p. 29). Beck (1979) states that there are two important differences between cognitive-behavioral therapy and “conventional therapy” (p. 6). The therapist is much more active and engaged with the client than in psychodynamic or client centered therapies. The session is structured according to a particular design “which engages the client’s participation and collaboration (p. 6). Cognitive behavioral therapy focuses on problems in the present. Exploring the psychological and behavioral experiences of the client during and between sessions is more important than exploring what has happened in the client’s past.

In substance abuse treatment, clients must learn new coping skills to help them through situations in which they normally use drugs or alcohol. The coping skills include identification of situations in which the addict of alcoholic typically uses. Instruction, modeling, role-plays, and rehearsals are used to teach the needed skills. Relaxation training and stress-reduction methods are included in the model to help the client discover that he or she can relieve some of the pressure of day-to-day life without using alcohol or drugs (Longabaugh and Morgenstern, 1999). Longabaugh and Morgenstern describe a type of CBT called Cognitive-Behavioral Coping-skills Training (CBST), which is aimed at improving the client’s cognitive and behavioral skills and changing the clients drinking and drug-using behaviors. This helps the client “identify specific situations in which coping inadequacies typically occur” (p. 78).

SAMHSA (1999) lists other necessary coping skills are the ability to cope with negative emotional states, conflict, physical pain, temptations or cravings to use, social pressures and even positive states and emotions. Another core element of CBT is relapse prevention. “Relapse prevention approaches rely heavily on functional analyses, identification of high-risk relapse situations, and coping skills training but also incorporate additional features” [that] deal directly with a number of the cognitions involved in the relapse process and focus on helping the individual gain a more positive self-efficacy” (SAMHSA, 1999, p. 81). Clients who are new in recovery often experience “passivity and a sense of helplessness that often accompany low self-efficacy” (p.81). To overcome this clients are taught things they were previously unable to accomplish. Through the use of homework assignments and coaching, clients gradually expose themselves to situations that would previously been too stressful to manage without relapse. As he becomes more comfortable in these situations, he begins to generalize his learning to other situations thereby reducing the sense of helplessness (SAMHSA, 1999).

Another technique of CBT relapse prevention is challenging the client’s positive self-expectancies about the effects of using alcohol or drugs. This is done in two ways: “change the client’s belief about the positive effects” of using the substance and have him “pay more attention to the knowledge and experience of the negative effects” (p. 82). Clients often state “I’ll feel more social at the gathering if I drink.” However, they fail to acknowledge the negative consequences such as “but I always drink too much and get into an argument with my friend or do something else stupid.” It is the function of the CBT therapist to help the client acknowledge that the two usually go together and to remember both scenarios in the same context.

Relapse prevention also stresses that a relapse is possible and steps must be taken to avoid the relapse or to prepare in the event it does happen. Leading a “more balanced and healthier lifestyle” (p.83) helps the individual make better decisions that prevent relapse and high-risk behavior. Role-plays, talking directly about the possibility of relapse, and including family members in relapse planning are of great importance. Often the family will see the behaviors that lead to relapse before the addict will see them or admit them.

CBT and Other Models

CBT is similar to Cognitive Therapy in that it emphasizes “functional analysis of substance abuse and identifying cognitions associated with substance abuse” (NIDA, 1999, p. 9). CBT is different from Cognitive Therapy in terms of emphasis on identifying, understanding, and changing underlying beliefs about the self and the self in relationship to substance abuse as the primary focus of treatment” (NIDA, 1999, p. 9). In CBT the initial strategies “stress the behavioral aspects of coping (p. 9). In Cognitive Therapy, the treatment attempts to reduce substance use by changing the client’s thinking. “CBT is thought to work by changing both what a client thinks and what he does” (p. 9).

The Community Reinforcement Approach (CRA) uses a “variety of reinforcers, often in the community to help substance users move into a drug-free lifestyle” (NIDA, 1999, p. 9). The most similar feature of both CBT and CRA are the “functional analysis of substance abuse and behavioral skill training” (NIDA, 1999, p. 10). CBT is different from CRA in that CBT does not typically use vouchers for abstinence or interventions outside the treatment sessions or clinic. CBT has some similarities to Motivational Enhancement Therapy by sharing an “exploration of what the client stands to gain or lose by continuing substance use as a strategy to change the substance use” (NIDA, 1999, p. 10). CBT differs from Interpersonal Psychotherapies (IPT) in that CBT is structured and IPT is more exploratory. CBT attempts to “teach and encourage patients to use skills to control their substance use” while IPT views substance use as secondary to other difficulties (NIDA, 1999, p. 11).

Strengths and Limitations of CBT

One of the main strengths of CBT is its efficacy. Morgenstern and Longabaugh (2000) state, “over the past 25 years, numerous cognitive-behavioral interventions to treat alcohol dependence have been developed and tested [and] have been demonstrated repeatedly to be effective” compared to other treatment methods (p.1475). As will be discussed below, CBT is also cost-effective in a number of settings (Holder, Cisler, Longabaugh, Stout, Treno, and Zwben, 2000). It also works well with clients who are resistant to the spiritual aspects of the 12-step recovery programs (Bristow-Braitman, 1995,).

SAMHSA (1999) also lists several strengths of CBT for substance abuse treatment. CBT is “flexible in meeting clients needs readily accepted by clients soundly grounded in established psychological theory structured in its guidelines for assessing treatment progress empowering clients” (p. 54). Limitations include the difficulty many therapists have in incorporating 12-step programs into treatment that uses CBT as the primary model (Bristow-Braitman, 1995). Since CBT encompasses a large number and variety of components, there needs to be more research to determine the most effective of these in treating substance-related disorders.

Implications for Social Worker Practice

Social workers are often the “first service providers to have contact with substance abusers through the major service delivery systems such as child welfare, family service, employee assistance, schools, programs for the elderly” and community mental health centers (Hall, Amodeo, Shaffer, & Bilt, 2000, p.142). Hall, et al. found that social workers had “significantly higher levels of knowledge and skill in seven of twelve treatment areas investigated”  (p.151).

Areas where social workers were lacking in skill and knowledge were use of specific screening instruments, brief treatment techniques, motivational interviewing techniques and manual-guided treatment. Of concern is that CBT, 12-Step Facilitation and the Minnesota Model require brief treatment techniques. Motivational interviewing techniques are used in substance abuse treatment. Twelve-Step Facilitation is a “manual-driven treatment approach NIDA, 2000, p.95). Social workers need more training to overcome deficits in these important areas.

Social workers and students need more training generally in the field of substance abuse and in the specific therapeutic models used in substance abuse agencies (Hall, Amodeo, Shaffer, & Bilt, 2000). Though social workers have the highest level of knowledge and skill in many substance abuse agencies, it is important not to rest there. Social workers encounter substance abusers and need the skills to recognize and deal with the problem when the opportunity presents itself. There is also a need for more training in the specific treatment models such as CBT and other models discussed above.

Conclusion

This writer feels that many therapists miss a very important aspect of recovery. Too often the only goal is abstinence and the client is not encouraged to commit to a long-term program of recovery. This may deny the client an opportunity to gain a more fulfilling and purposeful life in addition to remaining drug and alcohol free. If a therapist is not well trained in substance abuse or has no experience with addicts and alcoholics who have achieved sustained sobriety through the 12-steps, the therapist may not understand how much clients can gain from these programs. In 12-step circles, achieving abstinence without a life changing program or event is referred to as a “dry-drunk” meaning the person may still live the same unhappy existence though not using alcohol or drugs.

Cognitive-behavioral therapy gives treatment providers and therapists another tool to effectively help a large number of clients. CBT is proven effective in a broad range of settings with a wide range of clients. It is outcome driven and time limited, meeting the requirements of today’s managed care. CBT often works with clients who are unable or unwilling to commit to other types of therapy and recovery programs. In this writer’s opinion and experience, however, it usually does not replace the support, spiritual growth, and social aspects of 12-step programs. To clients for whom 12-step programs work, they can become the foundation for a whole new fulfilling life not just a means of survival.

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