Supporting evidence for the use of cognitive behavioural approaches in the treatment of addiction - A brief introduction
Author: Steven Dilks, Senior Occupational Therapist & Addiction Therapist, Cygnet Hospital Wyke
Throughout the 17th and 18th centuries addiction was viewed as a disease and treatment approaches focussed on acknowledging a loss of control for the client. The aim of abstinence was thought to be the only treatment option. Such philosophies have been adopted by organisations such as Alcoholics Anonymous. Heather and Robertson (1989) state in the 20th century, the disease theory of alcoholism began to look suspect as scientific evidence started to examine addiction in more depth and different treatment aims and approaches were developed.
The first piece of research which questioned the disease theory was in 1958 when Dr D. L. Davies along with E. Mayer (Social Worker), identified in their practice people who were previously diagnosed as ‘alcoholics’ were continuing to drink and showing no signs of social problems. Heather and Robertson (1989) report Davies carried out a study identifying seven out of ninety-three men continued harm-free drinking over a five year period. Davies published the report in the quarterly journal of Studies on Alcohol in 1962 after the Lancet had refused, stating a lack of significant interest in the report. The publication did however result in a number of highly critical commentaries from experts around the world. After Davies’s publication, further research was conducted corroborating his findings.
In 1976 the controversy around the theory of moderate problem-free drinking came into the public arena after the Rand Corporation was commissioned to collate and analyze data relevant to the outcome of the various treatments given by alcohol treatment centres. The study sample consisted of 2339 participants with six, eighteen and four year follow-ups. They reported for some people, who present with alcohol misuse, a return to moderate drinking was possible which was met with criticism as many experts felt this may lead to individuals, who have a history of alcohol misuse, experimenting with drinking and therefore resulting in high relapse rates.
Heather and Robertson (1989) highlighted a number of follow up studies providing evidence where individuals diagnosed as ‘alcoholics’ were presenting with ‘good’ social adjustment and continued social drinking. Such research has shaped treatment theories and approaches over the years with treatment goals starting to focus on a return to controlled drinking/social drinking. Heather and Robertson (1989) also concluded that severely dependant problem drinkers should always be advised to abstain rather than aim for a controlled drinking goal. Also the application of a controlled drinking goal and associated methods of behaviour change should be used only in low to moderate dependency and in the prevention of more serious physical harm.
As views started to develop away from the disease theory, further research was carried out looking at other influences on drinking patterns. Research such as household surveys and laboratory investigations of drinking and intoxication highlighted changes in society’s drinking patterns had also occurred due to life circumstance changes. Research by Cahalan and Kendall (1976), both cited by Heather and Robertson (1989), showed how drinking patterns have changed and people move in and out of problem drinking. They identified increases were due to social determinants such as the influence of peers, increased financial ability and more opportunities to drink. A decrease in individuals’ drinking was due to increased responsibility, less money, less need or desire and maturing or getting older. In Cahalan’s household survey some of the men who originally admitted to problem drinking had matured out of this behaviour during the second survey.
Cahalan and Clark (1976) conducted a further survey with 615 males in San Francisco, initially interviewing them in 1967 and repeating the interview in 1972. They indicated a presence of problem drinking during the first interview was not a predictor as to whether a problem was present in the second interview. Heather and Robertson (1989) advocate this as not a consistent finding with a model that suggests a progression from less to more severe problems with gradual accumulation of more problems as would be expected with the disease theory. Such research indicates drinking patterns can change due to both external and internal factors.
All of the evidence outlined above changed thinking and approaches to the treatment of drug and alcohol misuse/dependence. Additionally, theories such as social learning theory, classical and operant/instrumental conditioning support the psychosocial determinants are as important, if not more so, than just the pharmacological aspects of a drug in determining dependence, meaning to support the theory and giving evidence that dependant behaviours are learned and therefore can be unlearned. Social learning principles suggest drinking is a learnt behaviour which develops from living in a culture with social influences supporting such behaviour. Further, the expectation of euphoria and social influences reinforces both positive and negative aspects of drinking. The third principle of social learning is concerned with environmental cues which can elicit drinking or drug use behaviour, such cues may be people, places, objects, time periods and internal states associated with past experiences for example, the smell of one’s favourite drink, or wanting to celebrate.
Monti et al (2002) explain the role of genetics has a part to play in addiction and evidence twin studies which demonstrated genetic vulnerability interacting with psychosocial factors, resulting in either good coping with every day difficulties leading to a less likelihood of alcohol misuse, or in coping skills deficit that require coping skills training.
As Gossop (2006) states, a number of treatments have been developed based upon assumptions, theories and research traditions of psychology and especially of social learning theory. These are variously referred to as cognitive behavioural treatments or psychosocial treatments. Morgenstern and Longabaugh (2000) state over the last 25 years numerous cognitive behavioural interventions which treat alcohol dependence have been developed and tested. These intervention packages differ in their length, modality, content and treatment setting and whether other treatment approaches are integrated. An example of such an approach is the ‘Coping Skills Training Guide for the Treatment of Alcohol Dependence’ by Monti et al (2002).
Gossop (2006) highlights some of the most effective cognitive-behavioural based treatments as motivational interviewing, cue exposure treatments, contingency management and relapse prevention. Other recent research such as the Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders by Miller and Wilbourne (2001) also provide evidence and weight to the use of cognitive behavioural treatment approaches as they scored highly in efficacy and treatment outcomes. Such approaches were ‘brief intervention’, ‘social skills training’ and ‘motivational enhancement therapy’.
References
Gossop, M. (2006) Treating Drug Misuse Problems: Evidence of Effectiveness. London: National Treatment Agency
Heather, N., Robertson, I. (1989) (2nd Ed) Problem Drinking. Oxford: University Press
Miller, W., Wilbourne. P. (2001) Mesa Granda: A methodological analysis of clinical trials or treatments for alcohol use disorders. Addiction Vol. 97, p. 265-277
Monti, P. M., Abrams, D. B., Kadden, R. M., Cooney, N. L. (2002), (2nd Ed) Treating Alcohol Dependence: A Coping Skills Training Guide. New York: Guildford Press
Morgenstern. J., Longabaugh, R. (2000) Cognitive behavioural treatment for alcohol dependence: a review of evidence for it’s hypothesized mechanisms of action. Addiction Vol. 95, p. 1475-1490
