Cognitive Behavioral Therapy Enduring Effects and Mechanisms Bruce J. Rounsaville Yale University

Cognitive Behavioral Coping Skills  Based on social learning theory  Substance use is functionally related to other problems  Emphasizes learning of coping skills  Initiation and mastery of skills through practice, role playing, and extra-sessions tasks

Functional Analysis Exploration of substance use in relationship to antecedents and consequences

CBT for drug dependence  Introduction to functional analysis  Coping with craving  Shoring up motivation  Refusal skills and assertiveness  Seemingly Irrelevant Decisions  All purpose coping plan  Problem solving  Case management  Termination

Empirical support for CBT  CBT may be more effective for more severe cocaine abusers  Carroll et al., 1994, 1998; McKay et al 1997; Maude-Griffin et al, 1998

Empirical support for CBT  CBT’s effects appear to be durable up to one year after treatment ends  CBT appears to be associated with continuing improvement in substance use

Point (0)

Carroll et al., 1999:

Rawson et al., 2002: CM vs CBT in methadone maintenance

MTP: Marijuana use through 15 months

Does CBT work the way we think it works? Initial exploration of mechanisms of action of CBT:  Does CBT differentially increase coping skills?  Are coping skills related to outcome?

Cocaine Risk Response Test  Role playing task based on Chaney’s work, administered pre-and posttreatment  Example: “You are at a party, where you didn’t think cocaine would be available. However, you notice people going in and out of a back bedroom, and a friend invites you to join them. What do you do?

Cocaine Risk Response Test Audiotaped responses to 10 high risk situations scored on 6 dimensions:  Latency  Number of coping plans  Quality of best plan  Overall quality  Specificity  Type of coping response

Psychometric properties  Good interrater reliability ( )  Good internal consistency ( )  Significant pre-posttreatment increases in number of coping plans, quality of response, specificity of response

Treatment and coping skills acquisition  Significant treatment condition by time interactions suggest patients assigned to CBT, TSF, or Clinical Management show greater increases in coping skills associated with that treatment condition  Higher posttreatment CBT skills associated with significantly less cocaine use during follow-up