Behavioral Cognitive Therapy for Addictions
Senior Copyright Harvard Health Publications
Why “faking it ’til you make it” may help break an addiction.
Long-time Alcoholics Anonymous (AA) members often advise newcomers to “fake it till you make it.” The advice is based on the belief that following AA’s 12-step program, even when people are initially skeptical, will help them to overcome alcoholism.
A study of cocaine addicts suggested that the AA veterans may be onto something, and that their advice may apply to other addictions as well.
The National Institute on Drug Abuse (NIDA) Collaborative Cocaine Treatment Study enrolled 487 patients who were randomly assigned to one of four interventions (see box). All treatments decreased days of drug use in the previous month, from a mean of 10 days at the start of the study to three days a year later.
The intervention combining individual drug counseling (IDC) and group drug counseling (GDC) worked best. At the six-month mark, for example, 39% of people in the IDC-GDC intervention reported using cocaine in the previous month, compared with 57% of people who underwent cognitive behavioral therapy and GDC, 49% of those who received supportive-expressive psychotherapy and GDC, and 52% of those receiving GDC alone.
|Group drug counseling (GDC) alone||Learn about stages of change in recovery; engage in group problem solving; attend 12-step meetings|
|Cognitive behavioral therapy and GDC||Recognize and change distorted thinking about drug use, plus GDC|
|Supportive-expressive psychotherapy and GDC||Learn how addiction affects relationships and how to improve interpersonal relations, plus GDC|
|Individual drug counseling and GDC||Learn how to avoid drug triggers and adopt more positive behaviors, plus GDC|
Unexpected attitude changes
The investigators also assessed how much impact each intervention had on factors that contribute to addiction and recovery, such as beliefs about substance abuse or insight into interpersonal problems. One unexpected significant finding was that the IDC-GDC intervention proved most likely to change drug-related attitudes.
Because all interventions involved group drug counseling and encouragement to attend 12-step programs like AA or Cocaine Anonymous, they all involved some focus on behavior change. Two interventions, cognitive behavioral therapy and supportive-expressive psychotherapy, also incorporated techniques that addressed specific ways of thinking or relating to others. In contrast, only the IDC-GDC intervention focused exclusively on behavior change.
The fact that the IDC-GDC intervention worked best thus raised a question: why would focusing solely on behavior be more effective than cognitive-based approaches at changing beliefs?
Behavioral cognitive therapy?
The researchers offer two possible explanations. One is based on the reverse causation theory of behavior change. This holds that people who attend a 12-step group for any reason, because they are forced to legally, or because of pressure from family members, and who subsequently stop using drugs may attribute the change to their participation in the group rather than to legal or family pressure. This increases their commitment to participating in the 12-step approach, which helps to ingrain the new behaviors.
A related explanation is that addiction exerts such a powerful hold on people, physically as well as mentally, that an intensive focus on behavior is necessary to achieve sobriety. In contrast, disorders that involve distorted thinking, such as major depressive disorder or panic disorder, may benefit more from cognitive interventions.
What about people who don’t want to attend 12-step meetings? A follow-up analysis of the NIDA study suggested alternative approaches.
Investigators analyzed study records to determine which participants had actually attended 12-step meetings and which participated in other ways, such as by reading the literature or calling a sponsor for support. The researchers found that attending meetings without participating did not increase the chances of reducing cocaine use, but active participation did. This implies that people who are reluctant to attend 12-step support groups might still benefit if they read the literature or participate in online meetings.
The NIDA study provided evidence that behavioral change may precede cognitive change in people who are trying to overcome an addiction. As a result, practitioners may want to emphasize the importance of the behavioral component of cognitive behavioral therapy, particularly in the early phase of treating cocaine dependence.