Cognitive Behavioral Therapy Cognitive Behavioral Therapy Enduring Effects and MechanismsEnduring Effects and Mechanisms

Bruce J. RounsavilleBruce J. RounsavilleYale UniversityYale University

Cognitive Behavioral Coping Skills

Based on social learning theorySubstance use is functionally related to other

problemsEmphasizes 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

Outcome by baseline severity of cocaine use

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Low Moderate HighLong

est p

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CBT

CM

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

CARROLL ET AL (1994) Psychotherapy and pharmacotherapy, 1 YEAR FOLLOW-UP

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Pretreatment End 2 4 6 8 10 12

Months After Treatment

ASI

Com

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core

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CM

CBT

Point (0)

Cocaine use during follow-up: Alcohol-cocaine dependence (Carroll et al (2000))

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Termination 1 month 3 months 6 months 12 months

CBTCM

Carroll et al., 1999:

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

MTP: Marijuana use through 15 months

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BL 4-mo 9-mo 15-mo

% of Days Smoked per Week

Delayed Treatment Brief Treatment (2 sessions Extended Treatment

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 TestRole playing task based on Chaney’s

work, administered pre-and posttreatmentExample: “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:

LatencyNumber of coping plansQuality of best planOverall qualitySpecificityType of coping response

Psychometric properties

Good interrater reliability (.74-.89)Good internal consistency (.79-.96)

Significant pre-posttreatment increases in number of coping plans, quality of response, specificity of response

Treatment and coping skills acquisitionSignificant 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

Design: Double blind, placebo controlled Design: Double blind, placebo controlled outpatient trialoutpatient trial

Disulfiram

Placebo

CBT IPT

Sample characteristics, N=121Sample characteristics, N=121

•• Mean age 35Mean age 35

•• 26% female26% female

•• 31% African American31% African American

•• 63% Caucasian63% Caucasian

•• 44% unemployed44% unemployed

•• 23% on probation23% on probation

•• 54% high school grad54% high school grad

•• Mean cocaine use on 18 Mean cocaine use on 18 past 28 dayspast 28 days

•• Mean 10 years of regular Mean 10 years of regular useuse

•• 52% current alcohol 52% current alcohol dependencedependence

•• 25% current affective 25% current affective disorderdisorder

•• 41% antisocial personality 41% antisocial personality disorderdisorder

Estimates from random regression Estimates from random regression analysesanalyses

Fr equency of cocaine us e by tre atm ent w e ek

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Tre atment we e k

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CBT/Disulfiram

IPT/Disulfiram

CBT/Placebo

IPT/Placebo

Overall findingsOverall findings

•• Consistent main effect for disulfiram over Consistent main effect for disulfiram over placeboplacebo

•• Consistent main effect for CBT over IPTConsistent main effect for CBT over IPT•• Medication compliance significantly Medication compliance significantly

associated with better cocaine use outcomes, associated with better cocaine use outcomes, but…but…

•• ….the disulfiram and CBT effects remain ….the disulfiram and CBT effects remain significant when controlling for compliancesignificant when controlling for compliance

•• And…And…

Cocaine outcomes for Cocaine outcomes for subsamplesubsample meeting meeting criteria for alcohol abuse/dependence at criteria for alcohol abuse/dependence at baseline (n=63)baseline (n=63)

.00.006.046.04Covariate (baseline Covariate (baseline cocaine use)cocaine use)

.48.480.700.70Disulfiram x CBT x Disulfiram x CBT x timetime

.01.01--2.602.60CBT x timeCBT x time

.20.20--1.231.23Disulfiram x timeDisulfiram x time

.00.00--8.748.74TimeTime

ppzz

.00.006.296.29CovariateCovariate

.05.05--1.971.97Disulfiram x CBT x Disulfiram x CBT x timetime

.03.03--2.332.33CBT x timeCBT x time

.04.04--2.102.10Disulfiram x timeDisulfiram x time

.00.00--7.157.15TimeTime

ppzz

Cocaine outcomes for those who did NOT meet Cocaine outcomes for those who did NOT meet criteria for alcohol abuse or dependence (n=58) criteria for alcohol abuse or dependence (n=58)

ImplicationsImplications•• Strongest evidence to date for Strongest evidence to date for disulfiram’sdisulfiram’s efficacy in efficacy in

treatment of cocaine dependencetreatment of cocaine dependence•• Mechanisms for Mechanisms for disulfiram’sdisulfiram’s effects on cocaine use is effects on cocaine use is

not clearnot clear•• Baseline alcohol dependence is a significant Baseline alcohol dependence is a significant

moderator of response to disulfirammoderator of response to disulfiram–– Participants who drank during study less compliant, broke Participants who drank during study less compliant, broke

the blind, drank and used cocainethe blind, drank and used cocaine

•• Main effect for CBT regardless of whether participants Main effect for CBT regardless of whether participants used alcohol or notused alcohol or not

•• Illustrates importance of broad behavioral platformIllustrates importance of broad behavioral platform