Chapter 24. Cognitive-Behavioral Therapies

Kathleen M. Carroll, Ph.D.
DOI: 10.1176/appi.books.9781585623440.353022



Cognitive-behavioral treatments are among the most well-defined and rigorously studied psychotherapeutic interventions for substance use disorders. In contrast to the previous edition of this textbook (Galanter and Kleber 2004), behavioral, cognitive-behavioral, and motivational approaches are now covered in separate chapters, reflecting the increasing use of these strategies in clinical practice as well as their accumulating levels of empirical support. Thus, while this chapter will focus almost primarily on cognitive-behavioral approaches, it should be noted that cognitive-behavioral therapy (CBT) shares several features with these other empirically supported behavioral approaches. First, cognitive, behavioral, and motivational therapies are applicable across a broad range of substance use disorders; that is, well-controlled trials have supported their efficacy across alcohol-, stimulant-, marijuana-, and opioid-dependent populations. Second, these approaches were developed from well-founded theoretical traditions with established theories and principles of human behavior. Third, these approaches are highly flexible and can be implemented in a wide range of clinical modalities and settings. Moreover, they are compatible with a variety of pharmacotherapies and, in many cases, foster compliance and enhance the effects of pharmacotherapies, including methadone, naltrexone, and disulfiram treatment. Finally, these approaches are relatively short-term and highly focused approaches that emphasize rapid, targeted change in substance use and related problems. In this manner, they are very compatible in a health care environment that is increasingly influenced by managed care, best clinical practice models, and professional accountability.

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FIGURE 24–1. Percentage of clinicians trained to criterion, by training condition.
Table Reference Number

Cognitive-behavioral therapy (CBT) has strong empirical support across a range of different substance use disorders as well as psychiatric syndromes that frequently co-occur with substance use disorders (e.g., depression, anxiety).

CBT is highly compatible with available pharmacotherapies for addiction, and recent evidence suggests it can be delivered in a range of formats and settings.

Key components of virtually all CBT approaches include functional analyses of substance use and individualized skills training with emphasis on cognitive and behavioral coping.

Effects of CBT appear to be comparatively durable, with several studies reporting continuing improvement after patients leave treatment. Emphasis on skills training and practice may underlie this effect.

A variety of manuals, videotapes, and other training materials for CBT may be available. However, specialized coaching and feedback, with structured supervision, may be needed for many clinicians to implement CBT effectively.


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Cognitive-behavioral therapy (CBT), behavioral therapy, and motivational therapy share a number of features. Which of the following is not one of these features?
CBT has been shown to be effective in treating all of the following substance use disorders except
Cognitive-behavioral approaches involve a range of skills necessary to foster or maintain abstinence. One such skill is known as the decisional balance technique. Which of the following describes this technique?
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