426 CHAPTER 9
Interviewer: A feeling of total power and exhilaration, then.
Client: Yeah, but when I come down I pay for it. It’s a real downer, and it lasts
forever. Then I just want to get high again, and the whole thing is a
vicious cycle. And my kids are still whining.
Interviewer: So in the short run, it’s a big payoff, but in the long term the cost is too much.
Client: Yeah, I’ve been thinking that I should cut it way back.
Interviewer: You might want to change, but you’re not sure.
Client: No, I know I need to do something.
Interviewer: You’ve already thought about changes you might make.
(Moyers, 2003, pp. 141–142)
Studies have shown that this treatment is more successful when patients have a
positive relationship with their therapist and are at the outset strongly motivated to
obtain treatment (Etheridge et al., 1999; Joe, Simpson, & Broome, 1999). As with
most treatments, the benefi cial effects of motivational interviewing tend to fade over
the course of a year (Hettema, Steele, & Miller, 2005).Cognitive-Behavior Therapy
Cognitive-behavior therapy (CBT) for substance abuse focuses on three general
themes:- understanding and changing thoughts, feelings, and behaviors that lead to
substance use (antecedents); - understanding and changing the consequences of the substance use; and
- developing alternative behaviors to substitute for substance use (Carroll, 1998;
Marlatt & Gordon, 1985).
Behavioral treatment may focus in particular on decreasing the positive conse-
quences of drug use and on increasing the positive consequences of abstaining from
drug use (referred to as abstinence reinforcement). As patients are able to change
these consequences, they should be less motivated to abuse the substance. These
principles may be used more generally for contingency management, in which rein-
forcement is contingent on the desired behavior occurring or the undesired behavior
not occurring (Stitzer & Petry, 2006).
These principles have been applied to treatments for abuse of a variety of
types of substances, including heroin and cocaine (Higgins et al., 1993; Higgins &
Silverman, 1999). The desired behavior (such as attendance at treatment sessions or
abstinence from using cocaine, as assessed by urine tests) is reinforced with one or
more of these consequences:- monetary vouchers, the value of which increases with continued abstinence (Jones
et al., 2004; Silverman et al., 1999, 2001, 2004); - decreasing the frequency of mandatory counseling sessions if treatment has been
court ordered; - more convenient appointment times; or
- being allowed to take home a small supply of methadone (requiring fewer trips to
the clinic) for those being treated for heroin abuse.
Positive incentives (obtaining reinforcement for a desired behavior) are more
effective than negative consequences (such as taking away privileges) in helping
patients to stay in treatment and in decreasing substance use (Carroll & Onken,
2005). The cost of providing such rewards can be high, and relapse often in-
creases once rewards are discontinued, which limits the practicality and effective-
ness of abstinence reinforcement as a long-term treatment (Carroll & Onken,
2005). Figure 9.12 illustrates the effectiveness of monetary vouchers in promot-
ing abstinence among cocaine users.
Once the patient has stopped abusing the substance, behavioral treatment
may focus on preventing relapse by extinguishing the conditioned responseP SN