cognitive-behavioral therapy in individual psychother-
apy with clients who have substance use disorders. As
its name would suggest, cognitive-behavioral therapy
includes change strategies described subsequently that
target cognitions and behavior chains associated with
substance use patterns in clients.
Cognitive change strategies challenge and modify
beliefs about substance use behavior. For example,
beliefs about substance use influence motivation to
change behavior, which in turn predicts whether a
client will take steps to change behavior. Client motiva-
tion levels vary widely in treatment; so assuming that a
client is ready to change is unreasonable. In addition,
client motivation changes over time so that one minute
he or she can appear committed and then uncommitted
the next. Ambivalence about change is normal, espe-
cially early in therapy, and reflects the reality that
clients are weighing beliefs about the pros of substance
use against the cons. The Transtheoretical Stages of
Change Model, a widely used model to understand
addictive behavior change, indicates that commitment
to change will occur when clients resolve their ambiva-
lence in favor of resolve to take action.
Motivational interviewing and motivational enhance-
ment therapy have been found to be very helpful to
enhance motivation to change among clients.
Motivational interviewing is a scientifically validated
therapy that uses strategic methods to help clients to
explore and resolve their ambivalence about continued
substance use and that enhances motivation to change.
Research has found that use of motivational interview-
ing can be very effective to encourage reductions in sub-
stance use and can be used effectively in conjunction
with other therapies. Motivational enhancement therapy
is a scientifically tested therapy conducted over four ses-
sions and includes the use of motivational interviewing
along with other change strategies. Motivational inter-
viewing seems to be especially effective with clients
uncommitted to therapy.
Other beliefs associated with substance use include
expectancies and self-efficacy. Expectancies are beliefs
that people have about the expected outcomes of sub-
stance use, and they have been found to be a good pre-
dictor of substance use pre- and posttreatment. The
research suggests that interventions that increase nega-
tive expectancies and decrease positive expectancies
may be helpful to improve treatment outcomes.
Therapists use various cognitive strategies to accom-
plish this goal. Self-efficacy, or confidence and compe-
tence in being able to negotiate particular situationswithout substance use, is another consistent predictor
of treatment outcome. Therapists teach, rehearse, and
reinforce new skills to cope effectively with high-risk
situations to establish competence and to develop con-
fidence in appropriately using the skills to enhance self-
efficacy so as to avoid substance use in those situations.
Several behavior modification strategies have been
found to be effective to foster change. Aversion therapy
pairs substance use with aversive agents to discourage
the use of the substance. Typical methods are pairing
the smell or taste of the substance with electric shock or
an emetic agent to condition avoidance of substance
use. Studies have found that aversion therapy can result
in successful outcomes initially, but those posttreatment
gains may be lost over the long term without concurrent
use of relapse prevention (see below). Contingency
management strategies have been used successfully to
encourage positive outcomes in treatment. Contingency
management modifies client behavior by providing
incentives to successfully engage and complete tar-
geted tasks in therapy. Incentives have been used to
increase attendance and participation in sessions as
well as promote reduction targets or cessation of sub-
stance use. However, contingency management is not
widely used, perhaps because of the costs involved with
incentive-based care.
Coping skills therapy has been supported by sci-
ence as well. New skills are taught to aid clients to
cope effectively and solve problems without the use of
substances. Therapists may also teach anger manage-
ment, daily life management, assertiveness training,
and relaxation methods (including meditation) to
increase the repertoire of skills available to clients.
Relapse prevention methods developed in the cogni-
tive-behavioral model have been shown to be highly
successful to reduce the severity and duration of
relapse events when they occur. Relapse prevention
teaches clients that relapse is normative rather than a
failure and can be used to identify and correct prob-
lems in posttreatment behavior. Relapse prevention
also teaches substance refusal skills, develops and
rehearses plans to cope with relapses, and uses cogni-
tive and behavioral modifications previously men-
tioned in this section. In addition to one-on-one
methods with clients, cognitive-behavioral interven-
tions that target couples, family relationships, schools,
and other peer groups have been associated with
changes in substance use.Arthur W. BlumeSubstance Abuse Treatment——— 777S-Cutler (Encyc)-45463.qxd 11/18/2007 12:44 PM Page 777