90 COGNITIVE THERAPY IN CLINICAL PRACTICE

places associated with drugs because the addict is not strong enough to cope with them. Unfortunately, the patient in more cases than not will have to return to high-risk areas but does so ill-prepared. The shortcomings of present treatment methods are leading those who treat addictions to consideration of self-control and relapse prevention models. Nevertheless, systematic application of cognitive-behavioural methods is still quite rare.

Cognitive models of drug abuse

Two trends have contributed to the development of cognitive behaviour therapy with addicts: the adoption of a self-control perspective by addictologists coming from a behavioural tradition, and the success of cognitive therapies such as those of Beck, Meichenbaum, and Ellis with clinical populations. Marlatt’s work on relapse prevention illustrates the first of these lines of influence on cognitive therapy with addicts. Starting from the fact that most addicts successfully come off the drug for a short time and then resume their drug taking, he argues that attention to factors associated with relapse is vital. In a study of 311 clients with a variety of addictive behaviours (Cummings et al. 1980), Marlatt’s group found three varieties of highrisk situation. Negative emotional states such as anxiety, frustration, anger, or depression account for 35 per cent of relapses. Interpersonal conflict accounts for 16 per cent, and social pressure (e.g. being offered drugs, being in the presence of other users even if no drugs are offered) 20 per cent of the sample. Marlatt argues that if individuals have a sense of self-efficacy and a coping response, these high-risk situations can be dealt with, but if they do not have a coping response they experience a sense of helplessness. This increases the likelihood of giving in to the temptation to use the drug, which often represents a maladaptive coping response to situations like conflict or feelings of frustration. If the person has positive expectancies about the effects of the substance the probability of using it is further enhanced. Marlatt argues that the movement from a single lapse to a full relapse depends on the attributions the person makes about the cause of the lapse. If a person is committed to complete abstinence a single lapse is a sign of failure. This will lead to feelings of guilt. If the person blames themselves for the lapse this will compound the failure, and lead to a helpless stance (‘There’s nothing I can do about it, I might as well go on using’). This combination of the cognitive-affective elements of cognitive dissonance and personal attribution are termed the Abstinence Violation Effect. Marlatt has produced a system of relapse prevention which uses cognitive and behavioural methods to maintain abstinence (Marlatt 1978; Marlatt and Gordon 1985).

There have been a number of case reports of cognitive therapy with drug abusers (Weiner and Fox 1982; Collins and Carlin 1983). Woody et al. (1983) reported a study of psychotherapy with heroin addicts receiving methadone maintenance. Cognitive therapy and a brief psychodynamic therapy (over a period of 6 months) were compared with a drug-counselling control group. All groups showed improvement, but the psychotherapies proved more effective than the drug-counselling group in reducing symptoms and in allowing the addicts to manage with less prescribed medication. The manual of cognitive therapy used in this study provides a comprehensive introduction to cognitive therapy with drug abusers (Beck and Emery 1977), and will be referred to throughout the course of this chapter.

Other studies which have used cognitive-behavioural packages similar to Beck’s therapy have on the whole been with alcoholics rather than drug addicts. Carey and Maisto (1985) reviewed the literature on behavioural self-control methods and covert sensitisation. They felt that research design problems prevented any definite conclusions being drawn at that time, and noted that the researchers rarely conceptualised ‘the design and use of self-control procedures on the basis of individual deficits’. SanchezCraig (1980), Glantz and McCourt (1983), and Oei and Jackson (1982) have all described cognitivebehavioural programmes for problem drinkers, with encouraging initial results. Brandsma et al. (1980), however, reported that ‘rational behaviour therapy’ was no more effective than insight therapy. Although in one sense outcome measures are very simple in studies with substance abusers, in reality the methodological issues involved are complex. Treatment may improve psychological or social factors without changing the pattern of substance use; is this success or failure? The efficacy of a treatment will also depend on the criterion of ‘abstinence’ which the researcher defines. For instance, in a study of the application of Marlatt’s relapse prevention methods (Chaney et al. 1978) there were no overall differences between the treatment and control group at 1 year. When the results for the patients who had taken one or more drinks were analysed, the treated group showed a significant reduction in the amount of alcohol intake.

These considerations are important for the therapist dealing with the individual patient. Criteria for success need to be clearly defined, since it is easy to become demoralised by recidivism. Addiction is by its very nature a relapsing disorder. One of the principles of any self-control model of addiction is that relapse can be an opportunity for further learning and not an indication of total failure. The relapse process may occur several times before individuals acquire the necessary skills to overcome their addiction for good (Prochaska and DiClemente 1983). The therapist and patient need to be aware of this and not get too discouraged if treatment is not successful the first time round. Chaney’s results suggest that for many addicts a reduction in drug intake may be a successful outcome in its own right. Cognitive therapy is unlikely to prove a panacea for drug addiction, but there is encouraging evidence from clinical and research studies that it will make a significant contribution to the addictions.