Treating Psychiatric and Addiction Comorbidity With a Cognitive-behavioral (Non-12-step) Approach

As more addiction treatment programs treat comorbidity it seems likely that client confusion about treatment approach will increase. Comorbidity is here defined as having both a mental health disorder (such anxiety or depression) as well as an addictive disorder. Client confusion might arise because CBT (cognitive behavior therapy) has become the treatment of choice for many mental health disorders, but 12-step based treatment remains the most widely available treatment for addictive disorders. Clients receiving CBT for their mental disorders can be confused when they compare the self-empowering strategies of CBT with the emphasis on powerlessness in a 12-step approach. Although 12-step treatment now often incorporates relapse prevention and other CBT components, there remains a fundamental difference in the two approaches on the issue of personal empowerment.

At present there appear to be three potential solutions to this problem. Some providers might persuade themselves that this fundamental difference in treatment approach does not actually exist. If the client agrees, all may be well. However, if the client does experience a conflict between self-empowerment and powerlessness, then one approach could be dropped in favor of the other. Thus, the second possible solution would be to take a purely CBT approach and the third solution, a purely 12-step approach. Because a 12-step approach to mental health disorders is yet to be developed and tested, solution three appears to be only a theoretical possibility.

In a purely CBT approach to both mental health and addiction, clients are taught a basic model of behavior change. This model suggests that changing negative emotional experience (e.g., anxiety or depression) and maladaptive behavior (e.g., addictive behavior) can be accomplished by identifying, testing and modifying underlying beliefs. The leaders in the use of this model for mental health disorders include Albert Ellis, Ph.D. (1913-2007), who developed Rational Emotive Behavioral Therapy (REBT) and Aaron Beck, M.D., who developed Cognitive Therapy. For addictive disorders the most prominent leader is Alan Marlatt, Ph.D., who developed relapse prevention. Many of the other CBT oriented addiction treatments (e.g., behavioral marital therapy, the community reinforcement approach, social and coping skills training) have typically been developed by teams of researchers funded by government grants and working in universities.

The underlying beliefs that are the initial focus of CBT addiction treatment include the following, all of which are inaccurate (accurate beliefs shown also): Craving is unbearable (it is uncomfortable but it goes away). Craving makes me use/drink (I always have a choice). The experience of craving is harmful to me (it may be distracting but it hasn?t ever harmed me). I need to use or I can?t cope or have a good life (in time my life will be even better, and I?ll have new and better coping skills). I can?t change (others with even worse problems have changed; I can change if I focus and persist). If I slip I have to go all the way (I can pull out of a slip at any point, I don?t need to let it become a binge). If I stop using my life will be unbearable forever (there will be an initial transition period of weeks to months that will require substantial focus and persistence--probably more than I expected--but over time the process of recovery becomes easier and eventually may even become effortless). If I feel a certain way I have to act that way (I don?t; I may not be able to choose my internal experience but I can choose my behavior).

In early recovery, other dysfunctional beliefs emerge: My addictive behavior was completely destructive (I used because there were benefits, which at first might have been significant, but now are overshadowed by the costs). I have to completely avoid temptation (if I work by small steps in time I will build up strength to cope with temptation).

The support group of choice for a pure CBT approach to addiction is SMART Recovery (smartrecovery.org), but clients may still wish to attend 12-step meetings. Despite their overall emphasis on powerlessness 12-step meetings contain many elements compatible with a CBT perspective (e.g., paying attention to ?stinkin? thinkin??) and remain an unparalleled opportunity for obtaining social support.

When clients in comorbidity treatment feel confused about how to integrate self-empowerment and powerlessness, a pure CBT approach to treatment may be the solution.

A. Tom Horvath, Ph.D., ABPP, is a board certified clinical psychologist and president of Practical Recovery (Alcohol Addiction Treatment Center in San Diego), an addiction treatment facility in La Jolla (San Diego), CA, focusing on collaborative care and self-empowerment.