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COGNITIVE BEHAVIOR THERAPY (CBT) AND ALCOHOLISM.
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Investigates the effects of CBT on one group.... More...
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Paper Abstract:
Investigates the effects of CBT on one group. Treatment of depression in alcoholic clients who have been sober for 6 months. Assesses the CBT program in terms of effects on alcohol consumption, depression, anxiety, assertion, positive and negative thought. Theoretical framework. Major concepts of CBT. Research hypothesis. Variables. Research design.
Paper Introduction:
COGNITIVE-BEHAVIORAL THERAPY FOR SOBER CLIENTS
Part I
Introduction
Alcoholism is considered a major public health concern in the U.S., with around 15 million Americans annually diagnosed as suffering from alcohol abuse or dependence. Depression is also a large public health concern with prevalence rates for disorders ranging from 5% to 25% of the American population. Alcoholism and depression tend to occur together, with prevalence of the combined disorders being two times higher than each separately. Therefore it is logical to assume that treatment of alcoholism must include treatment for depression. Cognitive-behavior treatment (CBT) for depression has been shown to be effective and it is concluded that CBT would be an appropria
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This variable is operationally defined bythe questions on the Index of Alcohol Involvement.Depression Depression is conceptually defined as the experience of depressedmood, lack of interest or pleasure, fatigue, feelings of worthlessness,eating or sleep disturbances, or recurrent death thoughts (APA, 1994).This variable is operationally defined by the questions on the BeckDepression Inventory.Anxiety Anxiety is conceptually defined as the experience of excessive anxietyand worry, difficulty in controlling the worry, restlessness, difficultyconcentrating, irritability, muscle tension, and sleep disturbance (APA,1994). To monitor and insure that standard amounts ofhomework are done the following three measures will be taken: to provideinspiration, subjects will be instructed regarding the importance of doinghomework to obtain adequate treatment results; to insure standardization,subjects will be instructed regarding the amount of time to be spent doinghomework assignments; and to control for homework variations, subjects willbe instructed to record time spent on homework assignments, to be reviewedby the therapist. Information regarding the changes inassertion and thought content will assist in the understanding of variablesthat need to be addressed to add to long-term results and relapseprevention. References American Psychiatric Association (APA). In the case of depression, individuals tend to viewthemselves as undesirable and unworthy, they expect rejection and failure,and they therefore feel hopeless. cognitive-behavioral treatment for depression in alcoholism.Journal of Consulting and Clinical Psychology, 65(5), 715-726. Therapist responsiveness will be confined to the useof a narrow focus on content and an acceleration of developmental processesin treatment as proposed by Hardy, Stiles, Barkham, and Startup (1998). Schemas, or complex patterns of thoughts determine how experiencesare perceived and conceptualized, and are employed in the absence of data;therefore, schemas tend to reinforce preconceived ideas. In these cases behavioral approaches may beequally effective, more amenable, and less costly (Jacobson, Dobson, Traux,Addis, Koerner, Gollan, Gortner, and Prince, 1996). This variable is operationally defined by the questions on theState-Trait Anxiety Inventory.Assertion Assertion is conceptually defined as the acquiring of social skills orimproving interactions with others with more assertive responses in varyingsituations (Brown & Ramsey, 2 ). CBT has demonstrated positive results regardingdecreases in depression and alcohol consumption and these findings implythe need for further understanding of the topic. It was recommendedthat a future study needs to measure positive and negative thoughts andassertiveness as well as depression, anxiety, and alcohol consumption, andthat follow-up tests should also be provided. In addition, research has demonstrated thataffect and accessibility are linked in terms of mood congruity; informationthat matches a mood state is more easily recalled. This variable is operationally defined by the questions onthe Automatic Thought Questionnaire. 3b) Cognitive-behavioral therapy will result in less anxiety at 6 month follow-up. Cognitive models of depression, suicide, anxiety, andpanic disorders were supported. Follow-upstudies also show effective results, superior to pharmacotherapy andindividual therapy. Thus, the concerns listed in the literature will be addressedwith findings from this study. Studies regarding depression tended toexplore unipolar depression. Thecognitive triad regards negative thinking patterns of the self, the future,and the world. A. In anotherstudy cognitive-behavioral therapy alone and cognitive-behavioral therapyplus diazepam were more effective for treatment of generalized anxietydisorder in 1 1 patients, compared to diazepam placebo. Tocontrol for this variable, the following three measures will be taken: toprovide inspiration, the need for a narrow focus to control for responseswill be discussed with the therapist; to determine therapist tendencies andadjustments that need to be made, the therapist intentions will be assessedwith the Therapist Session Intentions measure, prior to initiation of theCBT program; and to implement necessary changes, results of the assessmentwith changes needed, will be discussed with the therapist to control forunlimited responsiveness. Study Intervention The study intervention will be 8 weeks of CBT as recommended anddescribed by Brown and Ramsey (2 ). S., Traux, P. The CBT components includeddaily mood rating, increasing pleasant activities, thought-changingstrategies (increasing positive and decreasing negative thoughts and theABC technique), assertiveness training, and maintaining gains. Specifically, the effects of the CBT program will be assessed toinclude effects on alcohol consumption, depression, anxiety, assertion,positive and negative thought numbers, at program conclusion and 6-monthfollow-up. CBT is based on the theory thatthe individual will process information in an adaptive manner that issurvival oriented. 4a) Cognitive-behavioral therapy will result in significant increases in assertion. Participants will be informed that their participationwill be voluntary and they may withdraw from the study at anytime. Jacobson, N. The program will begin with adiscussion which explains the relationship between thoughts, behaviors, andmood, the link of depression to alcohol, and the importance of learning newthoughts and skills that will offer coping strategies and eliminatetriggers for alcohol consumption. As atheoretical framework, the cognitive model focuses on the mentalrepresentations of a client's experiences. Depressed individuals demonstrate thefollowing errors in logic: selective abstraction, personalization,dichotomous thinking, and arbitrary inference. The humanbeing goes through the assimilation and accommodation of information.Assimilation refers to adapting external stimuli to existing mentalstructures and accommodation refers to adapting the mental structures tothe stimuli (Flavell, et al.). Professional Psychology: Research andPractice, 31(4), 418-422. 4) Does cognitive-behavioral therapy result in increases in assertion? I. Studies have shown that information is remembered when it isprocessed in relation to the self and these pieces of information arestored together in a cluster. Strengths and Weaknesses of Cognitive-Behavioral Theory A strength of cognitive therapy is that it uses a learning model ofpsychotherapy, and includes a collaborative relationship between thetherapist and the patient, which tends to build patient self-esteem. In a third studyof 57 patients with generalized anxiety disorder, cognitive-behavioraltherapy for 12 sessions was superior to behavior therapy and waiting-listcontrols. (1997). (1993). Brown and Ramsey (2 ) provide a clinical example of a patient whohad been treated for alcohol dependence, who also presented with Substance-Induced Mood Disorder with Depressive Features. 3a) Cognitive-behavioral therapy will result in significantly less anxiety. Purpose and Importance of Study The literature points out the positive and the negative aspects ofusing CBT for the treatment of depression in the alcoholic. The dependent variables for this study are alcohol consumption,depression, anxiety, assertion, negative thoughts, and positive thoughts,defined as follows:Alcohol Consumption Alcohol consumption refers to the frequency and quantity of alcoholdrinking (Brown & Ramsey, 2 ). While CBT hasbeen shown to be an effective treatment for depression, long-term resultshave not been demonstrated and indicate the need for additional componentsto be considered. Schemata are defined as mental structures thathelp organize past experiences; they range from concrete to abstract andoperate interactively with one another. For this study therapist responsiveness isoperationally defined as the use of a narrow focus on content and anacceleration of developmental processes in treatment, as opposed to abroader focus which would take into account the context, constraints, andhistory of the therapeutic relationship. The CBT-D groups showed more reductions in somatic depressivesymptoms as well as depressed or anxious mood. This model was chosen since itprovides a unique understanding of the depression associated withalcoholism, that must be considered as part of the overall treatment ofthis disorder. The cognitive modelof depression, developed by Beck in 1967 is based on the cognitive conceptsof the cognitive triad, the schemata, and cognitive distortions. Thought-changing strategies will consist oftwo methods, increasing positive-decreasing negative thoughts, and the ABCtechnique. This processing results in schemas, which are cognitivestructures, which represent beliefs about the self and the world. Thetherapist provides skills and techniques to assist the client who assumesresponsibility for observing and monitoring thoughts, completing homeworkassignments, and providing feedback (Freedman, Simon, Beutler, & Arkowitz,1989). 1b) Cognitive-behavioral therapy will result in significantly less alcohol consumption at 6 month follow-up. In a study of generalized anxiety disorder, cognitive therapy wasfound to be effective for 32 patients (8 weeks of treatment). (1998).Therapist responsiveness to client interpersonal styles during time-limitedtreatments for depression. K., Gortner, E., & Prince, S. V. Beck (1993) reported that knowledge accumulated in 199 revealedsupport for cognitive therapy and cognitive theory of personality andpsychopathology. H., Miller, P. A weakness of cognitive therapy is that it fails to considerunderlying causes and motivations for behaviors and it may not beappropriate for treatment of some disorders. Thought changing techniques were introduced to the client, whichincreased his positive thoughts and decreased his negative thoughts.Assertiveness training was also reported as a helpful component of thistreatment since it allowed the client to behave in new ways, which werecongruent with the new positive thoughts. Thesefindings demonstrated that CT was effective for treatment of depression,but raised questions regarding the use of CT as opposed to other treatments(BA or AT). 2) Does cognitive-behavioral therapy result in less depression and anxiety? K., Dobson, K. (1989).Comprehensive handbook of cognitive therapy. Research Questions and Hypothesis The following research questions will be explored for this study: 1) Does cognitive-behavioral therapy result in less alcohol consumption? Research Design An experimental design will be used for this study. Thedepressed individual has easy access to negative constructs (Segal, 1988). 6b) Cognitive-behavioral therapy will result in significant increases in positive thoughts at 6 month follow-up. A., & Ramsey, S. W., Burgess, E. B., Barkham, M., & Startup, M. Since the maintenance of treatment effects may rely onan increase of positive thoughts and a decrease of negative thoughts, thesevariables will be included in treatment with positive outcomes expected andexamined. 5a) Cognitive-behavioral therapy will result in significantly fewer negative thoughts. Hardy, G. Brown, R. Alcoholism and depression tend to occur together,with prevalence of the combined disorders being two times higher than eachseparately. Journal ofconsulting and Clinical Psychology, 64(2), 295-3 4. Segal, Z. Examined Outcomes The outcomes to be examined will be the dependent variables: alcoholconsumption, depression, anxiety, assertion, negative thoughts, andpositive thoughts. Journal of consulting and Clinical Psychology,66(2), 3 4-312. Cognitive-behavioral treatment for depression relapse prevention.Journal of consulting and Clinical Psychology, 66(2), 377-384. (2 ). (1996). Assessments will beconducted with the use of the Index of Alcohol Involvement, the BeckDepression Inventory, the State-Trait Anxiety Inventory, the AssertivenessSelf-Report Inventory, and the Automatic Thought Questionnaire (negativeand positive versions). Appraisal of the self-schema construct incognitive models of depression. A., Addis, M. Diagnostic andstatistical manual of mental disorders, fourth edition, DSM-IV).Washington, DC: APA. Data is accumulated, coded,categorized, and evaluated by schemas. Jacobson, Dobson, Traux, Addis, Koerner, Gollan, Gortner, and Prince(1996) conducted an experimental test of the theory that cognitive-behavioral therapy would be useful for treatment of depression. Independent, Dependent, and Extraneous Variables The independent variable for this study is cognitive behavioraltherapy (CBT), defined as the following:Cognitive Behavioral Therapy (CBT) CBT is conceptually defined as a system of psychotherapy with atheory of personality and psychopathology, a body of knowledge, and aprogram with strategies and techniques. E. It was concluded that CBT-Dis an appropriate treatment, combined with standard alcohol treatment, toreduce depressive symptoms and alcohol consumption. The client identified hisnegative moods as including loneliness and guilt, which triggered drinkingbehavior. Gortner, E. Cognitive theories of depression and social interactions betweenpeople provide an understanding of depression. 2a) Cognitive-behavioral therapy will result in significantly less depression. Fallacious thinking, orcognitive distortions, contribute to the feedback loops that supportpsychological disorders such as depression and alcoholism (Freeman, Simon,Beutler & Arkowitz, 1989). The authorspresented two-year follow-up data for 137 participants who were randomlyassigned to three treatment groups for 2 sessions. The ABCtechnique employs Ellis's Rational-emotive Therapy principles, whichidentifies events, which trigger irrational beliefs and resulting negativeemotions. Successful applicationof cognitive therapy has resulted in the consideration of new uses, such as alcohol dependency (Beck, 1993). Part III Research Project The purpose of this study is to investigate the effects of CBT fortreatment of depression in alcoholic clients who have been sober for sixmonths. Homework effects are defined as treatment results that are a result ofamount of homework done. Control of Extraneous Variables For this study, the extraneous variable, therapist responsiveness,will be controlled. An additional strength is its success with changing thoughtpatterns and resulting dysfunctional emotions and behaviors which has beenshown to reduce depression and alcohol consumption. Upper Saddle River, New Jersey: Prentice Hall. (1997)reported the need for a study to explore additional factors such asassertion and positive or negative thoughts, as well as follow-upinformation on all variables (depression, anxiety, alcohol consumption,assertion, positive, and negative thoughts). Brown et al. S.(1998). Cognitions are defined as thoseprocesses that encompass the organization of sensory input, and theinitiation of behavior (Freeman, Simon, Beutler & Arkowitz, 1989). Findings will serve nursingand other disciplines in their search for the most efficacious treatment ofthis population. New York: Plenum Press. This variable is operationally definedby the questions on the Assertiveness Self-Report Inventory,Negative and Positive Thoughts Negative and positive thoughts pertain to the view of the self and theworld. (2 ). Exclusion criteria will include those withsuicidal or homicidal risk, acute psychosis, multiple substance abuse, orcurrent drinking. A 6-month follow-up post-test will examine if changes weremaintained, as well as what aspects of the treatment were maintained. S., & Mueller,T. Cognitive therapy has also been shown to be effective fortreatment of panic disorder and superior to behavior therapy and antipanicmedication (Beck, 1993). Psychological Bulletin, 1 3(2), 147-162. In addition it requires anexperienced therapist which may not always be as accessible for treatmentof the alcoholic, which frequently employs the use of paraprofessional orless experienced therapists. H., & Miller, S. Subjects willreceive the CBT intervention for 8 weeks and will be pre- and post-testedat program initiation, program conclusion, and 6-month follow-up, withregard to the dependent variables. Hisstages of development include: sensorimotor (age to 2 years) whereinfants understand the world by acting on it and schemas becomedifferentiated and integrated forming mental representations of reality;preoperational (ages 2 to 7 years) where children use representations ofobjects and events; concrete-operational (ages 7 to 11 years) wherechildren acquire operations or systems of mental actions which lead tological thinking; and formal-operational (ages 11 to 15 years) where mentaloperations are applied to hypothetical as well as real instances. 3) Does cognitive-behavioral therapy result in less depression and anxiety at 6 months follow-up interview? Findings ofthis study demonstrated that while CT resulted in improvements, they werenot significantly higher than other treatment effects and these effects didnot prevent relapse at 24-month follow-up. The samplewill include 5 men and women, ages 18 years or older, to be recruited fromthe Alcohol and Drug Treatment services of a day partial hospital programfound locally. Sample The convenience sample will include a group of patients identified asbeing alcohol dependent, who have been sober for six months. Cognitive therapy past, present, and future.Journal of Consulting and Clinical Psychology, 61(2), 194-198. H., Stiles, W. The mental representation of experiences are found in theschema or the schemata regarding the self. The three treatmenttypes were initially reported on by Jacobson et al. 2b) Cognitive-behavioral therapy will result in less depression at 6 month follow-up. Brown, Evans, Miller, Burgess, and Mueller (1997) reported onalcoholics being treated for depression with cognitive-behavioral treatment(CBT-D). People develop personalconstructs regarding social events and those that are easily accessible aremore frequently activated which leads to the greater likelihood of theirbeing used in the future. E., Koerner,K., Gollan, J. Cognitive therapy views the personality as based on cognitivestructures and shaped by central values or core beliefs, called schemas,that develop early in life as a result of environmental factors, and areunique to each individual. Segal provides an explanation of the cognitive theoretical foundationwith regard to understanding and treating depression. While strengths and weaknesses of CBT are both reported, theliterature has also shown that it is an effective treatment for manydisorders, including depression. Piagetexplained that individuals go through the stages of developing humancognition as a form of biological adaptation to the environment. The program will then continue with theuse of a daily mood rating which will provide the identification of moodstates and influencing factors. The hypotheses for the study are as follows: 1a) Cognitive-behavioral therapy will result in significantly less alcohol consumption. 5b) Cognitive-behavioral therapy will result in significantly fewer negative thoughts at 6 month follow-up. COGNITIVE-BEHAVIORAL THERAPY FOR SOBER CLIENTS Part I Introduction Alcoholism is considered a major public health concern in the U.S.,with around 15 million Americans annually diagnosed as suffering fromalcohol abuse or dependence. It is expected thatassertion levels will increase with the CBT treatment and this phenomenonwill be examined. S., Dobson, K. Statistical analysis will include anANOVA for comparison of the means for pre- and post-tests on all variablesto test the study hypotheses. T., Gollan, J. The effects of a CBT program will be assessed to include a pre-and (2) post-measures of alcohol consumption, depression, anxiety,assertion, and positive and negative thought numbers, at programinitiation, program conclusion, and 6-month follow-up. Psychologicalproblems are viewed as stemming from faulty learning, incorrect inferencesbased on inadequate or incorrect information, and the lack of adequatedistinction between imagination and reality. Depression is also a large public healthconcern with prevalence rates for disorders ranging from 5% to 25% of theAmerican population. They usedthe three treatment approaches previously described (AT, BA, and CT).Findings were that each of the treatments were equally effective inaltering negative thinking and dysfunctional attributional styles. Bech's negativecognitive triad is understood in terms of this accessibility. Cognitive management techniques will be used to reduce thoughts(thought stopping, worrying time, and blow-up technique) and they will beused to increase positive thoughts (daily accomplishment lists, self-rewarding thoughts, priming and cues for positive thoughts). 6a) Cognitive-behavioral therapy will result in significant increases in positive thoughts. A meta-analysis of 27 studies showedcognitive therapy to be superior to other treatments, which includedbehavior, psychodynamic, nondirective, and other therapies. CBT-D patients (n = 19) demonstrated significantly betteroutcomes regarding total abstinence from alcohol consumption, percentage ofdays abstinent, and number of drinks per day, compared to relaxationtraining controls (n = 16); both groups also received standard alcoholtreatment. The patients will have met the Diagnostic and StatisticalManual of Mental Disorders-IV criteria for alcohol dependence, asdetermined by hospital records. in 1996 (see below).The BA treatment focused on life problems, solutions, and reinforcements,the AT treatment began with BA approaches and moved to identification andmodification of dysfunctional thinking, and the CT treatment included BAand AT approaches and incorporated identification and modification of corebeliefs which cause dysfunctional thinking and depression. Beck, A. Cognitive distortions are what resultsfrom misinterpretation and misperception of reality; these conclusionsconfirm negative expectations. The purpose of this study is to investigate the effects of CBT fortreatment of depression in alcoholic clients who have been sober for sixmonths. All test instruments will employ Liker-typescales, yielding interval data for analysis. Brown, R. 4b) Cognitive-behavioral therapy will result in significant increases in assertion at 6 months follow-up. Background of Study Gortner, Gollan, Dobson, and Jacobson (1998) studied cognitive-behavioral treatment for depression and relapse prevention. E., & Arkowitz, H. Therefore it is logical to assume that treatment of alcoholismmust include treatment for depression. Current interest in cognitive treatment research is the application ofcognitive therapy to new disorders such as drug abuse, bipolar disorder,HIV, personality disorders, sex offences, PTSD, multiple personalities,hypochondriasis, schizophrenia, and obsessive-compulsive disorder.Cognitive therapeutic approaches are also being applied to maritalproblems, and family and group therapy (Beck, 1993).Concepts and Definitions A broad definition of cognition is the inclusion of higher mentalprocesses such as "consciousness, intelligence, thinking, imaging,creating, generating plans and strategies, reasoning, inferring, problemsolving, conceptualizing, classifying and relating, symbolizing, andperhaps fantasizing and dreaming" (Flavell, Miller, & Miller, 2 , p. M., Miller, I. Increasing positive activities will be animportant part of the program and will be assessed by the Pleasant EventsSchedule-Mood Related Form. Addressing comorbid depressivesymptomatology in alcohol treatment. This narrow focus is viewed asmore appropriate for short-term treatment (Hardy, Stiles, Barkham, &Startup, 1998).Homework Effects Homework effects are described as the effects of amount of homeworkdone on the treatment results (Brown & Ramsey, 2 ). A., Evans, D. S., & Jacobson, N. Flavell, J. The schemata hold informationregarding past experiences that guide current perceptions of events andbehavior (Segal, 1988). Cognitivetherapy was superior to no treatment and pharmacotherapy. Cognitive-behavior treatment (CBT)for depression has been shown to be effective and it is concluded that CBTwould be an appropriate choice for treatment of depression in the alcoholic(Brown & Ramsey, 2 ). Lastly, Gortner,Gollan, Dobson, and Jacobson (1998) demonstrated that cognitive-behavioraltreatment for depression did not result in 24-month relapse prevention,indicating that for long-term results, additional therapeutic techniquesmust be employed. Part II Theoretical Framework Cognitive-behavioral treatment was chosen for the study intervention. In addition, Brown and Ramsey(2 ) point out the need for more studies, which address the treatment ofdepression in the alcoholic. Since research has also demonstrated theprevalence of depression being linked to alcoholism, it is logical toinvestigate the use of CBT for the treatment of the alcoholic patient.While the literature has pointed out possible limitations to these results,it has also mentioned that components leading to positive results mayinclude assertion and changes in numbers of negative or positive thoughts.Therefore it is reasonable to study these components with regard toeffectiveness of CBT for treatment of the alcoholic, to increaseunderstanding regarding the problem of alcoholism, its relationship todepression, and the CBT therapeutic context. M., Beutler, L. E. T. (1988). The advanced practice psychiatric registered nurse and otherhealth practitioners as well as the patient will benefit from thisknowledge regarding effective treatment of depression in alcoholism. Cognitive self-management techniques teach patients to monitorthoughts and distinguish between positive and negative thoughts (Brown &Ramsey, 2 ). Freeman, A., Simon, K. This psychotherapeutic method is based on the cognitive model. 2).Jean Piaget contributed to knowledge regarding cognitive development. CBTaddresses these cognitions and changes distorted beliefs, which result innegative moods, and disorders (Freeman, Simon, Beutler, & Arkowitz, 1989).For this study, CBT is operationally defined as the technique outlined byBrown and Ramsey (2 ). A componentanalysis of cognitive-behavioral treatment for depression. Since the literature reported that depression is linkedto alcoholism and that CBT is an effective treatment fordepression/anxiety, the effects of the CBT program are expected to includea decrease in these variables and this effect will therefore be examined.In addition, research has found that assertion is an important factor inthe treatment, which has not been previously measured. The extraneous variables for this study include therapistresponsiveness and homework effects, defined as follows:Therapist Responsiveness Therapist responsiveness refers to responses to a client'sinterpersonal style. Social skills will be developed with assertiveness training.All gains of treatment will be identified and monitored and this processwill be taught to the client (Brown & Ramsey, 2 ). It is theorized that regarding depressionand cognitive schemas, the depressed person retrieves negative self-descriptors since they tend to cluster together in memory, related to eachother (Segal, 1988). Cognitive-Behavioral Theory Propositions and Major ConceptsHistory and Evolution Three decades of effort have gone into establishing the cognitivetherapy approach. 5) Does cognitive-behavioral therapy result in fewer negative thoughts and increases in positive thoughts? Research findings have led to conclusions regardingefficacy of cognitive treatment for many disorders, and informationregarding this theory now fulfills criteria for a system of psychotherapy:cognitive theory now provides a coherent, testable theory of personality,psychopathology, and therapeutic change, with testable and teachableprinciples, strategies, and techniques, and empirical data to supporttheory and treatment efficacy (Beck, 1993). CognitiveDevelopment, fourth edition. (1994).
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