New evidence has been found in support of the hypothesis that a cocaine abuser's personal characteristics affect what kind of treatment will work best to reduce his or her drug use. The evidence surfaced in a recent study in a clinic at the San Francisco Veterans Affairs Medical Center (VAMC), in which Dr. Sharon Hall and her coinvestigators at the University of California, San Francisco (UCSF), compared the efficacy of cognitive-behavioral therapy (CBT) with 12-step facilitation (12SF). The study was supported by NIDA and the U. S. Department of Veterans Affairs.
CBT theory holds that our surroundings strongly influence our thinking and behavior, so CB therapists teach their patients new ways of acting and thinking in response to their environment. In the case of CBT for addiction, patients are urged to avoid situations that lead to drug use and to practice drug refusal skills.
The 12-step recovery method-used in Alcoholics Anonymous and Cocaine Anonymous, for example-involves fellowship and mutual support through regular group meetings as a path toward recovery from addiction. While 12-step programs are not affiliated with any religious group, there is a spiritual component-belief in a "higher power" of some kind that helps members achieve and maintain abstinence.
Patients who were abstinent in the cognitive-behavioral treatment (CBT) tended to have high abstract reasoning scores and low religious motivation scores, while patients who were abstinent in the 12-step facilitation (12SF) program tended to have low abstract reasoning scores and high religious motivation scores.
Dr. Hall and her team recruited 128 crack cocaine smokers from inpatient and outpatient programs at the VAMC. Patients were assigned to either CBT or 12SF. Both groups were expected to attend three group therapy sessions and one individual counseling session each week for 12 weeks.
The CBT approach aimed at helping patients strengthen their commitment to abstinence, deal effectively with urges and risky situations, recognize and change irrational thoughts, manage negative moods, and increase positive moods and social support. Therapists also encouraged participants to attend Rational Recovery, a cognition-based self-help group.
Participants in the 12SF group were introduced to the 12 steps of Cocaine Anonymous and encouraged to work on the first steps of the program. They were urged to attend 12-step meetings in the community in addition to their clinic-based group and individual sessions.
Group therapy was the primary intervention, but individual sessions allowed the therapists to conduct psychosocial histories and develop clinic-mandated treatment plans. In addition, the individual sessions gave participants an opportunity to discuss matters that were not covered adequately in group time.
Content for both CBT and 12SF was organized into manuals. "The Recovery Group Treatment Manual" was based on the work of cognitive theorists A. T. Beck, F. D. Wright, C. F. Newman, and B. S. Liese (Cognitive Therapy of Substance Abuse, New York: Guilford Press, 1993). "The Self-Management Group Treatment Manual" was drawn from J. Nowinski and S. Baker's Twelve-Step Facilitation Handbook: A Systematic Approach to Early Recovery From Alcoholism and Addiction (New York: Lexington Books, 1992).
Although participants attended, on average, fewer than half the planned group and individual therapy sessions, the great majority completed their followup assessments, in which urine samples were tested to confirm abstinence from cocaine. Eighty-nine percent of all participants were tested at the final, 26-week followup.
Overall, the CBT patients were more likely than 12SF patients to remain abstinent for 4 consecutive weeks. However, when the researchers added the patients' abstract reasoning skills into the analysis, another pattern emerged.
In the CBT group, patients who scored high on a test of abstract reasoning were more likely to achieve a 4-week abstinence than those with low scores. In the 12SF group, the opposite was found: those who scored low on the abstract reasoning test were more likely to achieve sustained abstinence. In addition, in the 12SF group, but not the CBT group, patients with high scores on a scale measuring religious motivation were significantly more likely than their peers with low scores to achieve 4 weeks of continuous abstinence.
The researchers caution that this study population was not typical of cocaine abusers nationwide: all were veterans, all were homeless or marginally housed, and men were over-represented. Nevertheless, "These findings show that treatment for cocaine abuse can work and that effective treatment can be provided in a typical clinic setting," says Dr. Hall. "Our study reinforces the importance of getting patients into treatment that corresponds to their personal characteristics."
Maude-Griffin, P.M.; et al. Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: main and matching effects. Journal of Consulting and Clinical Psychology 66(5):832-837, 1998.
For More Information
Copies of the CBT and 12SF therapy manuals in manuscript form are available from Dr. Hall at UCSF. Send e-mail requests to firstname.lastname@example.org.