Topic 8: CBT Groups for Substance Abuse & Aggression {by 11/5}
There are two readings due this week – Bieling et al. Chapter 13 & Lochman et al. (2007). Address the following two discussion points: (1) Although CBT is well known for effectively treating many mental health problems/disorders, it does not seem to have the same reputation when treating substance abuse. Why do you think this is the case? What about CBT for substance abuse makes it different from “traditional” approaches? (2) What are some possible concerns about running groups with aggressive youth? Are there any ways to overcome/mitigate these concerns? Your original post should be posted by the beginning of class 11/5. Have your two replies no later than 11/7. *Please remember to click the “reply” button when posting a reply. This makes it easier for the reader to follow the blog postings.
Dr. Adam M Volungis 
Nov 02, 2014 @ 12:29:40
For some clients in recent years, it has been found that CBT is differentially effective for individuals with substance use disorders. Individuals who are high in abstract reasoning ability tend to fare better with CBT than 12 step programs. On the other hand, individuals who hold strong religious beliefs tend to fare better with 12 step programs than CBT. 12 step approaches tend to prescribe to the disease model; the idea that, “Once you’re an addict, you’re always an addict.” CBT addresses substance use disorders from a social learning theory stance. Those who are less committed to changing their behavior are more likely to follow a traditional SUD treatment format. CBT forces the individual to take control over their actions and change these learned responses. For some individuals, putting faith in a higher power might be easier when at low motivation rather than putting faith in themselves.
When running groups with aggressive youth, the risk that a group member acts harmfully towards another member or therapist remains an ever present possibility. Group members may also reinforce other groups antisocial behaviors. These types of members are much more likely to use aggressive or antisocial behaviors in groups, thus influencing the norm in the group and in society. Providing structure to the group, and expressing clearly the group expectations and norms are important in reducing the likelihood of aggressive behavior. Aggressive acts should be followed by immediate consequences, which are processed as a group. Consistent consequences for negative behavior and positive reinforcement for “good” behaviors (e.g., participating, completing homework assignments, etc.) is instrumental in establishing order and structure for the group.
Nov 03, 2014 @ 17:41:37
I wonder if those findings about CBT compared with AA generalize to other disorders. Does abstract reasoning predict different success rates between CBT and medicine? Also It would seem like abstract reasoning would be more important with cognitive interventions. I wonder if these variables predict success with behavioral interventions as well? Ultimately a behavior does have cognitive effects, but is it necessary to be thinking about the cognitive side during behavioral actions?
Nov 03, 2014 @ 21:48:46
You make a really good point about problems that may occur when running groups for aggressive youth. One in particular that you mentioned, which I had not thought about is members behaving aggressively towards other members or the leader. This could be a very challenging thing to deal with and can greatly influence group dynamics and cohesiveness, not to mention the possibility of injury in the case of physical aggression.
Nov 03, 2014 @ 09:52:18
CBT’s reputation for treating substance abuse stems partly from previous views on substance disorders. “Alcoholism” was considered a moral issue initially and then has transitioned to becoming a disease. The social learning understanding of substance issues goes against the categorical understanding of substance abuse. Part of what makes any treatment successful is merely believing that the treatment will work and that completing the treatment is possible. Many participants enter into CBT treatment with a less-than optimistic view of its efficacy for treating substance abuse. The rhetoric from AA is more wide-spread than the social learning theory understanding of substance abuse. Previous explanations for substance abuse make even accepting the basic tenants of how CBT applies to substance issues, problematic. Participants may also feel that CBT may be the secular counterpart to the spiritual AA. Those who prize spirituality may feel that an obligation to support the spiritual model. Traditional approaches seem to be never-ending. CBT is normally designed to be time limited. Those who stay with AA are receiving benefits, although opponents point out that the benefits are not the ones espoused by AA.
Peer pressure and modeling are even more problematic before an individual develops a strong sense of self. For those aggressive you, counselors risk negative interpersonal effects. The group forces that making group therapy effective like cohesiveness and acceptance are less ensured. Aggressive behavior becomes more devastating when a child has decided to open up psychologically. However, when children do bond together, this also can have negative effects. Goal contagion effects may lead some youths to pursue unhelpful practices. Group leaders would be wise to avoid confrontational approaches that divide members and the leaders. Group leaders must be more present during groups to reinforce helpful behaviors and have members strengthen self-image to resist negative impulses. If some members are affecting the other youths, the leaders should speak with the member individually to address the issues.
Nov 03, 2014 @ 21:43:53
Gil, I like your discussion of the origins of how SUDs were viewed as a problem, progressing from a moral problem to a disease and how AA plays into those views. AA seems to encompass both explanations in its’ treatment approach which contributes to its’ popularity over CBT. AA also has a community-based and religious aspect to it, in contrast to the more individual basis of CBT.
Nov 05, 2014 @ 13:37:46
I agree with you that CBT can sometimes be at odds with more traditional approaches to substance use, namely 12 step programs that are ubiquitous in the field of substance use and can be very helpful to many users. AA/NA offers a strong sense of ongoing community and support that time limited and structured individual and group CBT can’t replicate. Some of the residents at the group homes I work at strongly adhere to AA/NA principles and believe that they have a disease that they manage at best, that they must turn to a higher power for help because they have become powerless, and if they lapse a little it will inevitably lead to relapse and start them back at square one with their recovery. I cannot imagine CBT working effectively with these clients as it may counter some of these beliefs. On the other hand, I’ve worked with clients who tried AA and hate it for it’s religious themes and emphasis on abstinence only and very much prefer the motivational interviewing and CBT techniques I’m using with them. I think it’s important to assess what the client is looking for, what they are comfortable with, and what their goals are before determining if pure CBT is appropriate to use with them in the area of substance use. Therefore I think any counselor who works in the area of substance use should become familiar with the 12 step model because it is so prevalent and may actually work better for some individuals than CBT.
Nov 05, 2014 @ 18:32:37
I think you make a good point about working with the client to see what the client prefers. Belief in the treatment is an important variable in change and it is not not the counselor’s job to enforce his or her views on clients. However, this also becomes murky because if the clients’ views set them up for relapse then that won’t help either. I wonder if it’s possible to pick and choose or adapt the story so that it makes them more likely to agree to treatment and then less likely to relapse.
Nov 03, 2014 @ 22:04:38
AA and its’ counterparts have become the gold standard for treating SUDs, one major reason for this is the popularity of these programs and how wide-spread they are. When one thinks about substance abuse treatment, their initial thought generally goes towards AA as it is widely accepted and publicized. Due to this popularity many people have internalized the values of AA including its’ religious basis and medical model explanation of SUDs. In contrast, CBT views SUDs much like other mental health disorders where maladaptive cognitions, behaviors and/or emotions are the cause. In treatment, CBT targets the maladaptive cognitions, behaviors, and emotions and therefore takes a more individualized approach where AA and other treatments tend to take a more community-based approach.
There are many concerns that become apparent when running groups with aggressive youth that may or may not be concerns with other populations or disorders. Some of these include parental involvement and willingness to change, members challenging the authority of the group leader, learning new aggressive behaviors from other members and mimicking them, and the high comorbidity of ADHD and managing some of those focusing and impulsive symptoms. Strategies to overcome some of these problems include emphasizing structure and rules of the group with rewards and consequences for behavior, assessment of families and individuals before admission to group, and monitoring and management of the group by the group leaders. Families of these youth should be willing to change and realize that the problems are not only within the child, but due to some environmental components that need to be altered as well. The group leader should also be able to monitor group interactions and make structural changes as necessary.
Nov 04, 2014 @ 08:51:31
I find it hard to call AA the gold standard. It is my personal (and I stress Personal) belief that if someone is going to treat substance use that one should attend at least one if not more AA meetings in order to understand its core. I have often wondered if individuals in AA do not become addicted to the meetings. There are individuals who will attend 5-7 meetings a week even after years in the program. Does the meeting at some point become dysfunctional in its own right? Having said this, it is a self-help group that is run by the dysfunctional members as a whole. It is a common illness and those afflicted band together in the belief that no one but another afflicted can possibly understand what they go through. One can begin to see why it is not as successful as it is led to belief it is. Remember when this program started one was considered to be weak of mind and had few true alternatives.
Nov 04, 2014 @ 09:49:38
AA has become a widely accepted form of treatment by those who suffer from substance use disorders. Though it lacks structure and empirical support, many turn to this form of treatment because they’ve “heard about it through the grapevine”. As of recently, it doesn’t seem that CBT has gained the word of mouth that AA has. CBT, as you mention, has an individual component in that one is taking responsibility for their habits and is making a change, while AA uses the community to help deal with sober living.
Nov 04, 2014 @ 10:05:04
But keep in mind that one reason that NA, AA, and others is so popular is because one does not have to take responsibility for having the dysfunction nor accept any responsibility to alter the affliction.
Nov 05, 2014 @ 13:48:20
I liked your statement about how CBT views SUDs as similar to other mental disorders with maladaptive thoughts, feelings, and behaviors. Substance use seems to most people (including many counselors) a whole different field from treating mental health disorders, requiring special treatment. There’s nothing really special about it. Of course, it’s tailored to the problem of substance use but the skills taught, such as challenging negative thoughts, scheduling pleasurable activities, learning and practicing social skills, etc, are very similar to those taught in other disorders we’ve studied so far.
Nov 07, 2014 @ 20:18:26
I agree with you, Jess, that CBT treatment for SUDs have much in similar to CBT treatments of other disorders. Yet, the general perception in Western society is that SUDs are rather different than other mental disorders despite their very high comorbidity. The biological model of SUDs still dominates the approach many people take towards it, which makes 12-step groups rather attractive. Like Rick, I think 12-step groups and the biological model remain so popular because they deemphasize personal responsibility and the role cognitions play in SUDs and mental disorders in general.
Nov 05, 2014 @ 18:27:32
Angela, you made a great point about the imporatnce of parents’ participation and willingness to partner with the counselor/s. Although I am so very new to this field, one thing that I am already learning is that when a child attends therapy, whether or not the caretakers or parents are physically in the room, they are very much a vital part of treatment. Parenting skill such as reward and consequence systems, understanding modeling, and communication strategies, can make a huge difference in a child’s life, emotional and cognitive world, and behavior. It’s a good standard toinclude parents of children in a social group such as this in treatment, and as able to provide parenting strategies and skills that can promote increased functioning and adherence to treatment plans, so that their child can reap the most benefits as possible from the therapeutic experience.
Nov 07, 2014 @ 22:00:29
I think the community approach is incredibly important in treating SUDs. Individuals that accept SUDs as an individual problem may still benefit from social supports and AA provides the opportunity to treat an individualized problem on a wider scale.
Nov 04, 2014 @ 08:39:31
Part of CBT is understanding that while substance-use disorder may fall into the disease category for formation, it requires an individual to take ownership of the recovery. Most widely used interventions use the disease model for both formation and recovery, such as AA whereby the individual is no responsible for one’s usage. That one can never truly recover and must remain vigilant for life. Whereas the CBT model attempts to change the behaviors that positively reinforce further usage. Thus individuals are asked to either see recovery as beyond their control or to take responsibility for their further actions once psycho-educated and shown alternative behaviors. Most popular program accept relapse as part of the SUD individuals future, this myth has been cast for years in self-help groups. This again alleviates the individual of all responsibility for the event. CBT admits that relapse can occur but believes that it can be prevented. Lastly, in the CBT model the initial intervention can be either abstinence or reduction as decided by the client. CBT models believe that use can be reduced to non-affective levels that will prevent the use from being or returning to pre-dysfunctional levels. That the client needs to decide what the goal will be, this will enhance the motivation of the client. However, it has been found that by starting out at the clients desired level of reduction that most will decide during intervention to proceed to abstinence. This can occur after the client realizes that one can be successful.
By virtue of the dysfunction, adult leaders may find clients non-compliant and standoffish to them simply because they are adults. The clients may perceive others in the group as rivals for the leaders attention, may attempt to dominate others in the group or the group as whole, or feel they are the ones being dominated by others. As one group member becomes aggressively aroused, it may fuel others to be too. Thus escalating aggressiveness of the whole group rapidly. Group members may begin comparing past aggressiveness in a display of one-upmanship. This can be extremely unhealthy where clients are reinforcing each other’s aggressive dysfunctional behaviors.
It is not beyond reason to consider splitting the group temporarily in order to provide space and allow competing individuals a chance to work on cognitive factors before rejoining the halves. Strict adherence to group rules. Applying buddy systems to individuals whom are progressing slower so that individuals whom are succeeding can model appropriate behaviors. Being aware of individuals competing for attention and ensuring that all are permitted ample time and input in the group structure and planning.
Nov 04, 2014 @ 10:03:11
I wonder if the client not knowing what their ultimate choice goal would be (to reduce or eliminate use) makes them more hesitant to try out the CBT method. In AA, they simply tell you exactly what the goal is, it is not created by the individual. The goal is complete elimination of use, as any single use is equivalent to full relapse. In CBT they must choose the goal they are working towards, this makes it very personal and the individual thus takes ownership over the results.
Nov 04, 2014 @ 10:15:23
I wouldn’t agree with that, I think part of it is that CBT is not widely known by the population. Therefore it is not a choice that is selected by the client. The complete elimination of use fly’s in the face of it being a dysfunction that is treatable by the mental health profession. One is saying that unlike every other mental illness where control, coping and empathy are the goals, it is impossible to treat substance use this way. Does every individual who smokes a joint become addicted? what is the difference between the recreational user and the addict then? By legalizing pot are we dooming countless others to addiction? I am not advocating one simply reduce usage and call it a success, but of those addicted couldn’t some of them fall into that category?
Nov 05, 2014 @ 14:36:05
CBT can be effective in treating SUDs, but it is different from the more traditional approaches for SUDs that are very prevalent, such as 12 step self help groups and programs which may teach things contrary to what CBT teaches. Even public service messages such as “This is your brain on drugs” introduce a disease model for SUDs that counters CBT’s emphasis on SUDs being a learned behavior. Also most traditional counselors in this field are recovered addicts who often believe abstinence is the only road to recovery and disagree with CBT or motivational interviewing emphasis on going with the client’s goals (which may be moderation). Due to all the messages already in the field, it’s hard for CBT to gain a reputation as a go-to treatment model for SUDs; instead it’s often presented as an alternative treatment method. This likely draws people with less severe SUDs who don’t feel AA/NA is appropriate for them, or those with more severe SUDs who tried with AA and other programs with little success and who may have more difficulty changing. Both of these types of clients may change more slowly and less dramatically as they progress through the model of change. This may seem less effective to the public than the sensationalism of hearing former addicts stating “After hitting rock bottom, I joined AA and been sober for X years/months/days.”
One important concern for running groups with aggressive youth (or getting a group of aggressive youth together for any reason) is that these youth will often reinforce each other’s aggressive and delinquent behavior. Few youth decide on their own without prompting or collusion from others to do things like try an illegal substance, to vandalize something, to steal from a store, etc. Thus client interactions in these groups should be closely monitored, and positive behaviors and talk reinforced while negative talk and behaviors gently reprimanded. Ideally this is done by hearing from peers the negative effects of these behaviors, because that will matter more to these kids than hearing it from an adult.
Nov 05, 2014 @ 18:21:32
It’s a good point that society has overall accepted the AA/NA treatment as the treatment of choice, and that this may be due in at least part to media’s promotion of it. We hear about AA for treatment of alcoholism, but when, on tv or the radio, have we heard about CBT? It’s truly rare, at least that I think we have seen such support of the CBT framework as a viable option. The less problematic cases are not, as you said, as sensationalized, or might not be as focued on. The many who may be benefiting greatly by CBT do so for a variety of reasons, but lack the AA advertisement. I”ll be honest with you that I never really knew much about CBT for treatment for this population at all until attending Assumption. I’m wondering if any of us, outside of our counseling program affiliations, hear about it at all….
Nov 05, 2014 @ 15:42:08
CBT does not seem to have the same reputation when treating substance abuse compared to treating other disorders, because most people tend to think of 12-step programs for treating substance abuse. CBT for substance abuse is different from traditional approaches because it is based upon social learning theory rather than the medical model. CBT for substance abuse can be viewed as a more individualized approach, whereas 12-step programs tend to focus on a collaborative method.
One potential concern about running groups with aggressive youth is the tendency for the youth to reinforce one another’s aggressive behaviors. When aggressive and deviant youth are in a group together, they positively reinforce deviant talk and behaviors amongst each other. The use of two group leaders can be effective in monitoring the behavior and conversations between members that could avoid reinforcement of deviant behavior.
Nov 05, 2014 @ 17:24:49
12 step models appear to be more widely accepted as effective for SUD’s, and I feel this has a lot to do with the client’s perspective of treatment. 12 steps are peer run and clients may feel it is easier to address substance use with individuals who have had personal experience with addiction. Individuals may be more likely to seek out AA to treat alcohol issues rather than what they perceive to be a strict, regimented, disease model approach with a superior who cannot relate. As mentioned previously, though CBT addresses SUDs as learned behaviors, media tends to portray SUDs through a disease model and clients may come into treatment with these perceived notions. Recovery is based on an individual’s desire to learn and change, and preconceived notions of CBT treatment may prevent this. Individuals may feel AA offers more direct involvement in their own recovery with collaborative support from peers who have similar experiences, thusly perceiving more benefit from this type of treatment.
Group leaders must be mindful of modeling within the group, especially with children who are so persuaded by peer pressure and social norms. Right off the bat, group leaders should reinforce strict group norms regarding aggressive behavior in a therapeutic way. Leaders should be assertive and not allow reinforcement of aggressive behaviors. Group leaders should help the children to understand how to appropriately address each other’s aggressive behaviors and reinforcing positive behaviors. Rewards can be particularly helpful with children when reinforcing behaviors. Also, parents should be involved in that they practice group strategies at home so positive behaviors are not only practiced within the group setting. If the environment at the home is not conducive to continued learning and practice, a family therapy referral may be appropriate.
Nov 06, 2014 @ 15:08:52
Sarah, you make a good point about the importance of involving parents in helping the youth practice group strategies at home. Practicing these skills within group is beneficial, but continuing to practice these skills within other settings can be even more effective for the youth in extinguishing aggressive behaviors.
Nov 05, 2014 @ 18:06:28
CBT approaches better for clients with better abstract reasoning ability as well as higher psychopathology. It can provide these individuals with coping skills, structure and motivation, and they can use their higher abstracting abilities to integrate the technical aspects of CBT in treatment. Clients with strong religious beliefs and those who view addiction more like a disease than a bad habit do less well in CBT than in a traditional 12-step approach. Individuals who ascribe to the disease model may find the overall treatment goal of CBT to be too ambiguous or threatening with the individual made responsible for the treatment goal. Unlike 12-step approaches, CBT can allow for moderation to be the treatment goal, though clients rarely choose moderation over than abstinence as their treatment goal.
Youth in group aggression therapy are very likely to not want to be in therapy, think they do not need it, and may view the therapists as another set of adults who wants to change their behaviors. These concerns can be mitigated by empathetic therapists who acknowledge this resistance, and lead clients to the realization their problematic behaviors are not working for them. Getting a group of angry youth together can lead to hostile behaviors becoming the group norm if therapists let it, with client’s negative behaviors reinforcing each other. Strict adherence to group expectations and providing structure is foremost, otherwise clients will exploit any gaps or inconsistencies for personal gain at the group’s expense. Consequences need to be immediate and fair to help rule out youths crying favoritism.
Nov 05, 2014 @ 18:12:59
Probably the most widely-known approach to the treatment of alcoholism is Alcoholics Anonymous (AA). This approach takes both a disease model and religious foundation of the program, very much unlike CBT. Proponents for AA might argue that asking clients to view the alcoholism as a disease rather than something that they can control may put the client in a position where they are more able to feel like it’s something they can manage and work on, rather than the product of lifestyle circumstances and choices. AA members are powerless, and rely on God to help them reach their goal of abstinence. AA proponents may dislike CBT’s exclusion of God as part of the inherent treatment. Rather than looking to God for strength, those in CBT learn coping and problem solving skills; ultimately, they are helping to reach the goals themselves that they created. Finally, the CBT approach does not rigidly require abstinence. There are many from AA and other approaches who would argue that someone who has struggled with alcohol abuse should completely abstain. CBT clinicians differ as well on this topic. However, overall, CBT does not apply the same rigid rules regarding abstinence. AA is widely known and well-liked. Their disagreement with CBT on these issues of religion, the disease model, and abstinence, as well as others, such as treatment framework and organization may contribute to people who are not well-informed about CBT’s benefits for this population, to disregard its potential and substantiated benefits.
CBT, as provided for substance abuse, follows the same basic foundational practices as it does for other disorders, such as depression and anxiety. Goals are made, agendas are set, homework is given and reviewed, and clients are educated. While some differences between the CBT and other approaches are listed above, possibly the most important is the use of CBT as a framework. Using motivational interviewing, CBT clinicians can work with clients in the pre-contemplative stage, and look to the client to develop and move toward goals that will promote functioning. Rather than focusing on only cessation of substance use, CBT provides the client with skills that can be applied to all areas of his or her life, taking into consideration a multi-dimemtional approach that considers factors from all areas of the individual’s life, and then providing a treatment plan that meets the client where he or she is at.
Groups formed for assisting aggressive youth may experience some challenges, as this particular population tends to have difficulty regulating behavior, and may have difficulty engaging in functional social interaction. Clients may react to negative automatic thoughts about others’ behaviors, language, or actions negatively by expression through anger, resistance, or attempts to control. These behaviors, transactional in nature, can cycle into problematic responses for other clients, facing similar reactive patterns.
Some people choose not to send their child to social groups addressing behavioral concerns of aggression, because they may be concerned that they will be exposed to and learn other dysfunctional behavior, and responses, through modeling and reinforcement. Children attending the group may have difficulty with focusing on a given task. Such difficulty can lead to impulsivity, and become disruptive for others, who are ready and willing to work, learn, and practice newly developing and emerging skills.
Communicating and applying group rules in a consistent way can help to minimize some of these issues. Leaders should be informed about treating this population, and have a repertoire of strategies, such as seating placement, and redirection techniques. Should a client’s behavior become overly problematic, and continue to interfere with group, it may be best for that child to attend individual counseling until he or she is ready to perform the basic tasks of group.
Nov 06, 2014 @ 15:27:03
Michelle, I liked your discussion about AA versus CBT for the treatment of substance abuse disorders. I thought it was interesting how you mentioned that CBT is not as strict with its rules around abstinence in comparison to 12-step programs which require complete abstinence.
Nov 07, 2014 @ 21:45:25
I think kids can be perceived as an especially difficult population to work with because of how impressionable they may be; as you stated it is truly important for the group therapist to be informed as to competent treatment. The adherence to norms becomes even more important because behaviors may be likely to be continued if reinforced regularly at a young age. Similarly, it may be easier to adjust behaviors at a younger age – it is difficult to teach an old dog new tricks.