A cognitive-behavioral approach to substance abuse treatment: Canada embraces social learning concept in treatment of substance abuse.

Perspectives on substance use and abuse have evolved over time, reflecting shifts in cultural, societal and professional standards. The last few decades have witnessed a transition from viewing substance abusers as morally bankrupt to attributing the problem to either a chronic and progressive disease or to a learned behavior with significant negative consequences.

While treating substance abuse as a disease rather than a moral deficiency has its proponents, this model has been characterized by a lack of substantive theory and supporting research. However, preliminary research has confirmed the effectiveness of behavioral and cognitive-behavioral techniques on substance abusers in correctional settings.

The concept of social learning is of pivotal importance in forming the theoretical base for correctional interventions that make use of behavioral and cognitive-behavioral techniques. The social learning perspective holds that complex behaviors such as the use of alcohol and other drugs are largely the product of prior experiences. This model holds that global cognitive processes, such as thoughts and emotions, have a significant impact on behavior. The individual's ability to actively modify and control addictive behavior is at the heart of the treatment component of this approach.

Results from numerous meta-analytic reviews of the adult and juvenile correctional treatment literature have repeatedly underscored the efficacy of structured intervention approaches that are built around behavioral and cognitive-behavioral techniques in modifying offenders' criminal behavior. Moreover, studies examining the impact of cognitive-behavioral intervention within the context of substance-abusing offenders also have yielded positive results.

Taken together, research has established that cognitive-behavioral techniques are a key component to correctional treatment. Intervention that is designed to teach substance-abusing offenders skills to successfully modify their behavior stand the best chance of reducing future substance use. Given that substance abuse is a primary criminogenic factor, the provision of effective treatment to offenders during incarceration and following release is critical for offenders' successful reintegration into society.

Behavioral Intervention 

Rutgers University researcher Fred Rotgers points out that there are three principle components to the process of providing behavioral intervention: assessment, skills training and relapse prevention. Structured assessment that integrates information from a variety of sources, including offender self-reporting, is the starting point for the process of developing and delivering a treatment plan. However, not all individuals manifest the same severity of substance abuse problems. As opposed to conceptualizing substance abuse problems in an all-or-nothing manner, recent research with offenders complements noncorrectional research, which demonstrates that offenders vary widely in terms of the severity of their use of a variety of illicit substances. In addition, the impact of substance abuse on a range of life areas such as employment, family and marital relations, educational level and criminal history increases dramatically as a direct function of problem severity.

Following the clear identification of the offenders' treatment needs, intervention incorporates the use of a variety of cognitive-behavioral modalities to skills, such as assertion, problem-solving and coping skills, and structured relapse prevention, that are vital to successful modification of problematic behavior both during the course of treatment and following the close of an individual's involvement in the treatment process.

Canada's Approach

The Correctional Service of Canada (CSC) provides a variety of treatment and program services that target criminogenic factors, based on exhaustive reviews of effective treatment models. CSC's systemwide treatment model has evolved in response to the vast need posed by the majority of offenders in the system for which alcohol and drugs are directly related to their criminal behavior. Indeed, an estimated 70 percent of federal offenders in Canada have substance abuse problems requiring intervention.

CSC has developed and implemented a variety of programs that vary in intensity, duration and cost to meet the diverse needs of the substance-abusing population. There are six core programs that span the institution and the community. based on an assessment process, some offenders are identified as requiring more intensive intervention than is provided within the security of an institution. Other offenders require a less intensive treatment plan than can be safely provided in the community.

The substance abuse programs developed and implemented by CSC also are founded on the principles of harm reduction. The key focus of the harm reduction model is to decrease the negative societal and individual consequences associated with alcohol and other drug use. Given this approach, total abstinence is not the only positive outcome for substance abuse treatment. This model recognized that some individuals can successfully moderate their substance use, and that any reduction of high-risk substance use behaviors is a solid indicator of treatment success. Recent research confirms this approach: Offers on release who were moderating their use were reconvicted at a lower rate than those who were attempting to abstain from all intoxicants, and were less likely to be reconvicted for a crime while under the influence of alcohol or other drugs.

Components of Treatment

The primary target of substance abuse treatment is the offenders' substance abuse problem. Cognitive techniques are employed to teach people that the way they think and feel directly affects their behavior, particularly their substance use behavior. Changing the thinking and behavior of program participants is accomplished through the integration of secondary treatment targets that must be altered if long-term changes in specific behaviors (i.e., substance use and crime) are to be achieved. The secondary components with the greatest empirical support include: structured relapse prevention and management techniques; social skills training; assertion training; problem-solving; controlled drinking strategies; employment training;and methadone maintenance treatment.

Structured relapse prevention is an approach that teaches individuals how to identify high-risk situations, develop skills to deal with these situations, and enhance expectations that using the newly acquired skills will result in a positive outcome. One objective of relapse prevention is to teach individuals to identify the situations under which they are most likely to use substances, and the consequences that tend to follow use. Addiction behavior consultant Alan Marlatt and his associates examined situations under which individuals were most likely to violate their substance use goals. He concluded that most risk situations could be placed in one of eight categories (negative emotional state, negative physical state, testing control, experiencing urges and temptations, positive emotional state, interpersonal conflict, social pressure and pleasant times with others). Once individuals are able to identify their personal problematic patterns of responding to high-risk situations, they require alternative coping strategies with which to replace those patterns. The assumption is that the individuals have deficits in their ability to cope with situations in a positive manner. CSC program participants are provided with cognitive and behavioral coping strategies - imparted in a clear, concise manner - that rely heavily on the use of repetition and personal application to ensure they are integrated into the person's repertoire of skills.

Skills training is heavily based on behavioral principles and techniques. That is, individuals are taught to behave in a different way to situations in which they once reacted in a problematic manner. The purpose of social skills training is to provide individuals with generic skills to help them function more effectively in social situations. Substance abusers are thought to be deficit in this particular skill set; therefore, when this training is incorporated into substance abuse treatment, it should emphasize the application of these skills to situations directly related to substance use.

Assertion training is a subset of general social skills training. The objective of assertion training is to train individuals how to respond to interpersonal situations with assertive rather than drinking/drug-taking behavior. At the root of many high-risk situations identified by substance abusers is a difficulty in interacting positively with other individuals (e.g., interpersonal conflict, social pressure). Enhancement of this skill is thought to have positive implications for maintaining substance use goals.

Problem-solving skills are another example of general coping skills. Problem-solving training involves teaching participants a general strategy for identifying and resolving a wide range of life difficulties. When applied to the context of substance use, this approach holds that individuals use substances to cope with difficult situations, and any enhancement in their coping skills should result in a corresponding decrease in their substance-using behavior.

Cognitive coping strategies focus on assisting individuals in monitoring and challenging their own thinking. Emotional reactions based on problematic thinking tend to be exaggerated, resulting in a decreased ability to skillfully confront the problem. Individuals are taught how to identify problematic thinking and to challenge these distortions. Common cognitive coping strategies include disputation and thought-stopping. A further benefit of cognitive coping strategies is that individuals are provided with an opportunity to examine their belief systems and challenge their thoughts and attitudes, which support criminal behavior and continued problematic behavior (e.g., high-risk substance abuse).

Positive Results

Preliminary CSC research supports the effectiveness of cognitive-behaviorally based substance abuse programs. An initial study of CSC's intermediate intensity institutional program demonstrated that offenders' performance in the program was predictive of their post-release success. A subsequent study illustrated that superior post-release outcomes were secured during the follow-up period by offenders who had participated in the cognitive-behavioral program over those who had participated in a traditional disease-model substance abuse recovery program.

Researchers Lynn Lightfoot and Fred Boland examined pre- and post-test change, as well as relapse and reconviction rates for offenders in the community program, and found that decreases in recidivism rates were comparable to those seen in more intensive treatment. CSC's research efforts have not ended with these initial studies. Currently, there is a national substance abuse program evaluation study in progress; results will be available in early 1999.

New developments and treatment technologies appear on a regular basis. However, despite the rapidly expanding body of research on effective substance abuse treatment, much of the treatment that is widely available to offender clients in North America continues to reflect traditional thinking regarding the nature and origins of offenders' alcohol and/or drug problems. As treatment providers, it is incumbent on us to provide the best possible service to our clients. It is crucial that CSC and others in the field remain apprised of, and contribute to, advances in treatment. Cognitive-behavioral strategies have been and continue to be thoroughly researched, and should remain part of well-developed programs, which focus on providing individuals with the appropriate skills to make significant changes in their lives.

REFERENCES

Andrews, D.A., I. Zinger, R.D. Hoge, P. Gendreau and F.T. Cullen. 1990. Does correctional treatment work: A clinically-relevant and psychologically-informed meta-analysis, Criminology, 28:369-404.

Botvin, G.J. 1990. Substance abuse prevention: Theory, practice and effectiveness. In Drugs and Crime, eds. M. Tonry and J.Q. Wilson. Chicago: The University of Chicago Press.

Correctional Service of Canada. 1997. Basic facts about corrections in Canada (1997 edition). Ottawa: Communications Branch.

D'Zurilla, T.J. and M.R. Goldfried. 1971. Problem-solving and behavior modification. Journal of Abnormal Psychology, 78:107-126.

Gendreau, P. and C. Goggin. 1991. Evaluation of Correctional Service of Canada Substance Abuse Programs: Ottawa: Correctional Service of Canada.

Goldstein, A.P., M. Sherman, N.J. Gershaw, R.P. Sprafkin and B. Gluk. 1978. Training aggressive adolescents in pro-social behavior. Journal of Youth and Adolescents, 7.

Izzo, R.L. and R.R. Ross. 1990. Meta-analysis of rehabilitation programs for juvenile delinquents. Criminal Justice and Behavior, 17:134-142.

Langevin, C.M., J.R. Weekes, A.E. Moser and C.A. Long. 1998. An analysis of alcohol-abusing offenders' treatment needs. Unpublished manuscript, Correctional Service of Canada.

Lightfoot, L.O. and F. Boland. 1994. Developing an Evaluation Framework for Choices: A Brief Treatment Relapse Prevention and Maintenance Program. Ontario: Correctional Service of Canada.

Lightfoot, L.O. and D.C. Hodgins. 1993. Characteristics of substance-abusing offenders: Implications for treatment programming. International Journal of Offender Therapy and Comparative Criminology, 37:239-250.

Lipsey, M.W. 1991. Juvenile delinquent treatment: A meta-analytic inquiry into the variability of effects. Meta-analysis for explanation: A casebook. Thousand Oaks, Calif.: Sage Publications.

Lipsey, M.W. and D.B. Wilson. 1998. Effective intervention for serious juvenile offenders: A synthesis of research. In Serious and Violent Juvenile Offenders, eds. R. Loeber and D.P. Farrington, pp. 313-345. Thousand Oaks, Calif.: Sage Publications.

Lipton, D.S., F.S. Pearson, C. Cleland and D. Yee, 1998. How do cognitive skills training programmes for offenders compare with other modalities: A meta-analytic perspective. Presented at the Stop and Think Conference, Her Majestry's Prison Service, York, Great Britain.

Marlatt, G.A. and J.R. Gordon, eds. 1985. Relapse prevention: Maintenance strategies in addictive behavior change. New York: Guilford Press.

Miller, W.R., J.M. Brown, T.L. Simpson, N.S. Handmaker, T.H. Bean, L.F. Luckie, H.A. Montgomery, R.K. Hester and J.S. Tonigan. 1995. What works? A methodological analysis of the alcohol treatment literature. In Handbook of alcoholism treatment approaches: Effective alternatives (2nd edition), eds. R.K. Hester and W.R. Miller. Boston, Mass.: Allyn and Bacon.

Miller, W.R., V.S. Westerberg, R.J. Harris and J.S. Tonigan. 1996. What predicts relapse? Prospective testing of antecedent models. Addiction, 91:155-171.

Miller, W.R. and S. Rollnick, eds. 1991. Motivational interviewing preparing people to change addictive behavior. New York: Guilford Press.

Millson, W.A. 1996. Evaluation of the recovery program at Collins Bay Institution. Ottawa: Correctional Service of Canada.

Millson, W.A., J.R. Weekes and L.O. Lightfoot. 1995. The effectiveness of the Offender Substance Abuse Pre-Release Program: Analysis of intermediate and post-release outcomes. Ottawa: Correctional Service of Canada.

Ogborne, A.C. 1997. Theories of addiction and implications for counseling. In Alcohol and drug problems: A practical guide for counsellors, 2nd edition, eds. S. Harrison and V. Carver, pp. 3-18. Toronto: Addiction Research Foundation.

Peele, S. 1989. Diseasing of America: Addiction treatment out of control. Boston: Houghton Mifflin.

Pfost, K.S., M.J. Stevens, J.C. Parker and J.F. Gowan. 1992. The influence of assertion training on three aspects of assertiveness in alcoholics. Journal of Clinical Psychology, 48:262-268.

Robinson, D. and W.A. Millson. 1991. Comparison of computerized interview and file information in the identification of offender substance abuse problems. Unpublished data, Correctional Service of Canada.

Ross, R. and L.O. Lightfoot. 1995. Treatment of the alcohol-abusing offender. Springfield, Ill.: Charles C. Thomas.

Rotgers, F. 1996. Behavioral theory of substance abuse treatment: Bringing science to bear on practice. In Treating substance abuse, eds. F. Rotgers, D.S. Keller and J. Morgenstern, pp. 174-201. New York: The Guilford Press.

Sobell, M.B. and L.C. Sobell. 1993. Problem drinkers: Guided self-change treatment. New York: Guilford.

Weekes, J.R., A.E. Moser and C.M. Langevin. 1997. Assessing substance-abusing offenders for treatment. Paper prepared for the International Community Corrections Conference, Cleveland.

Carmen A. Long is project manager, Chantal M. Langevin is project assistant, and John R. Weekes, Ph.D., is national manager of the Substance Abuse Programs Unit at the Correctional Service of Canada's National Headquarters in Ottawa, Ontario.