Cognitive Behavioral Therapy Treatment Within Addiction Care

Cognitive Behavioral Therapy Treatment Within Addiction Care

Abstract
The study aimed to evaluate an integrated intensive cognitive behavioral therapy (CBT) group
treatment for people with substance-related syndrome in outpatient care and to identify eventual
gender differences. The study population consisted of 35 outpatients (18 male, 17 female) at a
clinic in Western Sweden. The patients completed a four-month period of intensive group therapy
and participated in the data collection at admission and discharge. The data were collected using
the following inventories: Beck Depression and Anxiety Inventories, Rosenberg Self-Esteem Scale,
Hopelessness Scale, and Trait Hope Scale. Results showed decreases in anxiety, depression and
experience of hopelessness, and increases in self-esteem and hope. In females, the most dramatic
improvement was measured for the anxiety and depression attributes, while in males the strongest
effect was measured for hope and self-esteem. This study provides clinical evidence of the positive
effects of integrated intensive CBT in outpatient care of people with substance-related syndrome. Cognitive Behavioral Therapy Treatment Within Addiction Care

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Introduction
According to The Public Health Agency of Sweden,1 about 23% of men and 12% of women in
the Swedish population use illicit drugs at some time in their lives, while 2% of men and less than
1% of women state that they have used some kind of illicit drug in the past 30 days. In 2011, there
were approximately 500,000 people suffering from substance use and dependency in Sweden.2 The
Swedish findings about gender differences in risk factors and consequences of drug addiction are
similar to those found in other countries.3 Twice as many women as men use classified narcotics or
addictive medicines without physician prescription or at higher doses than prescribed.1 When
women initiate substance use, they tend to increase their consumption of drugs more quickly4 and
develop dependency more rapidly5, 6 than men. These facts reflect male-female differences in the
possibilities of abusing pharmaceuticals on the basis of the impact of the social or cultural
Address correspondence to Nóra Kerekes, PhD, Department of Health Sciences, University West, 46186, Trollhättan,
Sweden.
Kourosh Bador, MSc, AGERA KBT AB, Gothenburg, Sweden.
Journal of Behavioral Health Services & Research, 2019. 1–10. c) 2019 The Author(s). DOI 10.1007/s11414-019-
09657-5
Integrated Intensive CBT BADOR & KEREKES
environment.7 They also suggest variation among men and women in the biological response and
problem progression in relationship to substance use and dependence.8
Women with frequent drug use are substantially more vulnerable than men. They also have less
social support and greater co-existing mental illness. It is less likely that women seek help for drug
problems than men because women are more prone to overcoming the challenges that limit their
access to drugs than to seek help for their addiction.9 Globally, one out of three persons
with substance-related syndrome is a woman; yet only one out of five patients in drug treatment is
a woman. Men often seek help at the behest of their family, employer, or the criminal justice
system. Substance use and dependence in women is often associated with other problems such as
personality syndrom diagnoses or prostitution which do not necessarily entail contact with the Cognitive Behavioral Therapy Treatment Within Addiction Care
healthcare system.8
That people with substance-related syndrome have multi-dimensional problems, including
coexisting mental illness and social problems, is more frequently a rule than an exception.10
Nevertheless, even in highly developed social support systems, such as in Sweden, only about 20%
of people with substance-related syndrome are known to the healthcare system and social services.2
Traditionally, the most common approach for treating individuals with addiction and co-occurring
psychiatric disorders is to identify one disorder as Bprimary^ and the other(s) as Bsecondary.^ In this
type of sequential treatment strategy, one focuses on treating the Bprimary disorder^ first and treats the
secondary disorder(s) only when/if the primary disorder is believed to have been fully treated. The
challenges in defining the primary diagnosis are obvious and often cause disagreement between
clinicians. The issue of the transition between the completion of one treatment and the start of the next
can also be a source of concern. Another treatment strategy is the parallel treatment, which means that
individuals with coexisting mental illnesses are referred to different facilities or institutions for the
simultaneous treatment of addiction and mental illness. It is not uncommon that in this form of
approach the patient is expected to coordinate the treatment between different agencies, a responsibility
he or she obviously often cannot shoulder satisfactorily.
A new treatment strategy, which has been found to be both efficient and gentler for this patient
group, and possibly also more cost-effective, is integrated treatment.11, 12 In this approach, there is
no need to coordinate between different treatment facilities or agencies and there are no differences
between methodologies or ideologies, as the substance use problem and the mental disorder are
both treated by the same team implementing an overlapping strategy.
Several randomized trials and naturalistic analyses have compared intensive outpatient treatment
with inpatient or institutional care and have found similar results,13 such as that intensive outpatient
treatment is an effective form of treatment for patients who suffer from substance use and
dependence with or without co-occurring mental disorders, and who do not need medical
detoxification or round-the-clock care. Intensive outpatient treatment is an important part of the
care chain for substance-related care and can offer to promote better health in clients just as
effectively as can inpatient or institutional healthcare.13
This clinical study aimed to evaluate an integrated intensive cognitive behavioral group
treatment for individuals with substance-related syndrome in outpatient care settings and to study
eventual gender differences in terms of outcome.
Method
Study population
During the study period (October 2014 to September 2017), a total of 50 patients sought
outpatient addiction treatment in a cognitive behavioral treatment clinic in Western Sweden. The
clinic offers adults with substance-related syndrome a one-year program. During the first
four months of the program, the patients receive treatment five days a week. During the remaining
The Journal of Behavioral Health Services & Research 2019
eight months of the program, the patients participate in follow-up group sessions once a week. The
treatment program is not gender specific; the groups and all treatment moments (excluding
individual psychotherapy) include male and female patients at the same time. During the program,
the patients work with licensed psychotherapists, behavior scientists, alcohol and drug therapists,
and a certified acupuncturist. The clinic’s personnel hold team meetings once a week to secure the
progression and quality of the program.
At admission and at discharge, each patient completed a survey comprising several validated
instruments (see details under BInstruments^). The completion of the survey took on average of
30 min, during which time the patient was left alone in an undisturbed room.

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Design
The clinic’s outpatient program lasts for one year. The program starts with four months of
integrated intensive treatment followed by eight months of follow-up. The treatment is based on
cognitive behavioral therapy (CBT). In CBT, the aim is to directly address the patient’s
dysfunctional behavior and thinking in order to induce positive emotional changes. The fourmonth-long integrated intensive treatment includes the following interventions: psychoeducation,
cognitive processing, modulation, problem-solving exercises, affect regulation, exposure and
response prevention, behavior experiments and activation, mindfulness, skills training, auricular
acupuncture (NADA), and home assignments. During this initial four-month period the patient Cognitive Behavioral Therapy Treatment Within Addiction Care
undergoes treatment five days a week. The aim of this study is to evaluate the effects of the first
four months of integrated intensive treatment.
At admission, each patient is given information about the clinic’s daily routines and structure,
and about the rules and regulations (including ethical considerations) applicable during the
treatment period. All patients are given opportunity to ask questions freely before starting the
treatment.
Instruments
The survey began with demographic questions about gender, age, and marital status. These
questions were followed by previously validated psychological measures.
The Beck Depression Inventory (BDI)14 is a self-assessment scale consisting of 21 questions
with a four-point scale to measure depression symptoms and severity in the person during the past
seven-day period. The BDI has good internal consistency. The average value for Cronbach’s α is
0.86 in psychiatric tests15 and in the current study population it was 0.95. It also has adequate
validity in comparison with both clinical assessments and other self-assessment instruments.15 The
Swedish version also has high test-retest reliability (r = 0.93).15 The previously identified cutoffs
were used to define categories as follows: less than or equal to 13 points identified individuals with
no or minimum depression; points from 14 to 19 identified individuals with mild depression; from
20 to 28 points identified individuals with moderate depression and 29 points or over (maximum
63) identified individuals with severe depression.16
The Beck Anxiety Inventory (BAI)16 is a self-assessment scale consisting of 21 questions and
measuring the individual’s degree of anxiety by ranks of a Likert scale with the following items:
Bnot at all^ (0), Blittle, has not bothered me a lot^ (1), Bpartly, has been very unpleasant but I could
endure it^ (2), and Bvery much, barely could stand it^ (3). The BAI’s total score is calculated by
adding the scores of the 21 questions. The maximum score is 63. A total score of 0 to 7 points
indicates a minimum level of anxiety, from 8 to 15 points indicates a mild experience of anxiety,
from 16 to 25 points indicates a moderate experience of anxiety, and 26 points or more indicates a
severe experience of anxiety.16 The Swedish version of the BAI has an acceptable test-retest
Integrated Intensive CBT BADOR & KEREKES
reliability (r = 0.75).17 In this study, the internal reliability of the BAI scale was an acceptable
Cronbach’s α of 0.93.
The Hopelessness Scale (HS)18 intends to measure the degree of experienced hopelessness and
pessimism over future expectations, which is an indirect indication for suicide, and also a common
sign of depression.18 The scale consists of 20 statements to which the test person may answer
Btrue^ (1) or Bfalse^ (0). The total score is categorized as follows: 0 to 3 indicates no or minimal
hopelessness, 4 to 8 indicates a mild experience of hopelessness, 9 to 14 indicates a moderate
experience of hopelessness, and 15 to 20 indicates a high experience of hopelessness with
definitive risk for suicide.19 The reliability of the HS was high (Cronbach’s α of 0.86) in this study.
The Rosenberg Self-Esteem Scale (RSES) was developed by Rosenberg20 and translated into
Swedish by Jonson21. The scale contains ten different statements that together measure the
participant’s global self-esteem. Of the ten items, five are positive claims and five are negative
claims. The answer options are specified on a four-point Likert scale ranging from Bfully agree^ Cognitive Behavioral Therapy Treatment Within Addiction Care
(3) to Bfully reject^ (0). Scores from 15 to 25 points indicate normal self-esteem. Scores under
15 points indicate low self-esteem. Scores over 25 indicate high self-esteem.
Tafarodi and Swann22 have shown that the RSES measures two distinct but related dimensions,
namely Bself-competence^ and Bself-liking^. Self-competence is defined as a person’s experience
of being capable. This experience is based on the capability of being successful in achieving goals.
Self-liking is defined as a person’s subjective assessment of his or her personal value, not
necessarily performance, but according to an internalized set of criteria for social value as moral
agents. The reliability of both the total RSES and its self-competence subscale were acceptable
(Cronbach’s α of 0.81) in this study population, and was close to acceptable for the self-liking
subscale (Cronbach’s α of 0.63).
The Trait Hope Scale (THS)23 is used to measure a person’s experience of hope. The scale
measures a global experience of hope and is divided into two subscales, namely BPathway^
(four items) and BAgency^ (four items). The hope scale consists of 12 descriptive statements
such as BI can think of many ways to get out of a jam^ or BI meet the goals that I set for
myself^. Of the 12 items, four are distraction questions which are excluded from the actual
data analysis. Participants can answer the statements on an eight-point Likert scale ranging
from Bdefinitely false^ (1) to Bdefinitely true^ (8).24 The overall THS score can be 64, with
the two subscales pathway and agency representing a maximum of 32 points each. In the
current study, the overall THS and the agency subscale both had acceptable internal
consistency (Cronbach’s α of 0.80 and 0.73, respectively), while it was close to acceptable
for the pathway subscale (Cronbach’s α of 0.65).
Statistical analyses
All the data was processed using the Statistical Package for the Social Sciences (SPSS, version
22, IBM) software package. A Pillai’s mixed MANOVA (2 × 2 factorial design) was carried out
with gender (men, women) and treatment (before, after) as independent variables and with RSES,
THS, BDI, BAI, and HS as dependent variables. The effect sizes (Cohen’s d) were calculated and
interpreted according to Cohen (1988): 0.20 as a small effect, 0.50 as a medium-sized effect, and
0.80 or over as a large effect. The significance level was set at 5%.
Ethical considerations
The study complied with the Declaration of Helsinki.25 Strict compliance with the ethical
requirements laid down in the treatment contract was ensured. These requirements, namely 1) Cognitive Behavioral Therapy Treatment Within Addiction Care
the individual protection requirement, 2) the information requirement, 3) the consent
requirement, and 4) the confidentiality requirement, were designed to protect the participants
The Journal of Behavioral Health Services & Research 2019
from any physical and/or psychological harm, violation or humiliation, and to protect their
integrity against improper disclosure.26 The patients were informed that their participation in
the study was voluntary and that they could withdraw from it at any time without
consequence. All patients received written and verbal information on the purpose of the data
collection and were informed that the results obtained would be published in the form of a
scientific article. The participants were ensured that their individual answers would be
anonymized in the results and that all data would be managed confidentially. Written consent
was obtained from all participants.
Results
Characteristics of the study population
Of the 50 clients who took contact with the clinic during the study period, 35 individuals (18
male, 17 female) completed the four-month intensive treatment program. The participants’ average
age was 45.6 years (SD = 11.79, range = 24–65). Fourteen participants were in a relationship and
21 were single. Twenty-four participants were parents and 11 had no children. All of the
participants had previous healthcare system and/or social services records. Before admission to
treatment each participant underwent clinical screening establishing their substance use and
dependence.
Effect of integrated intensive CBT treatment
The analysis showed significant effects for treatment (p G 0.001, Eta2 = 0.77, power 9 0.99), and
for the interaction of treatment × gender (p = 0.005, Eta2 = 0.50, power = 0.94), but not for gender
by itself (p = 0.24, Eta2 = 0.27, power = 0.49). Univariate F tests showed significant treatment
effects for all the dependent variables: RSES [F (1, 33) = 57.13, p G 0.001]; THS [F (1, 33) = 37.07,
p G 0.001]; BDI [F (1, 33) = 50.34, p G 0.001]; BAI [F (1, 33) = 42.77, p G 0.001]; and HS [F (1,
33) = 9.85, p = 0.004]. As regards the interaction effect of treatment × gender the univariate F tests
showed no significant interactions.

In a 5- to 10-slide PowerPoint presentation, address the following. Your title and references slides do not count toward the 5- to 10-slide limit. Provide an overview of the article you selected. What population (individual, group, or family) is under consideration? What was the specific intervention that was used? Is this a new intervention or one that was already studied? What were the author’s claims? Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own clients. If so, how? If not, why? Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article. Use the Notes function of PowerPoint to craft presenter notes to expand upon the content of your slides. Support your response with at least three other peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Provide references to your sources on your last slide. Be sure to include the article you used as the basis for this Assignment. Also attach and submit PDFs of the sources you used Cognitive Behavioral Therapy Treatment Within Addiction Care

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The Assignment

In a 5- to 10-slide PowerPoint presentation, address the following. Your title and references slides do not count toward the 5- to 10-slide limit.

• Provide an overview of the article you selected.
  • What population (individual, group, or family) is under consideration?
  • What was the specific intervention that was used? Is this a new intervention or one that was already studied?
  • What were the author’s claims?
• Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own clients. If so, how? If not, why?
• Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article.
• Use the Notes function of PowerPoint to craft presenter notes to expand upon the content of your slides.
• Support your response with at least three other peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Provide references to your sources on your last slide. Be sure to include the article you used as the basis for this Assignment Cognitive Behavioral Therapy Treatment Within Addiction Care

By Day 7

Submit your Assignment. Also attach and submit PDFs of the sources you used.

Resources

• Review this week’s Learning Resources and consider the insights they provide about diagnosing and treating addictive disorders. As you watch the 187 Models of Treatment for Addiction video, consider what treatment model you may use the most with clients presenting with addiction.
• Search the Walden Library databases and choose a research article that discusses a therapeutic approach for treating clients, families, or groups with addictive disorders.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

• Chapter 9, “Motivational Interviewing”
• Chapter 19, “Psychotherapeutic Approaches for Addictions and Related Disorders”
• https://www.youtube.com/watch?v=eQkA0mIWx8A

187 Models of Treatment for Addiction | Addiction Counselor Training Series

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Cognitive Behavioral Therapy Treatment Within Addiction Care