A - Critical - Look - at - Dual - Focused - Cognitiv PDF

Journal of Cognitive Psychotherapy: An International Quarterly
Volume 19, Number 3 • 2005
A Critical Look at Dual-Focused

Cognitive-Behavioral Treatments
for Comorbid Substance Use and
Psychiatric Disorders:
Strengths, Limitations, and
Future Directions
Patricia J. Conrod, PhD

University of British Columbia, Vancouver, Canada, and
Institute of Psychiatry, King's College London
Sherry H. Stewart, PhD

Dalhousie University
Halifax, Nova Scotia, Canada
Several large-scale studies examining outcome predictors across various substance use treat-
ments indicate a need to focus on psychiatric comorbidity as a very important predictor of
poorer SUD treatment involvement and outcome. We have previously argued that current
cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the nec-
essary content in treatment in order to effectively address specific forms of psychiatric comor-
bidity, and thus only provide clients with generic coping strategies for managing psychiatric
illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000).
Furthermore, following our review of the literature on dual-focused CBT treatment programs
for concurrent disorders in this article, we argue that combining CBT-oriented SUD treat-
ments with specific CBT treatments for psychiatric disorders is not as straightforward as one
would think. Rather, it requires very careful consideration of the functional relationship
between specific disorders, patient reactions to specific treatment components, and certain
barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that
is meaningful and to which clients can adhere.
Keywords: substance abuse; cognitive-behavioral; diagnosis; psychiatric disorders; comorbidity
he efficacy of cognitive-behavioral treatments (CBT) for substance use disorders (SUDs)
T is now indisputable. The articles presented in the current special issue on CBT approach-
es such as relapse prevention, guided self-change, behavioral couples therapy, and the
community reinforcement approach, review evidence that clearly establishes that each produces
I 2005 Springer Publishing Company 261

262 CBT for Comorbid Substance Use and Psychiatric Disorders
significant improvements in SUD symptoms. The benefits of these various CBT approaches to
SUD treatment are now also revealing themselves in other domains, such as in improving em-
ployment (Meyers, Villanueva, & Smith, this issue), family discord and partner aggression (Fals-
Stewart et al., this issue), optimism and thought suppression (Witkiev^tz, Marlatt, & Walker, this
issue), substance abuse in special populations (Sobell & Sobell, this issue), adaptive coping
(Ouimette, Finney, & Moos, 1999), psychosocial functioning (Ouimette et al., 1999), criminal
activity and use of health care services (Sacks & DeLeon, 1997), and comorbid psychiatric symp-
toms (Brown & Schuckit, 1988).
Several large-scale studies examining outcome predictors across various substance use treat-
ments (MacLellan et al., 1994; Ouimette, Cima, Moos, & Finney, 1999; Project MATCH, 1997)
are now indicating that theoretical orientation of the treatment is not a strong determinant of
SUD treatment outcome. Nonetheless, such studies have also identified a need to focus on psy-
chiatric comorbiditjf as a very important predictor of poorer SUD treatment involvement and
outcome. Several reports indicate that individuals with SUDs who demonstrate psychiatric
comorbidity are less likely to access addiction treatment services (Wu, Kouzis, & Leaf, 1999),
demonstrate poor compliance with traditional substance use treatments (Drake, Mueser, Clark,
& Wallach, 1996), and generally show a lesser response to such treatments with respect to rates
of relapse to substance abuse, employment status, and psychosocial functioning (McLellan et al.,
1994; Ouimette, Cima, Moos, & Finney, 1999; Project MATCH, 1997). The current article will
examine the literature on the outcome of CBT approaches for the SUD client who suffers from
a concurrent mental disorder.
MODELS OF COMORBIDITY: H O W ARE SUD AND

MENTAL DISORDERS RELATED?
Before we examine different CBT approaches to treatment of concurrent SUD and mental dis-
orders, it is worthwhile to consider various theoretical models of the relationship between SUDs
and mental disorders. These models can inform ways of conceptualizing primary targets of ther-
apy for dually diagnosed patients.
The first model suggests that chronic and severe substance abuse is a strong contributor to
the development of psychopathology and accounts for much of the co-occurrence between SUDs
and other mental disorders. This model of comorbidity suggests that traditional SUD treatments
would be sufficient for the treatment of both concurrent disorders. However, several studies also
indicated that many types of psychiatric symptoms, for example, posttraumatic stress disorder
and psychotic symptoms, either do not subside after traditional SUD treatment (Ouimette,
Ahrens, Moos, & Finney, 1998), or if present in the absence of substance abuse posttreatment,
are strong predictors of relapse to substance abuse (Curran, Flynn, Kirchner, & Booth, 2000).
Therefore, the evidence also supports an alternative second model in which psychiatric symp-
toms are viewed as causing, exacerbating, or at least maintaining SUDs. Treatment implications
of this second model of comorbidity would indicate a stronger therapeutic focus on the psychi-
atric problem than would the first model. A third model of the relationship between SUD and
psychiatric comorbidity proposes that each disorder involves a separate etiology, but that the two
disorders possess common and overlapping courses of illness that mutually exacerbate each
other, such as in the case of comorbid thought disorder and SUD, which are each known to sig-
nificantly interfere with the other's treatment to exacerbate illness course. Treatment impHca-
tions of this third model would suggest concurrent treatment of both disorders. A fourth model
suggests that SUD and psychiatric disorders may be linked through a third variable and has
rather different implications for treatment. Personality factors represent one such possible third
variable. This model would suggest that effective treatment of comorbid disorders should target
Conrod and Stewart 263
the common etiologic mechanism, which, in this case, is personality risk (van den Bosch, Verheul,
Schippers, & van den Brink, 2002). We have elsewhere expanded on this fourth model (e.g.,
Conrod, Pihl, Stewart, & Dongier, 2000; Stewart & Conrod, 2003). Our expanded model takes
into account both research on the role of personality in predisposing to both SUD and certain
mental disorders (e.g., Caspi, Moffitt, & Nevraian, 1998), as well as findings suggesting that SUD
and psychiatric symptoms have reciprocal, deleterious effects on the course of each disorder
(Model 3 above). Thus, we have suggested that a common underlying pathogenesis explains spe-
cific patterns of comorbidity between SUDs and psychiatric disorders, but that at later stages of
illness, each disorder can exacerbate the other to further complicate their course (Conrod, Pihl,
Stewart, et al., 2000; Stewart & Conrod, 2003). Treatment implications of this model emphasize
early intervention targeting personality risk factors for concurrent SUD and mental disorders to
avoid complications associated with comorbidity at later stages of each disorder.
OUTPATIENT DUAL-DIAGNOSIS TREATMENT PROGRAMS

In recognition of the potential bidirectional relationship between SUD and mental health disor-
ders and the research indicating that untreated psychosocial and psychiatric distress at discharge
are predictive of relapse to substance abuse (Hodgins, el-Cuebaly, Armstrong, & Dufour, 1999;
Mullen, Burges, Wallace, Palmer, & Ruschena, 2000; Scott et al., 1998), treatment programs across
North America and Europe have begun to provide additional outpatient dual-diagnosis treat-
ment programs for the comorbid client. The inclusion criteria for such programs usually involve
the client being diagnosed with concurrent SUD and nonaddictive psychiatric disorders (typ-
ically posttraumatic stress disorder and other anxiety disorders, mood disorders, including
unipolar and bipolar disorder, and schizoaffective disorders). Treatment usually involves med-
ication management for the psychiatric disorder, group-based programming for the SUD,
psychoeducation and support, and routine drug screening (Petrakis, Conzalez, Rosenheck, &
Krystal, 2002).
WTiile psychiatric severity is generally associated with noncompliance and poor treatment
response, programs that have a dual-diagnosis focus generally result in more improvement on
substance- and psychiatric-related symptoms, as well as psychiatric service utilization. For exam-
ple, Moggi, Ouimette, Moos, and Finney (1999) recently examined the outcome of a large group
of dual-diagnosis patients accessing in- and outpatient treatment through the Veterans Admin-
istration hospital system in the US. They demonstrated that dual-diagnosis patients participat-
ing in traditional addiction treatments generally achieved abstinence rates of about 40% at 1-year
follow-up and improved on psychiatric symptoms and employment status. Nonetheless, par-
ticipation in programs vrith a stronger dual-diagnosis treatment orientation, and more in-
volvement in outpatient care or self-help groups were related to greater likelihood of abstinence
at follow-up. Interestingly, formal treatment variables (e.g., continuing care and mental health
visits) were not related to the likelihood that patients were free of psychiatric symptoms at fol-
low-up, suggesting that traditional treatments for SUDs do not offer the active ingredients nec-
essary to help comorbid patients recover from their psychiatric disorder which is, nevertheless,
related to SUD relapse risk. Civen the limitations of traditional addiction treatments in meeting
the needs of comorbid patients, several reports have been published providing suggestions on
how to better address comorbidity in clinical practice. While some experts suggest that the effec-
tive treatment of comorbid SUD and psychiatric disorders can be achieved by simply offering
standard treatment of psychiatric symptoms and more extended care (Sloan & Rowe, 1998), oth-
ers have suggested that certain treatment orientations, such as the CBT approach, are more suit-
ed to address psychiatric comorbidity (e.g., Kadden, Cooney, Cetter, & Litt, 1989; Najavits, Weiss,
Shaw, & Muenz, 1998; Thevos, Roberts, Thomas, 8c Randall, 2000; Weiss, Najavits, 8c Creenfield,
1999). However, the evidence does not necessarily support this latter view. CBT approaches have
not been shown to be any more effective than traditional 12-Step approaches in helping dually
diagnosed clients achieve abstinence, maintain abstinence, or reduce their psychiatric and psy-
chosocial disturbance (Finney, Noyes, Coutts, & Moos, 1998; Project MATCH, 1997). Elsewhere,
we have argued that current CBT approaches to SUD treatment do not focus on the necessary
content in treatment in order to effectively address specific forms of psychiatric comorbidity, and
thus only provide clients with generic coping strategies for managing psychiatric illness (as would
be achieved in other SUD treatment approaches; Conrod, Stewart, Pihl, et al., 2000). Further-
more, follov«ng our review of the literature on dual-focused CBT treatment programs for con-
current disorders in this article, we will argue that combining CBT-oriented SUD treatments
with specific CBT treatments for psychiatric disorders is not as straightforward as one would
think. Rather, it requires very careful consideration of the functional relationship between spe-
cific disorders, patient reactions to specific treatment components, and certain barriers to treat-
ment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and
a program to which clients can adhere. What follows is a review of studies that examine the effi-
cacy of dual-diagnosis treatment programs that have provided clients with focused CBT ap-
proaches for their psychiatric disorder. We have organized these by the type of comorbid
psychiatric disorder from which the SUD client suffers to examine patterns of results across a
range of types of comorbidity.
ANXIETY DISORDERS
While SUDs are often comorbid with various anxiety disorders, including social phobia (SP),
posttraumatic stress disorder (PTSD), panic disorder, and generalized anxiety disorder, to our
knowledge, only SP and PTSD have been investigated for efficacy of dual-focused treatments.
Posttraumatic Stress Disorder and SUD

PTSD and SUDs are highly concurrent conditions (Stewart, 1996; Stewart 8c Conrod, 2003). An
overwhelming majority of patients (80-95%) seeking treatment for an SUD report having expe-
rienced intense trauma (Brown, Read, 8c Kahler, 2003). PTSD is three times more common
amongst alcohol- and drug-dependent individuals than in the general population and conserva-
tive estimates of rates of PTSD amongst patients seeking treatment for SUDs range from 20-35%
(Chilcoat 8c Menard, 2003). A couple of controlled trials examining the effectiveness of com-
bined CBT and SUD treatments for this type of comorbidity shed light on the difficulties associ-
ated with addressing concurrent disorders in treatment. Traditional addiction treatments have
been shown to be moderately effective in reducing SUD-related behaviors in patients with PTSD,
but they appear to possess poor efficacy in reducing PTSD symptoms. Moreover, untreated
PTSD symptoms appear to place dual-diagnosis patients at increased risk for SUD relapse, faster
return to drinking after treatment (Brown, Vik, Patterson, Grant, 8c Schuckit, 1996), and poor-
er psychosocial functioning (Ouimette et al., 1998; Ouimette, Finney, 8c Moos, 1999). A study by
Ouimette and colleagues (1998) suggests that SUD patients with comorbid PTSD report less moti-
vation to maintain abstinence in traditional SUD treatment programs and report less improve-
ment on coping-related variables from SUD treatment. Brown (2000) demonstrated that specific
types of PTSD symptoms at pretreatment baseline were most predictive of relapse to SUD in
comorbid PTSD and SUD patients who received traditional SUD treatment. Specifically, intru-
sion symptoms were shown to be predictive of relapse to substance abuse. We demonstrated that
SUD patients wdth PTSD experienced more severe substance dependence profiles than SUD
patients v«thout PTSD (see review by Stewart 8c Conrod, 2003). We also showed that comorbid
SUD-PTSD patients were more likely to meet DSM-III criteria for dependence on substances
that possess sedative properties and they were more likely to report using their drug of choice for
negative affect reduction. Furthermore, we showed that hyperarousal symptoms were most relat-
ed to sedative drug use in this sample. Therefore, it may be that traditional abstinence-based
SUD treatment programs are particularly difficult for patients who are dependent on substances
to cope with the very disturbing cognitive and physiologic symptoms characteristic of PTSD,
such as nightmares and exaggerated startle.
Accordingly, Ouimette, Finney, and Moos (1999) reported results of a treatment study over
a 2-year period that compared patients with comorbid SUD and PTSD to patients with SUD only
or SUD with some other psychiatric illness. They found that patients v«th SUD and PTSD
changed less significantly on measures of psychological symptoms, social supports, employment
status, and arrest history at the 2-year follow-up relative to the other two patient groups.
Ouimette, Moos, and Finney (2000, 2003) recently reported the 2-year and 5-year outcome of
these PTSD patients, respectively. Their results indicated that involvement in PTSD services over
the 2-year period following SUD treatment predicted SUD remission status over and above
involvement in substance abuse and psychiatric treatment services. These studies suggest that
patients with comorbid PTSD and SUD can benefit in the short-term from traditional SUD
treatments. However, over and above the contribution of other psychiatric disorders, these
patients require additional psychological interventions focusing specifically on PTSD symptoms
in order to improve their coping behaviors, and reduce their increased risk for eventual relapse
to SUD following treatment.
Researchers are beginning to develop and investigate the efficacy of CBT treatments that
provide a dual focus on SUD and PTSD symptoms. Two preliminary open trials of combined
approaches to PTSD and SUD treatment have been conducted, and although they did not com-
pare their outcome with a traditional single-treatment approach, their findings have implications
for understanding some of the difficulties in combining CBT treatments for comorbid disorders.
Najavits and colleagues (1998) examined the treatment outcome of 27 women with comorbid
SUD-PTSD diagnoses following participation in an open trial investigation of a new CBT pro-
gram called "Seeking Safety" that targeted PTSD and SUD concurrently. Patients who complet-
ed the treatment showed significant improvement on measures of psychiatric symptoms,
substance-related attitudes, and psychosocial functioning. However, treatment was not shown to
be effective in reducing PTSD symptoms, with somatic symptoms actually increasing from pre-
treatment to posttreatment and only 55% of those patients who met eligibility criteria for inclu-
sion in the study actually attending at least 6 of 24 sessions of the treatment program. More
recently, Brady, Dansky, Back, Foa, and Carroll (2001) similarly conducted an open trial inves-
tigation of the efficacy of a 16-week, combined CBT treatment integrating SUD relapse preven-
tion principles with exposure-based treatment for PTSD. The PTSD exposure treatment
involved 6 to 9 sessions of imaginal exposure in which patients narrated their traumatic event,
including thoughts, emotions, and physiologic sensations associated with the memory and were
scheduled to begin following 7 sessions of relapse prevention for SUDs. Brady and colleagues
(2001) found that the combined treatment was effective in treating substance abuse, was associ-
ated with reduced addiction severity scores, PTSD symptoms, and depressive symptomatology
and treatment completion, according to Najavits and colleagues' criteria (attending at least 25%
of treatment sessions) was improved (69%). However, taking into account the fact that in this
program PTSD sessions only occurred in the second half of the 16-session program, Brady and
colleagues (2001) used more conservative criteria to assess treatment comphance (attending 10
or more out of 16 sessions) which indicated that treatment attendance was still quite low, with
only 15 of 39 patients (39%) classified as treatment completers and only 7 patients available for
follow-up 6 months later. Brady and colleagues (2001) examined baseline differences between
treatment completers and noncompleters to determine whether a certain type of patient was most
suited to this type of treatment. They found very few differences between groups on severity of
psychiatric illness or substance abuse measures. However, noncompleters reported significantly

higher levels of baseline avoidance symptoms. The majority of noncompleters in this study
dropped out before they initiated the exposure therapy component, and reported transportation
difficulty, entering inpatient treatment, scheduling difficulties as the main reasons for their ther-
apy termination. It is possible that these patients terminated therapy early out of avoidance of
the exposure exercises. Alternatively, they may have been unable to conform to the demands of the
relapse prevention sessions earlier in therapy.
In conclusion, the results from two open trials of combined CBT treatments for PTSD and
SUDs indicate that treatment compliance and avoidance behaviors must be addressed before
efficacy of dual-focused programs for comorbid PTSD and SUD are estabhshed. There is some
indication that PTSD patients are less able than others to commit to abstinence in traditional
SUD treatments (Ouimette et al., 1998), and that avoidant patients are less likely to comply with
treatment in terms of remaining in therapy (Brady et al., 2001). Relapse prevention programs
should be modified to better address these patients' needs and may have to focus on reducing
drug use rather than achieving abstinence at early stages of treatment. It is also possible that
motivational interventions geared toward increasing motivation to reduce drug use and increase
treatment compliance may be more suited to this dual-diagnosis group than abstinence-based
or relapse-prevention approaches. Within a program that combines motivational interventions/
guided self-change and CBT for PTSD, clients would be assisted in making decisions to achieve
abstinence. They would also be provided with skills to help them tolerate the psychological dis-
tress associated with PTSD symptoms that arise as a result of rebound from termination of drug
use, or are unmasked with abstinence, or provoked by exposure-based therapies. Finally, it is also
worth exploring the extent to which briefer and more cognitively oriented therapies for PTSD are
more easily tolerated by such patients than exposure-based therapies (Tarrier et al., 1999). The
cognitive approach to treatment of PTSD focuses on peritraumatic appraisals of the trauma and
current beliefs about the event (memory appraisals), rather than on reliving the trauma and
habituating to traumatic memories (exposure). Cognitive therapy for PTSD was recendy shown
to be just as effective in treating PTSD as exposure-based therapy, but was more easily tolerated
by patients than the exposure-based program (Tarrier et al., 1999). This randomized trial com-
paring cognitive therapy to imaginal exposure therapy revealed that more patients in the imagi-
nal exposure therapy showed worsening of symptoms during treatment and a greater tendency
to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the
therapist. While the imaginal exposure therapy was shown to be as effective as cognitive therapy
in reducing PTSD symptoms at the end of treatment, the cognitive approach appeared to be
more easily tolerated by patients and may be more appropriate for use vnth patients who suffer
from PTSD and SUDs. Clearly, the combination of CBT treatments for SUD and PTSD appears
a promising approach to treating patients with comorbid PTSD and SUD; however, there is still
much work to be done with respect to fine-tuning treatments to better address the needs of this
particular dual-diagnosis population.
Social Phobia and SUDs

The prevalence of alcohol abuse or dependence among individuals with social phobia is two
times higher than that observed in the general population (Thomas, Thevos, 8c Randall, 1999)
and rates of social phobia among alcoholic patients are similarly elevated (Kessler et al., 1997). It
has been estimated that the rate of comorbidity between alcoholism and social phobia is at least
20% (Randall, Thomas, 8c Thevos, 2001). Alcohohc patients with comorbid social phobia report
using alcohol to self-medicate anxiety symptoms (Woody, 1996). Such patients may have diffi-
culty complying with treatments that involve group meetings, suggesting specific treatment
needs of this subgroup of dual-diagnosis patients. Thevos and colleagues (2000) and Thevos,
Thomas, and Randall (2001), recently examined the extent to which socially phobic alcohohcs
responded to alcohohsm treatments that had different theoretical orientations and group de-
mands. Socially phobic alcohohcs who received one of three different treatments (i.e., CBT,
Twelve-Step Facilitation [TSF], or Motivational Enhancement Therapy [MET]) as part of a larg-
er client-treatment matching study (Project MATCH, 1998), were evaluated for time to first
heavy drinking day and improvement on measures of social support during treatment and dur-
ing the first year following treatment. Participants showed significant improvement on drinking-
related variables (Thevos et al., 2000) and social supports (Thevos et al., 2001) regardless of the
type of treatment they received. Unfortunately, results also indicated that the majority of social
phobia patients returned to drinking within the first year of follow-up (Thevos et al., 2000).
Female social phobics were significantly more likely to return to heavy drinking if they received
TSF compared to CBT (Thevos et al., 2000). This study also showed that females with social pho-
bia who were assigned to the TSF condition attended half as many AA meetings as females with-
out social phobia, suggesting that untreated social phobia may interfere with comphance with
traditional SUD treatment, at least among women. A second study by this same research team
indicated that CBT and TSF were equally effective in improving social support and each was
more effective than MET in this regard (Thevos et al., 2001). The results of these two studies sug-
gest that CBT and TSF for alcoholism possess several therapeutic components that serve to
improve social skills in social phobics, but that CBT for alcoholism appears more effective in
helping SP patients reduce their drinking because its delivery is less dependent on attendance
at group meetings—an aspect of TSF with which SP patients appear to be particularly reluctant
to comply.
Only one study has evaluated the efficacy of a treatment program that more directly address-
es social phobia concurrent with SUD relative to the efficacy of single-focused CBT for SUD.
Randall, Thomas, and Thevos (2001) recently reported a study in which alcoholics with social
phobia were randomly assigned to either receive 12 weeks of individual CBT for alcoholism {n =
44), or concurrent CBT treatment for alcoholism and social anxiety problems (n = 49). The dual-
focus treatment included alcohol-only modules as well as anxiety management and relaxation
training, construction of a behavioral hierarchy and exposure treatment, and cognitive restruc-
turing of thoughts around social situations. The treatment conditions were matched for number
of sessions (n - 12). Patients were assessed for drinking behavior, social anxiety, and depression
at the end of the 12 weeks of treatment and 3 months after treatment. This treatment program
yielded much better compliance from patients relative to combined CBT treatments for comor-
bid PTSD-SUD. Nevertheless, only 55% of clients attended 10 of the 12 sessions and were
referred to as "completers," suggesting that compliance may still be somewhat of an issue for this
patient group.
Analyses on outcome measures indicated that clients in both treatment groups improved on
drinking measures after treatment, but chents who received the dual-focus treatment had worse
drinking outcomes (days abstinent, percent days heavy drinking, and total number of drinks
consumed) than clients who received the alcohol-only treatment. Moreover, despite the fact that
only the combined treatment received therapy focused on social phobia symptoms, there was no
evidence of an effect of treatment condition on any of the social anxiety or depression measures.
Both treatment groups showed only modest reductions in social anxiety (self-report and collat-
eral rated) from baseline to posttreatment and 3-months follow-up, with many patients still
showing significant impairment at the end of treatment. Furthermore, there did not appear to be
any relationship between the extent to which social anxiety reduced following treatment and
changes in drinking behavior. Alcohol abstinence rates following treatment for patients in this
study were low (20%). Moreover, few clients regularly attended AA meetings before, during, or
after treatment (8.5%, 18%, and 5.5%, respectively), suggesting that neither treatment ade-
quately addressed patients' social avoidance and did not help them to improve their involvement
in self-help groups for alcohol addiction. The fact that treatment was provided on a one-on-one
basis may at least partly account for this poor treatment response, considering reports from these
same researchers indicating that treatment approaches that encourage involvement in 12-step
groups or that emphasize skills training are more effective than individualized, motivational
therapies for women with this dual diagnosis (Thevos et al., 2000; Thevos et al., 2001).
It appears that CBT modules for SUD and SP can be combined into an integrated dual-
focused treatment program and have an effect on both SUD and psychiatric symptoms.
However, relative to single-focused interventions targeting substance abuse, combined treat-
ments appear to lose some of their treatment efficacy by requiring that patients focus on more
than one target symptom at a time. Drawing from the evidence indicating that patients with
PTSD and SUD benefit from longer involvement in treatments that target the psychiatric disor-
der and more attendance at 12-step meetings (Ouimette et al., 2003), it seems possible that dual-
focused CBT programs should be offered over a longer period of time (perhaps up to 1 year) in
order to achieve significant treatment effects on substance use and psychiatric symptoms.
Alternatively, social phobics who abuse substances to cope with their social anxiety may require
special interventions targeting social avoidance to permit them to benefit from other helpful
addiction resources such as group 12-step meetings.
Finally, it is worth mentioning that current CBT programs targeting SP without SUD are
limited in their ability to effectively treat SP with only 40% to 60% of patients achieving "high
end state functioning" (Fedoroff & Taylor, 2001; Mattick & Peters, 1988). Considering these
findings, it appears that single-focused CBT for substance abuse and CBT for SP alike fail to tar-
get the necessary contents in treatment in order to effectively address social phobia and social
anxiety-related motives for drinking. Clearly new developments in research on SP and its treat-
ment are required. Recent cognitive models of SP and its treatment hold promise as they focus
on maintenance processes that may explain why SP patients benefit less from exposure-based
therapies (e.g., Clark & Wells, 1995).
MOOD DISORDERS
SUDs are ofren comorbid not only with various anxiety disorders, but also with both major
mood disorders—major depression and bipolar disorder. In this section, we review studies that
have investigated the efficacy of integrated treatments for each of these forms of comorbidity.
Major Depression and SUDs

Comorbidity estimates for major depression and SUDs appear to be similar to or even slightly
higher than those reported for social phobia: around 20% to 35% (Ross, Glaser, & Germanson,
1988). The Epidemiological Catchment Area (ECA) survey revealed the co-occurrence of these
disorders is almost two times higher than would be expected by chance (Helzer & Przybeck,
1988; Regier et al., 1990). When depressive symptoms are assessed using self-report ratings,
comorbidity estimates are generally higher than those from studies using structured diagnostic
interviews (Hesselbrock, Hesselbrock, Tennen, Meyer, & Workman, 1983; Keeler, Taylor, &
Miller, 1979), with as many as 85% of patients entering alcohol treatment reporting clinical sig-
nificant depressive symptomology (e.g., Dorus, Kennedy, Gibbons, & Ravi, 1987). The presence
of major depression before or afrer alcoholism treatment is associated with poorer alcoholism
treatment outcome (Hodgins et al., 1999) and situations involving negative affect are the most
common type of situation reported by substance users as preceding their slips and relapses to
substance use (Marlatt & Gordon, 1985). Despite these fmdings, there appears to be much debate
in the literature as to the extent to which depressive symptoms should be addressed in SUD treat-
ment programs. For example. Brown and Schuckit (Brown, Inaba, Gillin, et al., 1995; Brown &
Schuckit, 1988) have reported that depressive symptoms significantly remit following inpatient
SUD treatment, suggesting that we may not need to specifically focus on depressive symptoms
in SUD treatment. Nevertheless, these researchers emphasize the importance of distinguishing
between primary (experiencing depression before and without symptoms of SUD) and second-
ary depression (experiencing depression after or while also experiencing symptoms of SUD) in
the context of SUDs and suggest that primary depressed patients may indeed require a treatment
approach with a dual-diagnosis focus.
However, other studies suggest that dual-diagnosis programs may even benefit alcoholics
who would not meet full criteria for primary depression or current secondary depression. For
example, a recent study assessed approximately 300 veterans who had completed a 21-day inpa-
tient alcoholism treatment program 3,6, 9, and 12 months after treatment (Curran et al., 2000).
They found that mild-to-moderate depression at 3 months posttreatment predicted a threefold
increased risk of relapse at the later follow-up periods. Severe depression at 3 months posttreat-
ment was associated with a fivefold increased risk for relapse to SUD across follow-ups. This
study also demonstrated that regardless of depression status at pre-treatment, participants were
at greater risk for SUD relapse if they reported depressive symptoms at the 3-month follow-up
assessment. Thus, contrary to the position of Schuckit and his colleagues, this study appears to
suggest that an additional focus on depressive symptoms is indeed necessary for SUD clients with
even mild depressive symptoms to prevent SUD relapse.
Despite the demonstrated efficacy of CBT for major depression (Young, Wienberger, &
Beck, 2001), it is surprising that only one randomized control trial has examined the additional
benefit of providing CBT depression coping skills treatment to alcoholics with elevated depres-
sive symptoms. Brown, Evans, Miller, Burgess, and Mueller (1997) randomly assigned alcoholics
who scored higher than 10 on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock,
& Erbaugh, 1961) to either receive CBT depression coping skills training or a relaxation train-
ing control (RTC) intervention in addition to their usual addiction treatment. The standard
abstinence-based, day-treatment program for alcoholism included detoxification services, gen-
eral cognitive-behavioral skills training, and encouragement of 12-step involvement. The added
depression intervention was based on Brown and Lewinsohn's (1984) Coping with Depression
(CBT-D) course, which is a multicomponent treatment for depression, focusing on training
depression-relevant skills such as daily mood monitoring, pleasant activities, constructive think-
ing, and social skills and assertiveness training. Thirty-two of 35 patients who finished either
program completed follow-up assessments at 1-, 3-, and 6-months posttreatment. It is impor-
tant to point out that despite the fact that all patients had elevated depression scores and report-
ed depressive symptoms before treatment, not all participants would be considered to have dual
diagnoses of alcoholism and depression and very few of the participants in this study had a pri-
mary depression diagnosis. Nevertheless, results indicated that the CBT-D intervention was asso-
ciated with greater decreases on self-report measures of depressed and anxious mood, and on
interviewer-based depression scores from pre- to posttreatment than the RTC intervention.
However, these treatment group differences disappeared at 1-, 3-, and 6-month follow-up. There
were no treatment effects on self-report depression scores, and because interviewers making
depression ratings were aware of treatment group status when interviewing clients, these treat-
ment effects may actually refiect an experimenter bias rather than an actual treatment effect.
Drinking outcome was also assessed using a semistructured interview (and it is not clear whether
interviewers were blind to treatment group status). Nevertheless, the CBT-D group reported
more percent days abstinent at the 3-month follow-up, but did not differ from the RTC group
on abstinence rates, number of heavy drinking days, and number of drinks per day. Differences
between treatment groups were revealed at the 6-month follow-up period in which the CBT-D
group reported a higher percentage of days abstinent (90%) relative to the RTC group (68%),
fewer drinks per day (.5 vs. 5.7), and greater rates of total abstinence over the 3-to-6-month
follow-up period (47% vs. 13%). Moreover, Brown and colleagues (1997) showed that the rela-
tionship between treatment and drinking outcome at 6 months was partially mediated by the
greater reduction in depression scores following the CBT-D treatment.
If the results of this study can be replicated under double-blind conditions, they will suggest
that CBT treatment targeting depressive symptoms in alcoholics can benefit alcoholics evidenc-
ing some depressive symptoms over and above standard addiction treatment. These findings also
suggest that regardless of whether a patient is diagnosed with comorbid depression, depressive
symptoms play an important role in relapse to alcohol misuse and should be addressed in treat-
ment. It is interesting that this added component to a standard alcoholism treatment program
was able to produce effects on substance- and depression-related variables, without even pro-
viding instruction on how to integrate the concepts discussed in each intervention. It is possible
that relapse prevention programs for SUD have more of a conceptual overlap with CBT for
depression than with other forms of CBT, which makes integration of the two therapies more
straightforward. Indeed, several of the principles of relapse prevention are based on the CBT
approach to treating depression (Beck, Rush, Shaw, & Emery, 1978) and target similar problems
in therapy, such as cognitive distortions, stress management, activity scheduling (Marlatt &
Cordon, 1985). It is possible that CBT interventions for other Axis I and Axis II disorders pro-
vide more specific focus on concepts that do not necessarily overlap with those addressed in
relapse prevention therapy for SUD (e.g., exposure exercises in the case of anxiety disorders).
Bipolar Disorder and SUDs

In recognition of the very high rate of co-occurrence between bipolar disorder and SUDs (Regier
et al., 1990) and the evidence that each coexisting disorder worsens the prognosis of the other
(Keller et al., 1986), Weiss and colleagues (1999) recently proposed a method of combining re-
lapse prevention (RP) group therapy for SUD with group therapy for bipolar disorder. What is
novel about this approach is its attempt to provide dual-focused treatment that fully integrates
concepts from the more traditional single-focused CBT programs for individual disorders. Inte-
gration of these two kinds of treatment has the advantage that bipolar patients offen require
training in areas that are addressed in RP, such as, identifying and coping with high-risk situa-
tions, self-monitoring, cognitive distortions, and modifying lifestyle to reduce risk for relapse.
That is, treatment goals in RP for SUD and CBT for bipolar disorder are very similar and focus
on one main concept: managing risk for relapse. In fact, the CBT approach to treatment of bipo-
lar disorder was closely based on RP principles and has been shown to be effective in assisting
bipolar clients improve their psychosocial functioning, reduce their risk for relapse to a manic
episode, experience fewer fiuctuations in manic mood, and cope better with prodromal indica-
tors of manic mood (Lam, Watkins, & Hayward, 2003). The dual-diagnosis treatment program
proposed by Weiss and colleagues (1999) is a very good example of how CBT for SUD and psy-
chiatric symptoms can integrate themes that are relevant to each disorder. Rather than requiring
that patients adopt a "dual" focus in treatment, this approach focuses on CBT concepts that can
be applied to either SUD or bipolar symptoms.
Weiss and colleagues (2000) recently reported the results of a pilot study examining the effi-
cacy of this integrated group therapy (ICT) for patients with bipolar disorder and SUD.
Participants were recruited when they were inpatients at McLean Hospital if structured clinical
interviews revealed that they met criteria for bipolar disorder and substance dependence.
Following discharge, they were recruited in sequential blocks to participate in either the ICT (« =
21) or monthly assessments only (non-IGT; n = 24). Treatment was approximately 20 sessions
and participants were assessed at baseline and monthly during treatment and for 3 months after
treatment completion. The non-ICT group were assessed monthly for 6 months. The rate of
assessment completion was quite high with 77% of the 278 scheduled assessments being fully
completed. IGT participants attended a mean of 71.6% of the groups offered, with only 2 of 21
patients dropping out of treatment after attending only two sessions. The IGT group showed
lower addiction severity and fewer days of alcohol and drug use. Furthermore, IGT patients were
more likely to maintain abstinence for 3 or more consecutive months and reported lower mania
scores. The groups did not differ in medication compliance or interviewer-rated depression
scores at any of the follow-up points.
While this study lacked a single-focus control group that would have allowed us to deter-
mine whether IGT is superior to standard RP for bipolar patients, the results of this pilot study
suggest that IGT for comorbid bipolar disorder and SUD shows promise as an effective treatment
for both mania and substance use. However, the authors of this study recently reported addi-
tional data from this study sample focusing on self-report reasons for substance use at intake
(Weiss et al., 2004). Nearly all patients reported initiating substance use as a way to cope with at
least one bipolar symptom, with depression as the most commonly reported (77%) reason for
use. Considering that the IGT group did not show more improved outcome on depression meas-
ures suggests that an additional coping with depression component should be added to IGT to
better manage risk for SUD relapse in this comorbid group.
SCHIZOPHRENIA AND S U D S
Approximately half of all patients who are diagnosed and treated for schizophrenia also meet cri-
teria for an SUD (Dixon, 1999; Regier et al., 1990). Schizophrenic patients who abuse substances
are more likely than those who do not abuse substances to require higher doses of neuroleptic
medication to achieve clinical stability, relapse to psychotic illness, become homeless, become
HIV infected, commit suicide, or be incarcerated following discharge (Brunette, Bellack, &
Gearon, 2001; Hall, 1998; LeDuc & Mittleman, 1995; Linszen, Dingemans, & Lenior, 1994;
Mullen et al., 2000; Scott et al., 1998; Soyka, 2000). Substance abuse in schizophrenic patients is
considered one of the most significant problems facing mental health systems in the world
(Bellack & Gearon, 1998). A recent 4-year prospective study examining the effect of comorbid
SUD on the course of schizophrenia follovnng discharge from hospitalization showed that even
in the context of medication compliance, dual-diagnosis clients are admitted to hospital sooner
(10 months after discharge) compared to patients who do not use substances (37 months; Hunt,
Bergen, & Bashir, 2002). The combination of substance abuse and medication noncompliance
was even more clinically significant with such patients averaging their first readmission within 5
months of discharge for their last admission.
Because schizophrenic patients with SUDs are more likely to be treated in a general psychi-
atric facility than in an addiction treatment facility, these patients are much less likely to receive
treatment for their SUD than SUD patients with or without other forms of psychiatric comor-
bidity. There is a recent recognition that dually diagnosed patients with schizophrenia require
special programs that integrate components of psychiatric and SUD treatments (Bellack &
Gearon, 1998; Carey, 1996), and that such programs should reconsider their emphasis on absti-
nence as schizophrenic patients tend to be less able to make commitments to abstinence (Osher
& Kofoed, 1989). Furthermore, a few studies have indicated that schizophrenics do not report
using substance to cope with schizophrenia-specific issues (e.g., psychotic symptoms, or med-
ication side effects) as was initially thought. Rather, they report using for reasons that are simi-
lar to other substance abusers, namely, in response to negative affective states, interpersonal
conflict, and social pressures (Dixon, Haas, Weiden, Sweeney, & Frances, 1991; Noordsy et al.,
1991; Sandberg & Marlatt, 1991).
Accordingly, there have been several attempts to tailor traditional substance abuse treat-
ments, such as the 12-Step Approach, CBT, Motivational Interviewing, and the Community
Reinforcement Approach and Contingency Management, to accommodate the needs of people

with psychotic illnesses (Carey, 1995,1996; Drake, Bartels, Teague, Noordsy, & Clark, 1993; Drake
& Noordsy, 1994; Higgins, Budney, & Bickel, 1994). However, very few well-controlled trials have
examined the effects of these integrated treatments in managing substance abuse in schizophrenic
patients. One of the best-controlled studies was conducted by Jerrell and Ridgely (1995) in which
participants were randomly assigned to treatment conditions comparing: 12-step program,
behavioral skills training, and intensive case management with community-oriented treatment.
While the latter two treatments were shown to be more effective than the former, the effects on
substance abuse were modest. Bellack and Gearon (1998) reviewed the literature examining the
effects of dual-diagnosis treatments for schizophrenic patients with SUDs and concluded that in
order for treatments for dual-diagnosis patients to be effective, they will have to be modified to
address the cognitive and motivational deficits in schizophrenic patients. They suggest that cur-
rent psychosocial SUD treatments are based on principles of change that strongly focus on moti-
vation to change, commitment to abstinence, and social support, yet also point out that the
avolition and poor psychosocial functioning that characterize schizophrenia present serious
obstacles to benefit from traditional SUD treatments. They present a new behavioral approach
to treatment that addresses the specific needs of this population, called Behavioral Treatment for
Substance Abuse in Schizophrenia (BTSAS). This treatment involves five components:
1. monthly motivational interviews to discuss treatment goals;

2. urinalysis contingency in which patients earn small amounts of money for negative screens
for a self-selected drug goal;
3. training in drug-refusal skills;
4. education regarding the impact of drug use in schizophrenia;
5. problem-solving and RP training to improve coping in high-risk drug-taking situations.
The intervention is also designed to reduce the load on memory, attention, and higher cognitive
processes. For example, sessions are highly structured and emphasize behavioral rehearsal.
A pilot study tested the efficacy of this program in dual diagnosis patients with schizophre-
nia and SUD who were referred fi'om Veterans Affairs and community mental health centers in
Baltimore. Of the 42 patients who consented to participate in the BTSAS program, 28 (70%)
actually presented at the clinic for treatment and only half of those completed more than 3 ses-
sions. Of the participants who attended more than 3 sessions (n = 14), one third (ti = 5) pro-
duced negative urinalyses on approximately 70% of their tests, whereas the other two thirds («
= 9) failed more than 45% (range 45%-100%) of their tests. Interestingly, this study revealed that
the factors that were associated with dropout from treatment appeared to be different than those
associated with a poor prognosis in treatment. Amongst those participants who attended the
BTSAS program, those who did not respond had lower levels of readiness to change at intake
compared to those who did respond to treatment. However, lower motivation to change did not
necessarily characterize the dropouts or nonattenders. Rather, they appeared to discontinue
treatment for reasons such as inpatient hospitalizations, incarceration, or scheduling confiict
with other treatment-related meetings (i.e., reasons related to their schizophrenic illness). These
findings further suggest the need for more integrated services in which programs such as BTSAS
are fully integrated into larger mental health systems to remove these systemic barriers to SUD
treatments for schizophrenic patients. In light of these findings, Belleck and Cearon (1998) have
made several changes to their BTSAS protocol, including involving case managers in the treat-
ment recruitment process, offering motivational interviewing earlier in the intervention to
enhance treatment compliance and engage patients at early stages of treatment, and increasing
the contingency payments for negative urinalysis.
Barrowdough and colleagues (2001) also recently tested the efficacy of a similarly dual-
focused intervention program for this patient group. Their intervention combined motivational
interviewing, CBT for psychosis, and family intervention involving a family member or caregiv-
er. Interventions took place over a nine-month period and generally took place in the caregiver's
and patient's homes, to minimize potential obstacles to treatment for these patients. Of the 66
eligible patient-caregiver pairs invited to participate in the study, 30 pairs refused to participate
in the intervention. Analyses of 12-month follow-up data on 36 pairs who were randomly
assigned to the dual-focused program or a TAU control revealed significant intervention effects
on measures of global functioning and psychotic symptoms. Across all substance use outcome
measures there was a trend for the integrated CBT intervention to be associated with greater
improvement (e.g., greater number of days abstinent). One limitation of this study was that the
two patient groups were not matched for therapy time, with the integrated CBT group receiving
more care than the TAU group. Therefore, it is not possible to conclude that the addition of the
integrated CBT program significantly contributed to patient improvement. Furthermore, this
study may not have been sufficiently powered to detect significant intervention effects on sub-
stance-related behaviors. There is definitely room for more work in this area, but these prelimi-
nary results suggest that integrated CBT programs hold promise for patients with comorbid SUD
and psychosis.
PERSONALITY DISORDERS
The co-occurrence of Axis II disorders and SUDs is estimated to be between 2 and 25 times high-
er than would be expected by chance (Compton, Cottier, & Phelps, 2000). This high rate of
comorbidity is now reflected in the DSM-IV-TR (American Psychiatric Association, 2002) diag-
nostic criteria of two of the most commonly observed personality disorders, antisocial personal-
ity disorder (APD) and borderline personality disorder (BPD)—which have substance abuse
amongst their list of diagnostic criteria. In this section, we v^U review the literature on the effec-
tiveness of CBT treatments for SUD when it is comorbid with these personality disorders.
APD and SUD

While the co-occurrence of APD and SUD is generally associated with reduced response to tra-
ditional SUD treatment (Rounsaville et al., 1987), some studies do not indicate a specific effect
of APD diagnosis on outcome relative to other Axis I and II diagnoses (Ouimette, Gima, Moos,
& Finney, 1999; Verheul, van den Brink, & Hartgers, 1998; Verheul, van den Brink, Hartgers, &
Koeter, 1999). Verheul and colleagues (1998) found that among alcoholic clients admitted to The
Jellineck, an addiction treatment center in the Netherlands, the presence of any Axis II diagno-
sis was associated with a 3.5-fold increased risk for relapse at 3-months follow-up, but APD (and
other Cluster B personality disorder diagnoses) was not associated with poorer outcome relative
to other personality disorders. The 3-month relapse rate for alcoholic outpatients with comorbid
Axis II diagnoses was 46% relative to a 12.5% relapse rate for alcoholic outpatients without an
Axis II diagnosis. Interestingly, comorbid patients who were treated on the inpatient service
demonstrated relapse rates that were similar to noncomorbid patients (11.4%), suggesting that
Axis II comorbid patients may benefit from more intensive inpatient services. This study also
examined the factors that appear to mediate poor response to treatment in the comorbid patients
who received outpatient services. A surprising finding was that variables such as time in program
and motivation for change were shown to moderate rather than mediate comorbid patients' poor
response to treatment. That is, the relationship between Axis II diagnosis and relapse risk was
strongly exacerbated by poor motivation to change, with unmotivated Axis II comorbid patients
being 28 times more likely to relapse within the first 3 months of treatment than those without
Axis II comorbidity. Motivated Axis II comorbid patients showed similar relapse rates to patients
without Axis II comorbidity (high and low motivation). This study also showed that regardless
of motivation. Axis II comorbidity was associated with quahty of therapeutic alliance estabhshed
in therapy, which may explain why Axis II comorbid patients are less able to benefit from short-
term treatment when they are not motivated to change (i.e., the therapeutic alliance is less effec-
tive in activating or maintaining motivation for change in these clients). The results of this study
challenge the widely held perception that Axis II comorbidity, particularly APD, is related to
poorer addiction treatment outcome, and suggest that if treatment for SUDs and comorbid APD
is offered within a context that facilitates the development of a good working alliance (i.e., inpa-
tient care), or greater motivation for change, then Axis II comorbid patients can indeed benefit
from SUD treatment. What remains to be determined is whether a "stepped approach" to treat-
ment involving motivational and CBT interventions will lead to improved treatment involve-
ment in less-motivated Axis II comorbid patients.
Cooney, Kadden, Litt, and Getter (1991) conducted a study examining whether there was
any validity to the notion that APD alcoholics require specific skills training in order to benefit
from addictions treatment and whether interactional therapy would address the interpersonal
deficits that appear to impact on APD substance abuser's response to treatment. In this study,
alcoholic clients were assigned to one of two aftercare treatments (coping skills training vs. inter-
action group therapy) for 26 weekly, 90-minute group sessions. The coping skills training inter-
vention (Monti, Abrams, Kadden, & Cooney, 1989) was designed to develop skills for problem
solving, communication, and relaxation, coping with negative moods, urges to drink, and high-
risk drinking situations. The interactional group therapy intervention (Getter, 1984) focused on
clients' interpersonal relationships by exploring immediate feelings and reactions to "here and
now" interactions as they occurred in each session. Participants were initially assessed for the pri-
mary matching variables: global psychopathology, APD symptoms, and neuropsychological im-
pairment. Outcome measures focused mostly on latency from inpatient discharge to the first
heavy drinking day and frequency of heavy drinking.
First, this study revealed that at the 2-year follow-up period there was no significant inter-
action of treatment type with time, supporting other reports of comparable outcome following
coping skills and interactional treatments for alcoholism (Kadden et al., 1989). Furthermore,
similar to the results reported by Verheul et al. (1998), they found that APD traits were not relat-
ed to treatment outcome overall, but interacted with type of treatment provided. With respect to
time to the first heavy drinking day, patients who demonstrated more APD symptoms at assess-
ment responded more favorably to the coping skills treatment whereas patients with less-severe
APD symptoms responded more favourably to interactional therapy. Those with APD who
received coping skills treatment demonstrated a twofold greater abstinence rate (50%) at the
2-year follow-up than the APD group who received interactional therapy (25%). The results of
project MATCH, an 8-year multisite study of how patients respond to different treatment
approaches for alcoholism (i.e., 12-Step, CBT, and MET), suggest that MET and 12-Step ap-
proaches to treatment of APD alcohohcs lead to similar outcomes as CBT-oriented therapy
(Project MATCH, 1998).
In conclusion, despite the previous findings of the role of motivation and interpersonal fac-
tors in APD patients' response to addiction treatments, the evidence does not necessarily suggest
that a more effective therapeutic approach is one that is interpersonally oriented. Rather, research
suggests that antisocial substance abusers may benefit from alternative treatment approaches,
such as the CBT approach, 12-step and motivational approaches, which potentially "get around"
the interpersonal deficits seen in these chents by focusing less on the interpersonal processes
and more on internal motivation for change and acquisition of more adaptive coping skills in and
outside the interpersonal domain. The outcome results reported by Cooney, Kadden, Litt, and
Geller (1992) suggest that CBT interventions that focus on each of these components can be rea-
sonably integrated into a single treatment program and are effective for patients with comorbid
APD and SUD. Furthermore, the results of Project MATCH suggest that APD clients can respond
to motivational interventions, and Verheul and colleagues' (1998) findings indicate that clients
who are less ready to change may benefit from interventions that address motivation for change
before they participate in treatment targeting other problem areas.
BPD and SUD

Some lessons have been gained from three controlled clinical trials on CBT for concurrent
SUD and BPD, which have provided an interesting perspective on the potential efficacy of dual-
focused behavioral interventions for SUD clients with Axis II disorders. According to a con-
trolled clinical trial conducted at The Jellineck, Dialectic Behavior Therapy (DBT; Linehan,
1993), a form of CBT that has been shown to be effective in treating BPD, was shown to be just
as effective for BPD patients with SUDs as those without SUDs in terms of reducing BPD symp-
tomatology (e.g., self-mutilating behaviors, self-damaging impulsive acts, retention in therapy;
van den Bosch, Verheul, Schippers, & van den Brink, 2002). However, there was no demon-
strated effect of DBT on substance-related behaviors relative to the effects of a treatment as usual
control intervention focusing on substance abuse. Neither treatment was effective in reducing
substance-related behaviors in BPD patients.
Linehan and colleagues (1999) developed a modified version of DBT that included all of the
standard components of DTB over a 1-year treatment period, but that also targeted substance
abuse (DBT-S). In this program, therapists emphasized a "dialectical" approach to promoting
abstinence that involved a combination of "unrelenting insistence" on total abstinence before any
illicit drug abuse takes place, and acceptance and nonjudgmental problem solving and relapse
prevention affer any drug use has occurred. This approach also recommends a necessary return
to "unrelenting insistence" on abstinence following the lapse. This program also included a
"replacing pills with skills" protocol in which patients were provided with 4 months of "transi-
tional maintenance" replacement medication pharmacotherapy (to facilitate acquisition of cop-
ing skills), followed by 4 months of drugs tapering (to promote skills strengthening), and 4
months ofno drug replacement (to promote skills generalization). Linehan and colleagues (1999)
showed DBT-S was associated with greater reduction in substance-related behaviors and greater
improvement in psychosocial functioning over a 16-month follow-up period relative to treatment
as usual (referral to psychotherapy and addiction treatment services in the community) for BPD
patients with SUDs. More DBT-S participants (64%) were retained in treatment than treatment
as usual participants (27%) remained with their primary therapist in the community. However,
both interventions were shown to be associated with significant reductions in BPD symptoms and
the modified DBT-S treatment was not shown to be any more effective than the treatment as usual
protocol with respect to reducing symptoms such as parasuicide episodes and anger.
While it appears that DBT can be modified such that it includes multiple behavioral targets
to address concurrent personality and SUD problems, dual-focused behavioral therapy does
not appear to achieve the same effect size as single-focused therapy for BPD. Considering the
research by Moggi and colleagues (1999) reviewed above, it may also be necessary to provide such
dual-focused treatments over a longer period of time to allow patients with comorbid BPD and
SUDs the time to adequately address all problem behaviors.
Van den Bosch and colleagues (2002) argue that alternative potentially useful approaches to
treating comorbid BPD and SUDs would be to target the core personality features of BPD that
fuel impulsive and self-damaging behaviors (e.g., boredom susceptibility, emptiness, identity dis-
order), to provide clients with personality-relevant coping skills training that will more easily
generalize to other risk-taking behaviors. They recommend insight and psychodynamically ori-
ented psychotherapeutic approaches to achieve these goals. This stands in contrast to Linehan's
approach to treating BPD, which is strongly based on principles of behavior change and involves
procedures such as behavioral analyses, training in behavioral skills, contingency management.
exposure-based training, and thus requires that therapy focus on a particular behavior or set of
behaviors. Should researchers wish to explore alternative avenues for treating comorbid BPD and
SUDs, it will be important to first explore the extent to which the core personality features of
BPD are actually functionally related to substance use in BPD clients. For example, Casillas and
Clark (2002) recently described the personality deficits that underlie the association between
Cluster B personality disorders and SUDs as being extreme deviations of normal personality
traits such as neuroticism and disinhibition. Interventions that target these core personality vari-
ables may prove to more easily generalize to a variety of impulse control and health compromis-
ing behaviors that characterize Axis II disorders.
Cognitively oriented therapies that focus on self-statements, problem-solving skills, per-
spective taking, self-regulation, and self-monitoring (Kazdin, 1991) are effective in helping chil-
dren better manage their personality vulnerability to inhibited and disinhibited psychopathology
and appear to generalize across a variety of behavioral problems (Kazdin & Crowley, 1997).
Recently, similar cognitive therapy programs have been developed for concurrent Axis II and
SUDs in adults, in which relapse prevention for substance dependence is integrated into a 24-
week cognitive therapy program for personality disorders targeting personality-specific early
maladaptive schemas (enduring negative beliefs about oneself, others, and events) and coping
styles (Ball, 1998; Ball & Young, 2000). While the efficacy of this cognitive approach to treating
concurrent BPD and SUDs has yet to be investigated, considering the potential limitations of
more behaviorally oriented treatments for concurrent Axis II and SUDs, it may be worthwhile
exploring the extent to which cognitively oriented therapies for personality disorders are effec-
tive in addressing the numerous problem behaviours that characterize patients with SUD and
Axis II disorders.
INTEGRATED CBT-ORIENTED INTERVENTIONS TARGETING PERSONALITY

RISK FACTORS COMORBID FOR SUD AND PSYCHIATRIC COMORBIDITY
We recently conducted two studies exploring the efficacy of cognitive-behavioral interventions
targeting those personality factors most linked to substance abuse and specific mental health
problems in adulthood (Conrod, Stewart, et al., 2000). Sensation seeking (SS), anxiety sensitivi-
ty (AS), hopelessness (H) and impulsivity (I) are personality risk factors for SUDs, each associ-
ated with a specific drug use and psychopathology profiles (Conrod, Pihl, Stewart, & Dongier,
2000). We previously showed that SS female substance abusers demonstrated a pattern of sub-
stance abuse that focused primarily on alcohol dependence, whereas AS was associated with life-
time dependence on anxiolytic substances and anxiety disorders, H with lifetime dependence on
opioids and depression, and I with lifetime dependence on cocaine and higher rates of APD
(Conrod, Pihl, et al., 2000). To explore the extent to which CBT interventions targeting the core
personality features of these patterns of comorbidity could reduce drug-related behaviors, we
developed a novel set of personality-matched interventions that were designed to intervene at
the level of personality risk and associated motivations for substance use. Manuals were devel-
oped to accompany each intervention and contained psychoeducational information on the target
personality risk factor and how it is understood to be associated with risky substance use and
other maladaptive coping. For example, in the AS management intervention, clients were taught
about the nature and characteristics of AS and how AS motivates alcohol and anxiolytic drug use,
as well as more general avoidance behaviours, to cope with negative emotions. The AS clients
were also taught about how anxiety symptoms are paradoxically increased in the long term
through avoidance, and through alcohol/drug use. The manuals also contain personality-specif-
ic cognitive-behavioral exercises designed to facilitate training of more adaptive coping strate-
gies. For example, in the SS group, tendencies toward impulsive responding are countered
through exercises training the client in problem solving through examining the advantages and
disadvantages of possible actions in both the long- and short term.
In our first test of this novel approach to addressing SUD in comorbid clients, we recruited
200 women from the community to participate in an initial 3-5 hour assessment and random-
ized control trial comparing three different intervention groups. The first personality-matched
intervention targeted personality risk as described above during a 90-minute feedback and therapy
session. The second intervention involved mismatching to personality to examine the specific
effects of personality-matched CBT training relative to the effect of exposure to personality-
irrelevant CBT training. The third intervention involved viewing a film that was designed to
motivate women to enter into treatment for their SUD then engaged women in a 45-minute dis-
cussion with a therapist in which they were encouraged to talk about their drug-related concerns
and their motivation for change. All participants were provided with a list of addiction and psy-
chiatric services at the end of the brief intervention. Approximately 80% of participants were
reassessed on alcohol and drug use measures 6 months after participation in one of these three
interventions. Analyses indicated that all participants demonstrated significant reductions in fre-
quency and quantity of alcohol use. However, the women who received the personality-matched
intervention showed significantly greater reductions in drug-dependence symptoms and greater
abstinence rates relative to the other two groups. There was also a consistent trend across all
drug-related measures for the personality-matched intervention to be associated with better out-
come relative to the personality-mismatched intervention, suggesting that brief CBT interven-
tions may be improved if they pi"ovide targeted training on personality-relevant principles.
SS, AS, and H were recently shown to be associated with substance abuse in adolescents and
each personality trait appears associated with a specific risky drinking motive (i.e., SS with
enhancement motives and AS and H with coping/conformity motives, respectively; Comeau,
Stewart, & Loba, 2001). We recently developed another set of personality-matched preventa-
tive interventions for at-risk teenage drinkers, derived from the community-based personality-
matched treatments for addictive disorders (Conrod, Stewart, Pihl, et al., 2000) and interviews
with SS, AS, and H teens (Comeau, Theakston, Stewart, Conrod, & Loba, 2002). We have been
testing the efficacy of these novel interventions over the past 2 years in high schools in urban
British Columbia and rural Nova Scotia, Canada. These novel programs were designed as early
interventions to decrease heavy drinking and prevent the escalation of teens' alcohol and mental
health problems by intervening at the level of personality risk and associated risky drinking motives.
We developed manuals to accompany each intervention that were similar to the personality-
matched manuals developed for adult substance abusers, but modified to be developmentally
appropriate for youth. The interventions were administered to students demonstrating personal-
ity risk in a group format over two sessions, in which within- and between-session exercises were
assigned. The sessions were very dynamic and interactive, and the exercises encouraged group
interaction so that the teens could learn from one another's experiences. Stories or "scenarios"
derived from qualitative interviews with AS, SS, and H teens were featured with lively and "edgy"
artwork throughout the manuals to illustrate various points and to make the interventions visu-
ally appealing and meaningful to the lives of these at-risk teens (Stewart et al., 2002a).
In the first year, we conducted a pilot project to test the efficacy of the interventions by invit-
ing 26 teens who indicated drinking and showed personality risk to participate in the interven-
tions and provide us with qualitative feedback on their experience. Results showed that of the
teens who did participate in one of the two interventions, 25% were no longer drinking 4 months
affer the interventions, compared to 8% of 21 teens who did not participate in the interventions
but reassessed at the 4-month follow-up period (Conrod et al., 2003). Students indicated finding
the personality descriptions relevant to their own experiences and reported appreciating the
group format. They reported making use of the skills acquired in the interventions in their every-
day lives (Stewart et al., 2002b).
In the second year of the investigation, students were randomly assigned to the appropriate
personality-matched intervention or to a no-treatment control group at each site and then
reassessed 4 months later. At the two sites (Nova Scotia and British Columbia) the interventions
were conducted in an identical fashion with the only exception being that in Nova Scotia, only
the AS and SS management interventions were tested whereas in British Columbia, these two
interventions were tested along with an additional H management intervention.
At the Nova Scotia site, analyses revealed significant reductions in drinking quantity and
alcohol problems for girls in the experimental group but there were no changes in these variables
for experimental boys, or for either boys or girls in the control group. Finally, the magnitude of
reduction in risky drinking motives (i.e., coping, conformity, and enhancement combined) was
twice as large in the girls assigned to the experimental group than in teens assigned to each of the
other three groups. At the British Columbia site, we tested the AS, SS, and H management inter-
ventions in a similar randomized controlled design. A significantly greater proportion of stu-
dents in the experimental interventions (35%) than the no-treatment control groups (15%) did
not drink alcohol during the 4-month follow-up. The intervention group also reported a signif-
icant reduction in binge drinking rates (fi-om 42% to 25%), whereas those in the no-treatment
control group did not appear to change their rate of binge drinking (46% to 52%). Significant
intervention by time interactions for total number of alcohol problems and other reckless behav-
iors (e.g., unprotected sex, speeding, drug use) indicated that such behaviors decreased in fre-
quency and severity over time in the intervention group and increased in the control group.
These results thus suggest promise for the personality-matched early interventions in reducing
problem drinking. It is currently unclear why the interventions were only effective for the girls at
the Nova Scotia site, but this could pertain to the fact that of the five facilitators and two cofa-
cilitators who ran the interventions, all but one was female, whereas facilitators and cofacilitator
pairs at the British Columbia site were always mixed gender. Stewart, Comeau, Loba, Conrod,
and Maclean (2003) suggested that therapist-chent gender matching effects may account for the
results at the Nova Scotia site.
Across the two sites and the 2 years of data collection, we have obtained data consistent with
the idea that brief cognitive-behavioral interventions targeting personality risk factors for heavy
and problem drinking may be a promising strategy for reducing risk for alcohol abuse in at-risk
youth. Given that these personality factors are also associated with other forms of comorbid psy-
chopathology (e.g., AS with anxiety disorders; H with depressive disorders), these interventions
show promise as methods for preventing or intervening early with comorbid psychopathology as
well. Of course, future research would need to evaluate the effects of these interventions on a
broader array of outcome measures than the simple assessment of drinking levels, motives, and
problems assessed here.
SUMMARY
To summarize, the few studies that have examined the efficacy of CBT-oriented programs for
dual-diagnosis clients yield somewhat inconsistent findings. It appears that programs that com-
bine CBT principlesfi-omsingle-focused treatment programs are most effective for mood disor-
ders and it may be because there is more conceptual overlap betvi^een the relapse prevention
programs for SUDs and CBT-oriented treatments for bipolar and unipolar depression. The
results for dual-focused CBT programs targeting anxiety disorders are not as promising, and it
may be that they do not adequately address severely problematic avoidance behaviors in patients
with comorbid SUD and anxiety disorders. Exposure-based programs may be more difficult to
integrate with relapse prevention programs for SUD as the former focuses on confronting fears
and the latter focuses on reducing exposure to high-risk situations. Furthermore, there is some
indication that exposure-based treatments are associated with more symptom expression and
poorer attendance during treatment than more cognitively oriented treatments. It is worthwhile
exploring whether cognitive-oriented treatments for anxiety disorders are more easily integrated
with SUD treatments and better tolerated by comorbid patients.
The literature on comorbid SUD and schizophrenia revealed that this patient group is pre-
sented with several systematic barriers to benefiting from dual-diagnosis CBT programs and a
need for programs to be offered within a comprehensive system of care in which patients are
assisted in meeting the demands (e.g., scheduling, treatment compliance) of multiple treatment
services. Finally, our review of the literature on CBT-oriented dual-diagnosis treatments for
comorbid Axis II and SUD led to a conclusion that current behavioral treatments for each indi-
vidual disorder are easily integrated into a dual-focused program, but they may lose some of their
efficacy by targeting both sets of problem behaviors simultaneously. Our review suggests that
patients with SUD and Axis II disorders may require longer-term access to dual-focused behav-
ioral programs to allow them the time required to develop a strong therapeutic alliance in treat-
ment, and to allow them the time required to focus on multiple target behaviors and coping
skills. There was also some indication that CBT treatments for personality disorders may also
provide an alternative to behavior therapies, which appear limited in their ability to target mul-
tiple symptoms and behaviors. While research on dual-focused CBT for comorbid Axis II and
SUDs is lacking, our review indicates that this approach may hold promise (Ball, 1998).
We ended our review with a discussion of our novel personality-matched approach to treat-
ing and intervening early with concurrent SUD and psychiatric problems to provide an exam-
ple of how CBT principles fi-om empirically supported interventions for SUDs and psychiatric
conditions can be integrated into brief interventions focusing on underlying personality risk fac-
tors for specific patterns of comorbidity. The advantage of this approach is that by targeting
shared antecedents of SUD and psychiatric symptoms, interventions do not burden clients with
too many treatment goals, are more easily generalized to multiple maladaptive coping strategies,
and have the potential to prevent onset of, or relapse to, either set of problems. While studies
have yet to demonstrate whether brief personality-focused interventions are also effective in
reducing or preventing mental health problems, two studies from our group indicate that this
new approach is effective in reducing substance-related behaviors and may also prove to be par-
ticularly effective for the concurrent treatment and prevention of SUDs with comorbid Axis II
pathology.
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Acknowledgments. We would like to thank Dr. Paige Ouimette and Dr. Michael Cossop for their helpful
reviews of this manuscript. Preliminary results of a study entitled "Preventative Efficacy of Cognitive
Behavioural Strategies Matched to the Motivational Bases ofAlcohol Misuse in At-Risk Youth" are presented in
this manuscript and we would like to thank the Alcoholic Beverage Medical Research Foundation for funding
this project.
Offprints. Requests for offprints should be directed to Patricia J. Conrod, PhD, National Addiction Centre, 4
Windsor Walk, Denmark Hill, London, SE5 8AE, UK. E-mail: [email protected]

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A - Critical - Look - at - Dual - Focused - Cognitiv PDF

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Journal of Cognitive Psychotherapy: An International Quarterly

Volume 19, Number 3 • 2005

A Critical Look at Dual-Focused

Patricia J. Conrod, PhD

Sherry H. Stewart, PhD

Keywords: substance abuse; cognitive-behavioral; diagnosis; psychiatric disorders; comorbidity

he efficacy of cognitive-behavioral treatments (CBT) for substance use disorders (SUDs)

I 2005 Springer Publishing Company 261

MODELS OF COMORBIDITY: H O W ARE SUD AND

OUTPATIENT DUAL-DIAGNOSIS TREATMENT PROGRAMS

Posttraumatic Stress Disorder and SUD

psychiatric illness or substance abuse measures. However, noncompleters reported significantly

Social Phobia and SUDs

Major Depression and SUDs

Bipolar Disorder and SUDs

Reinforcement Approach and Contingency Management, to accommodate the needs of people

1. monthly motivational interviews to discuss treatment goals;

APD and SUD

BPD and SUD

INTEGRATED CBT-ORIENTED INTERVENTIONS TARGETING PERSONALITY

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