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C ognitive-Behavioral Therapyfor People with Addictions

Bruce S, Liese

John, a successful 36-year-old businessman, is married with threeyoung children. He is addicted to cocaine and will go to any lengthsto use. He also smokes marijuana daily. His drug dealer operates outof a dangerous inner-city crack house. John knows he risks his lifewhenever he goes there to buy cocaine. At times he even gets high inhis dealer's crack house for lack of a better place to use.

Mary, 50 years old, is a heavy drinker and cigarette smoker. She alsohas a gambling problem. She is unhappily married and when she feelslonely at home she goes to the casino. After gambling her money awayMary heads home, typically too drunk to be driving. When she has nomoney to spend at the casino, Mary drinks at home until she passesout.

'Why is it so difficult to change addictive behaviors? Why are peoplelike John and Mary so willing to risk everything to abuse drugs, drink,smoke, and gamble? \What will it take to get them to change their addic-tive behaviors? What cognitive-behavioral tools are available to help Johnand Mary? These are some of the questions addressed in this chapter.First, addictive behaviors are defined from the perspective of cognitive-behayioral therapy. Cognitive-behavioral theory and therapy are thendescribed, with emphasis on the importance of the collaborative therapeu-tic relationship and case conceptualization. Finally, lessons learned fromdecades of practicing cognitive-behavioral therapy with addicted patientsare presented.

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Cognitive-Behavioral Therapy for Addictions. In S.L.A. Straussner (Ed.), Clinical work with substance abusing clients (3rd ed.; pp. 225-250). New York: Guilford Press, 2014.

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226 VARYING PERSPECTIVES ON INTERVENTION

Defining Addictive Behaviors

Addictive behaviors produce immediate gratification or relief from discom-fort at the expense of long-term physical and psychological well-being. Asportrayed in the previous examples of John and Mary, addictions can causepain, suffering, and ultimately an individual's demise. In the past, addic-tions were narrowly defined. To "qualify" for an addiction, a person had todrink, smoke, or consume drugs. Nowadays it is understood that excessivegambling, eating, Internet use, sex, and other behaviors function much likeaddictive behaviors, in that they produce immediate gratification or reliefwhile carrying long-term risks.

Cognitive-Behavioral Theory and Therapy

The term cognitiue-bebauioral therapy (CBT) is somewhat misleading.There are actually many cognitive-behavioral (CB) therapies that fall underthe umbrella of CBT. Some of these (e.g., cognitive therapy, rational-emo-tive behavior therapy) place primary emphasis on identifying and modify-ing maladaptive thoughts and beliefs. Others place primary emphasis onchanging maladaptive behaviors (e.g., community reinforcement approach,contingency contracting, behavioral couple therapy, cue exposure therapy).One relatively new trend that has developed over the last two decades is

the integration of CBT and mindfulness training (e.g., Hayes, Strosahl, &Wilson, 201.2; Marlatt, Larimer, & 'Witkiewitz,2012; Segal, Williams, &Teasdale, 201,2). Hayes et al. (201,2) call these integrated CBTs the "'thirdwave' cognitive and behavioral treatments" (p. 91). There are more simi-larities than differences among these CBT theories, but in general CBTsfocus on maladaptive thoughts, feelings, and behaviors.

CBT is based on the premise that emotions, behaviors, and physio-logical responses (adaptive and maladaptive, functional and dysfunctional)develop early in life and are driven largely by automatic thoughts and basicbeliefs (see Figure 10.1). First applied to treat depression and anxiety, it isnow established that CBTs are effective in the treatment of addictive behav-iors (Manuel, Hagedorn, 6{ Finney, 201,1,).

To illustrate, John (described earlier) grew up in a home with a

demanding, competitive, judgmental father who frequently said, "You'reonly as good as your last accomplishment" (see Figure 10.2). His father alsopreached, "You work hard and then you can play hard." John eventuallyadopted these basic beliefs as his own. As a result he felt perpetual anxiety,fear of failure, and worry about disappointing his father. In college, Johnwas introduced to marijuana and cocaine (critical incidents in his life), andhe used these drugs to work hard, play hard, and deal with the deep sense

of inadequacy that came from believing he was only as good as his lastaccomplishment. After graduating from college he continued to use these

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Cognitive-Behavioral Therapy 227

@@FmrlFIGURE 10.1, Basic cosnitive-behavioral developmental model.

drugs and became addicted. Only later in life did he realize that he was self-medicating; cocaine was giving him a false sense of confidence, and mari-juana was numbing his perpetual tension and other symptoms of anxiety.

Beck, !7right, Newman, and Liese (1.993) developed a CB model thatorganizes addiction-related thoughts and beliefs into categories: basicbeliefs, automatic thoughts, permissive thoughts/beliefs, and action-ori-ented beliefs (see Figure 10.3). Following a high-risk stimulus situation(e.g., friends drinking and gambling at the casino) Mary's basic beliefs wereactivated, including "I can't have any fun without drinking and gambling,""Life is great when I'm loaded," and "There's no better way to make a

buck than gambling" (see Figure 10.4). Following the activation of thesebasic beliefs, Mary's automatic thoughts were triggered. These thoughtswere brief and abbreviated (e.g., "Party!"1"Drink up!"; and "It's my luckyday!"). Some automatic thoughts might also take the form of visual imagesrather than words. For example, Mary would often recall images of beingwith friends at the casino-drinking, smoking, and having a great time.Automatic thoughts such as these reliably triggered Mary's urges and crav-ings to drink, smoke, and gamble. Before Mary engaged in these addictive

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FIGURE 10.2. John's cognitive-behavioral development.

behaviors, however, she granted herself permission to do so. Examples ofpermissive beliefs include "I'll quit eventually," "I don't have a problem,"or "I'm no different from anyone else." Following these permissive beliefs,Mary had action-oriented thoughts that involved strategies for engaging inher addictive behaviors. She would think, for example, "Get out your wal-let," "Get some change for the slot machines," and "!7hile you're at it, goget yourself a beer." So after Mary's basic beliefs were activated, her auto-matic thoughts triggered, her urges and cravings begun, with permissiongranted and actions chosen, Mary's continued use was inevitable.

Mary's addictive thoughts and behaviors had become an ongo-ing vicious cycle. Any time she encountered another smoker (a high-risk

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Cognitive-Behavioral Therapy

FIGURE 10,3. Coenitive-behavioral model of addictive behaviors.

situation) her basic beliefs were activated: "I'm a smoker, too, so I need a

cigarette." Her automatic thought might be a short phrase, such as "Lightup!" Following urges or cravings she would grant herself permission (e.g.,

"I won't smoke the whole cigarette"), then focus on actions necessary tosmoke (e.g., reach for a cigarette, place it in her mouth, light up). Her even-tual indulgence served to reinforce her basic belief that she was a smokerwho continued to smoke, as the vicious cycle perpetuated itself.

Addictive behaviors are initially self-reinforcing since they producedesired mood-altering affects. For example, alcohol may reduce inhibitionsand anxiety in a heavy drinker, nicotine in cigarettes may provide stimula-tion to a smoker, comfort foods may give relief to a binge eater, and win-ning at a slot machine may provide exhilaration to a gambler. Eventually,

FIGURE 10.4, Mary's vicious cycle of thoughts, beliefs, and addictive behaviors.

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VARYING PERSPECTIVES ON INTERVENTION

however, individuals habituate to the effects of their addictive behaviorsand these behaviors lose their potency. When this happens, anticipatorythoughts and beliefs (rather than actual physiological effects) perpetu-ate the drive to continue addictive behaviors. This phenomenon has been

referred to as "chasing the high." 'When Mary began to gamble and drinkat casinos, she did so with a group of friends who had a great time. Even-tually her friends became less interested in gambling and chose to spendmore time in other activities. Though she never again had as much fungambling alone, Mary continued to believe "Maybe I'll meet great people

at the casino, win lots of money, and have a great time." These things neveractually happened again. Nonetheless, Mary continued to believe that theyeventually would. Each time she went to the casino alone she was chasingthat high.

For many individuals, addictive behaviors devolve into compensatorystrategies used as substitutes for effective coping skills. For example, peerpressure and the sensation of getting stoned drove John's initial drug use.

However, as time passed, drug use became John's primary strategy for cop-ing with life's challenges. He never fully developed effective coping skillsbecause he habitually used cocaine and mariiuana to relieve unpleasantfeelings. Often getting high alone, John went from being a recreational userto an addict-consuming drugs to deal with tension, frustration, anxiety,and eventually depression.

'S7enzel, Liese, Beck, and Friedman-Wheeler (2012) propose a CBmodel that conceptualizes chemical and behavioral addictions as being aresult of proximal (recent) and distal (past) processes. The terms proximaland distal are important to understanding the dynamics of addictive behav-iors. Proximal processes are those processes that have occurred recently.For example, they can include the automatic thoughts that cause a personto reach for a pack of cigarettes (e.g., "I need a smoke") or physiologicalurges and cravings to use. Distal processes are those that have occurred inthe more distant past (e.g., having parents who smoked, or cultural beliefssuch as "Smoking is cool").

So again the question is raised: Why would people like John andMary risk everything to take illegal drugs, smoke cigarettes, or gamble?According to most CB models, they do so because past (distal) and present(proximal) thoughts, beliefs, circumstances, triggers, and cues lead themto these maladaptive behaviors. John grew up with a judgmental fatherwho was always critical and demanding (distal causes). As a result Johndeveloped unrelenting standards, perfectionist striving, and the core belief"I'll never be good enough." John's urges to use cocaine can be traced torelief-oriented thoughts following extended periods of hard work with littlesatisfaction (e.g., "I've been busting my ass all week for my family. Now Ineed to get away from it all"). As he gets closer to buying and using cocaine,

John's negative beliefs about his own self-worth counterbalance any fears

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he might have about getting caught, harmed, or even killed. He decides

"\7hat the hell . . . " and heads to the inner-city to score cocaine.The transtheoretical model (TTM) of change (Connors, DiClemente,

Velasquez, 8a Donovan, 2013; Prochaska, DiClemente, & Norcros s, 1.992)

has been integrated into most addiction treatment approaches, and CBTis no exception. According to the TTM there are five stages associatedwith readiness to make major life changes: precontemplation, contempla-tion, preparation, action, and maintenance. Without understanding thesestages, therapists of all types and theoretical models are missing an impor-tant piece of the addictive behaviors puzzle (Norcross, Krebs, 6c Prochaska,2011; Prochaska & Norcross, 2001).

The following is a brief description of the five sfages of change andcommon thoughts and behaviors associated with these stages. In the pre-contemplation stage, individuals are not yet ready to contemplate changingtheir addictive behaviors. They may deny or admit to problems associatedwith their addicted behaviors. For example, if Mary is in denial, then she

might think, "I'm just coughing because I have a little cold." In contrast,she may admit that she has a problem but not be ready to make changes: "Iknow this cough is caused by smoking, but I can't think about quitting rightnow." In the contemplation stage, individuals are ready to consider behav-ior change but they have not actually prepared for or begun actual change.Their thoughts have shifted from "It's not a problem" or "I'm not ready todo anything about this" to "It might be time to change." At 50 years oldMary might begin to contemplate change. She might think, "I can't keepdoing this. I'd better make some changes." As they enter the preparationstage, addicted individuals begin to mobilize for change (cognitively andbehaviorally). For example, Mary might search the Internet for an Alcohol-ics Anonymous (AA) group or quit smoking program and choose one. She

might even choose a quit date based on something meaningful, such as herdaughter's birthday. In the action stage, Mary would actually quit smok-ing, drinking, or gambling. For example, she might wake up one morningthinking, "I'll never smoke again," and actually stop smoking. After morethan 6 months of abstinence, Mary would be in the maintenance stage ofchange. Besides sustaining behavior change by not smoking, Mary mighthave thoughts like "I can't believe I was ever a smoker" and "Smoking isdisgusting."

The value of the TTM (stages-of-change model) is that it provides a

conceptual basis for customizing interventions based on patients' readinessto change. Mary and John are likely to enter into CBT only when they havebegun to contemplate change. Mary's motivation might follow an arrestfor driving under the influence of alcohol. John's motivation might followhis wife's discovery of his covert drug use and the threat of divorce. In bothcases, the CB therapist would assess John or Mary's readiness to change,then decide on techniques most appropriate for their stages of change.

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The Five Essential Components of CBT

CBTs are active, directive, structured, collaborative, educational approachesaimed at helping individuals with psychological, behavioral, and emotionalproblems. There are five essential components to CBT: (1) the collabora-tive therapeutic relationship, (2) case conceptualization, (3) structure, (4)

education, and (5) CB techniques. These components are described in thefollowing sections.

The Collaborative Therapeutic Relationship

Effective psychotherapy requires collaboration between therapists andpatients (Norcross 6c Lambert, 201,1). Patients must take interpersonal risksthat enable therapists to access, understand, and help them. At the sametime, therapists must provide safe collaborative settings where patients canbe honest and get help with their addictive behaviors. Most addicted indi-viduals are somewhat ambivalent about changing their addictive behaviors.They may believe "I can't live with my addiction but I can't live withoutit." They likely feel guilty about their behaviors or are fearful about get-ting caught. Many find it difficult to tell the truth and reveal their secrets,because their addictive behaviors are illegal or judged by friends, family,coworkers, and society to be wrong.

It was obvious that John had much to lose if others learned of his addic-tions. He was ashamed, but even more, he was afraid that his wife, friends,family, and colleagues would find out that he was addicted to cocaine. Asa result of his fear and shame, John was very reluctant to seek help. Heassumed that a therapist would judge him, or even worse, he thought, "If Italk to anyone my secret will be out. Everyone will know about my addic-tion and my life will be ruined." Consequently, he did not believe he couldtrust even a mental health professional.

John's CB therapist understood John's reluctance to trust him, so hewas particularly attentive to John's ambivalence about pursuing therapy.He directly inquired about John's difficulty trusting others. He empa-thized with John, assured him that their relationship was confidential,and explained how the CBT process works. He then answered any ques-tions John may have had. John eventually overcame some of his reluctanceto seek help, though he remained hesitant about exposing all the detailsregarding his risky behaviors. This hesitancy created some challenges to thetherapeutic relationship.

A common misconception about CBT is that techniques are moreimportant than the collaborative therapeutic relationsbip. This is simplynot true. Experienced and skillful CB therapists understand that effectivetherapy requires a strong therapeutic relationship. Effective therapists arewarm, genuine, authe-ntic, and, perhaps most important, empathetic (Moy-ers 6( il4ifl.r, *+ZV,A""ther misconception about CBT is that therapy

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sessions are rigidly structured. Excessive rigidity may compromise thetherapy relationship, and CBT requires the formation of a collaborativetherapeutic relationship to be effective. S7ithout such a relationship thepatient is likely to drop out of therapy (Liese & Beck,1.997). Conversely,when the relationship is collaborative, the therapist is most likely to exerta positive influence on the patient, who will then be more likely to stay intherapy.

As discussed earlier, addicted individuals vary greatly in their readi-ness to change. Therefore an understanding of the TTM stages of change(precontemplation, contemplation, preparation, action, or maintenance) isessential to developing a collaborative therapeutic relationship. Therapistswilling to "meet patients where they're at" are most likely to make a posi-tive impact. For example, John was not ready to quit using drugs "cold tur-key" at his first visits to his therapist. He thought, "I know this guy willtell me to quit, and I'm not ready." If John's therapist had demanded thathe quit immediately, John would have dropped out of therapy. In contrast,

John's therapist asked (nonjudgmentally), "'What do you get out of yourdrug use?" and John actually told him the truth: that it provided someescape from the stress and pressure in his life. John's therapist respondedempathetically and the conversation continued. John's therapist eventuallypersuaded him to view his addiction as self-destructive. This would nothave been possible without the formation of a trusting, collaborative thera-peutic relationship.

Case Conceptualization

Accurate case conceptualizations are among the essential ingredients ofall effective psychotherapies, and CBT is no exception. An accurate case

conceptualization enables the therapist to make good choices about whenand how to intervene with CB techniques. An essential key to formulatingan accurate case conceptualization is empatbetic listening. In the absenceof therapist empathy, the case conceptualization is necessarily flawed andlikely incomplete. Thus, in addition to guiding CB techniques, accuratecase conceptualizations contribute to the establishment of strong, collab-orative therapeutic relationships.

According to Beck et al. (1,993) the cognitive case conceptualizationshould comprise the following:

. Releuant background information, including early life experienceswith community, family, and peers, with close attention paid to suc-cesses and failures, trauma, crises, major losses, and so forth.

o Current life problems in general and those related to addictivebehaviors.

o Salient emotions, especially those associated with the patient's prob-lems.

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. Core beliefs and scbemas, especially the patient's views of self, theworld, others, and the future.

. Conditional assumptions, beliefs, and rules, for example, "If I do X,then Y is likely to happen."

o ComPensatory strategies, including addictive behaviors that func-tion in the absence of effective skills.

. High-risl< stimuli and situatiozs likely to trigger problems (addic-rions, negative emotions, etc.).

c Automatic thoughts and beliefs, especially those related to addic-tlons.

o MaladaPtiue behauiors associated with addictive behaviors andemotional problems.

. Readiness to change according to the TTM (precontemplation, con-templation, preparation, action, maintenance).

o Integration and treatment plan, including potential problems, pit-falls, and methods for overcoming these.

This structure allows organization of information about addictedpatients. Some information is collected in early visits, but additional infor-mation is collected over the course of therapy. Hence, the case concep-tualization continuously evolves as more information about the patient is

uncovered. In the following sections case conceptualizations are presentedfor both Mary and John.

Mary's Case Conceptualization

o Releuant background data. Mary is 50 years old, has a high schooleducation, and has been unhappily married to her husband George for 32years. The couple has two grown children. George and Mary were marriedright out of high school, which, Mary says, "is just what we did back then."George works as a long-haul truck driver. When asked about her unhappymarriage Mary says, "It's OK. George is gone most of the time, so I hardlyhave to deal with him."

Mary had a difficult childhood. Her father owned a small business

and, according to Mary, "He only cared about himself." She described hermother as "angry all the time." Mary explained, "My parents never gotalong. They were heavy drinkers. Alcohol was always around the house,and the more they drank, the more they fought with each other."

t Current life problems. Mary's problems include addictions to alco-hol, nicotine, and gambling; chronic loneliness; depressive episodes; anunhappy marriage; and a nonexistent support system.

o Salient emotions. Mary feels chronically depressed, lonely, restless,bored, and sometimes guilty or fearful about the effects of her addictivebehaviors.

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. Core beliefs and schemas. Mary's core beliefs and schemas involvea deep sense of inadequacy. She believes "I'm nothing special and neverwas," "I've never been smart, rich, or pretty and I never will be" and "It'sno surprise that my life stinks."

. Conditional assumptionslbeliefs/rules. Mary's conditional beliefsinclude "If I take risksl'll only fail," and "If I try to fix or leave my mar-riageql'll only have bigger problems."

o ComPensatory strategies. Mary's compensatory strategies allinvolve avoidance. She smokes and drinks to ward off anxiety and loneli-ness. She gambles to avoid boredom. She keeps her distance from Georgeto avoid conflict.

o High-risk stimuli and situations. Mary is at risk whenever she feels

unpleasant emotions (e.g., anxiety, loneliness, and boredom), which is mostof the time.

o Automatic thougbts and beliefs. The automatic thoughts and beliefsthat lead Mary to drink include "Life sucks," "I need a drink," and "Noth-ing matters anyway," The automatic thoughts that lead Mary to gambleinclude "I can't stand my house another secondr" "I've got to get out ofhere," and "Maybe I'll get lucky." Automatic thoughts that lead to cigarettesmoking include "It's time for a smoke" and "Light up."

. MaladaPtiue behauiors. 'When Mary goes to the casino to gambleshe always drinks and smokes, then drives home drunk. Gambling placesMary at risk for serious financial problems, and her drinking puts her atrisk for legal problems and potential harm to herself and others. Thesebehaviors are part of a larger pattern of avoidance (e.g., in her marriage),isolation, and withdrawal. and are likely to result in the exacerbation ofher depression.

o Readiness to change. Mary is in a perpetual state of contemplation.She wakes up most days with a hangover and says to herself, "This is killingme." 'When she remembers that she lost money the night before she thinks,"I can't afford to keep gambling." She then remembers a phrase she learnedin a 12-step meeting: "I'm sick and tired of being sick and tired." Nonethe-less, Mary feels stuck in the contemplation stage.

Eventually Mary may transition out of the contemplation stage; how-ever, she is likely to do so at different times for her different addictivebehaviors. For example, she might suddenly quit gambling because she

cannot afford the expense, while continuing to drink and smoke. Next she

might prepare to quit drinking, or cut down, but believe that she cannotquit, because it will be too stressful to give up all of her addictions.

o Integration and treatment plan. Mary's multiple addictions to alco-hol, tobacco, and gambling coexist with her depression, loneliness, anda profound sense of inadequacy. Her life is a perpetual vicious cycle in

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which (1) depression triggers addictive behaviors, (2) addictive behaviorsreinforce negative beliefs about herself, (3) these negative beliefs exacerbateher depression, and (4) her depression triggers addictive behaviors meant toprovide escape from this uncomfortable emotional state. Mary knows thather addictive behaviors are self-destructive, but for a long time she has notbelieved she is capable of changing them.

Mary's therapy must begin with the development of a safe, secure,trusting relationship with her therapist. Through this relationship, it ishoped that she will be receptiye to modifying her maladaptive thoughts,beliefs, and behaviors. It will be necessary to conceptualize fully the com-plex relationship between Mary's addictive behaviors and emotions, so shecan be taught strategies for emotion regulation that will replace her addic-tive behaviors. Mary will be at risk for relapse until she secures these newcoping strategies. It will be important for Mary's therapist to understandthat Mary might be ready to make some changes (e.g., stop gambling) butnot others (e.g., cigarette smoking).

John's Case Conceptualization

c Releuant backgrownd information. John is 36 years old and mar-ried, with three young children. He makes a good living as a self-employedfinancial advisor. According to John, his wife had no idea that he wasaddicted to cocaine. After developing some trust in his therapisqJohnadmitted, "My wife thinks I only smoke pot. If she knew I got high oncocaine in the 'hood,' she'd freak."

John talked briefly about his childhood, claiming "It was very happy,"but eventually he admitted to having a critical, demanding father and a

passive mother. The tension and criticism John experienced while growingup left him feeling tense and insecure for most of his life. John masked hischronic feelings of inadequacy with drugs and compulsive work.

o Current life problems. John's biggest problems revolved aroundhis addictive behaviors. Besides the dangerous health effects from usingcocaine and marijuana, John was at risk for legal problems, being a victimof violent crime, marital and family problems, and the loss of his careerand livelihood. He lived a double life, which made it necessary for him tolie and deceive his wife, friends, and family. He lived in constant fear ofbeing "discovered" and was therefore under constant pressure to pretend"everything's all right."

o Salient emotions. John has chronic feelings of tension, frustration,anxiety, and irritability. Though John claims to love his job, it is very stress-ful, and John's stress is exacerbated by his need to lie, deceive others, andprotect his secret life.

. Core beliefs and schemas. For much of John's life he has had alooming sense of inadequacy. John's father perpetually told him, "You

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can be whatever you want in life" and "You won't amount to anythingif you're lazy." As a result of these messages John constantly battledwith the core belief, "I'm just one mistake away from being a miserablefailure."

. Conditional assumptionslbeliefs/rules. One of John's most salientdysfunctional beliefs is that he is only as good as his last success. He wasplagued by the thought, "If I succeed I'm someone; if notl'm a nobody."Some of his rules, learned from his own father, include "'Work hard, playhard," "Don't belazyr" "Don't be weak or vulnerable," and "You shouldn'tneed to ask anyone for help."

o Compensatory strategies. Given John's personal resources (e.g.,

drive, intellect, education, career, financial stability) he has the capacityto be adaptive, effective, successful, and happy. However, instead of usingthese resources to cope with life's challenges John has used drugs to com-pensate for his coping skills deficits. In addition, John has lied and coveredup the truth (also compensatory strategies) to maintain his self-destructiveaddictive behaviors.

. High-risk stimuli and situatiozs. John's high-risk stimuli and situa-tions can be broadly categorized as negative mood states and various envi-ronmental cues. For example, John drives home from work often feelingtired and frustrated. His route home takes him through a part of town rifewith drugs, dealers, and temptation. It is no wonder that he often beginsto have addictive thoughts and cravings prior to leaving his office for thedrive home.

o Automatic thoughts and beliefs. John's automatic thoughts andbeliefs include "I work hard. I deserve to have some fun," "It'll feel sogood," "My wife will never know," and "I'll be OK."

. MaladaPtiue behauiors. Most of |ohn's maladaptive behaviorshave revolved around drug use, leading to lies, deceit, and extremely riskychoices.

t Readiness to change. At the recommendation of his family physi-cian, John initially entered CBT to get help with his anxiety. He talkedabout his drug use reluctantly and only in response to specific questionsasked by his therapist. At the time, John was in the precontemplation stageof changing his addictive behaviors. He explicitly stated, "Cocaine and potare rewards for working my ass off. I love to get high and do not intendto change that in the near future." However, over the course of therapy,

John came to trust his therapist and to share his therapist's concern that he

was risking everything with his cocaine use. This cognitive shift enabled

John to enter into the contemplation, preparation, and even action stages.

Though he eventually quit cocaine, he maintained the belief "Smoking potis harmless, especially compared to cocaine." \flhen it came to marijuana,

John remained in the precontemplation stage.

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. Integration and treatment plan. John entered CBT at a critical timein his life. From his therapist's perspective, John's drug use had escalatedto dangerous levels. Everything he valued was in jeopardy. Through CBT,

John was guided to discover his strengths and use these to build other strat-egies (besides drugs) for solving problems and getting satisfaction in hislife. John's treatment plan eventually included a commitment to stop usingcocaine. After he quit using cocaine, John's therapy focused on relapse pre-vention (for cocaine) and harm reduction (for marijuana). John was helpedto learn effective coping strategies to replace less durable compensatorystrategies and especially his drug use.

Structure

All forms of psychotherapy are structured to some degree, with both thera-pist and patient following certain rules and parameters. Beck and his coau-thors (1993) recommend the following structure for individual CBT ses-

sions (typical therapist questions are in parentheses):

. Agenda ("'!7hat would you like to work on today?" or "I(/hat's onyour agenda today?")

. Mood check ("How have you been feeling since I last saw you?" and"How are you feeling today?")

. Bridge from last session and review of homework ("S7hat did youget out of our last session?" and "'W'hat homework have you donesince the last session?")

o Prioritize and discuss agenda items with emphasis on problem solv-ing ("lWhich agenda item is most important?" and "Is that the oneyou'd like to work on first?")

. Decide on appropriate bomeworA ("S7hat would you like to do as

homework follow-up on our session?" and "How can you work onthis between now and the next session?")

o Summarize the session and conclude ("Here's what we've workedon today . . . " and "Ifhat have you gotten out of the session?")

Generating and following an agenda is a way to hold both therapistand patient accountable for the process and content of therapy. Whereasthe patient is responsible for generating a problem list, the therapist isresponsible for helping the patient solve problems on the list. Most patientseventually appreciate the structure of CBT as they realize that it facilitatesthe therapy process and CB changes. Some patients find this structure tobe intimidating. They report "feeling that they have been put on the spot"when reminded that they are responsible for coming up with an agenda ateach visit. When this occurs, the therapist needs to reassure them that theagenda is simply a list of problems they will solve together. It should benoted that some patients may actually become distraught when therapists

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insist on structured therapy sessions. They may ask, "'Why can't you justlisten?" In these cases, it is advisable for the therapist to be flexible, placingthe highest priority on the development of a collaborative relationship.

The assignment and review of homework is a vital part of CBT.Patients are taught, "During sessions we discuss skills for improving yourlife, and between sessions you get to practice these skills." Just as somepatients resist the structure of CBI others resist the idea of homework.This is often the case when patients have negative associations with home-work from early life experiences (e.g., educational difficulties or failure).In these cases, as with patients who are resistant to structure, the highestpriority should be placed on developing and maintaining the collaborativerelationship.

Education

CBT is founded on the premise that thoughts, beliefs, and behaviors arelearned and shaped over a lifetime. Accordingly, thoughts, beliefs, andbehaviors associated with addictive behaviors are also learned and shapedover a lifetime. As the years pass, these thoughts and beliefs become deeplyrooted, automatic, and increasingly difficult to change. Hence, a major goalof CBT is to facilitate changes in maladaptive thoughts, beliefs, and addic-tive behaviors through education. And given that a vital component of CBTis education, a yital role of the CB therapist is to be an edwcator.

The following are some salient concepts taught to patients receivingCBT:

. Your addictive behaviors.o-prir.fi.arned CB habits.o In therapy you will learn a useful model (CBT) for understanding

and gaining control over your addictive behaviors.. Change typically occurs in stages, and it is helpful to understand the

processes that underlie these changes, so you can gain control overthem.

o Relapse is common, and it is important to recognize your vulner-ability to relapse, so that you can prevent it.

o Emotions are common triggers of addictive behaviors; therefore, it isimportant to learn CB coping skills for controlling and dealing withyour emotlons.

. The CB skills learned in CBT are essential for resisting your urgesand cravings, and controlling your impulses.

. Interpersonal skills learned in CBT (e.g., assertiveness, conflict reso-lution, communication) are important for managing your relation-ships, so that relationship problems do not trigger addictive behav-lors.

o Organization skills (e.g., goal setting, delay of gratification, activ-ity scheduling, time management) are also important, because they

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enhance your ability to solve problems and reduce your need forcompensatory addictive behaviors.

While these topics might seem simple or linear, the educational pro-cess in CBT (and therapy generally) certainly is not. Every effort to pro-vide education and information must be tailored to patients' needs, beliefs,intelligence, culture, psychological mindedness, readiness to change, andso forth. This is especially true, since patients come to therapy with theirown unique, preexisting worldviews and beliefs about addictive behaviors.

Upon entry into therapy, some patients view their addictions as a dis-ease, others view their addictions as resulting from character defects; someblame others for their addictions, and others even view their addictionsas sinful. CB therapists teach patients to view their addictions as an accu-mulation of self-defeating, learned thoughts, beliefs, and behaviors. Boththerapist and patient are encouraged to be nonjudgmental about addictivebehaviors (rather than label them as character defects or sinful), and theyare discouraged from seeing the disease model and CBT as mutually exclu-sive.

As an example, prior to entering into CBI Mary had attended AAmeetings, where she was taught that alcoholism is a disease. At the startof CBT, she told her therapist that the disease model had helped her. She

explained, "After I was told I had a disease, I stopped feeling ashamedabout my drinking problem, which made it easier to ask for help." She thenasked her therapist, "Do you believe that alcoholism is a disease?" Mary'stherapist explained, "The CBT model does not conflict with the diseasemodel. The CBT model just takes a different approach to addictive behav-iors." The therapist further clarified that Mary's focus in CBT would beon addressing the habitual thoughts, beliefs, and behaviors associated withher drinking and other addictive behaviors. Mary's therapist compared heralcohol problem to hypertension: "Hypertension is a disease, and some ofthe best hypertension treatments involve cognitive and behavior changes(e.g., education, diet, exercise). Similarly, addictions are seen by many peo-ple as a disease, and some of the best addiction treatments involve cognitiveand behavior changes."

Among the most basic topics taught to patients with addictions is theCB model. For the sake of simplification, this model is sometimes referredto as the "ABC model." A standard method for teaching the ABC modelis to explain that A represents antecedents (stimuli, circumstances, situa-tions), B represents beliefs, and C represents emotional and behavioral con-sequences of these beliefs. Patients are taught that the ABC model providesa simplified method for identifying and modifying problematic thoughts,feelings, and behaviors. They are taught that understanding the ABC modelis an important skill learned in CBT. Mary's therapist teaches her the ABCmodel in the following way:

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"The letter A stands for 'antecedent.' Think of an antecedent as a trig-ger. For you, the strong feelings of loneliness and depression tend to betriggers. The letter B stands for 'beliefs.' Your strong feelings tend totrigger beliefs such as 'I need a drink,' 'I need a cigarette,' or 'I need toget out of here and go to the casino.' C stands for the'consequences'ofyour beliefs, including your behaviors and emotions. Mary, you maynot be able to change your living situation right away. You might findyourself alone and lonely at times. But you can change the way youthink about being alone. Instead of letting it trigger addictive behav-iors, you can change your thinking. For example, you might considerthinking, 'I need to go to an AA meeting instead of drinking, smoking,and gambling.'"

Mary's therapist reminds her that the most serious problems in herlife-depression, loneliness, and addictions-comprise unhealthy behav-ioral patterns (e.g., isolation, passivity, avoidance) and emotions (sadness,

despair, frustration, fear). He encourages Mary to understand that she iscapable of changing these behavior patterns and emotions, first by learningabout the thoughts and beliefs that trigger them.

Techniques

Techniques are structured activities designed to facilitate learning (i.e., theacquisition of new thoughts, beliefs, behaviors, skills). In his classic text,Mahoney (1,991) defined techniques as "meaningful rituals of communica-tion, human relatedness, awareness, and self-influence" (p. 253). He alsoreferred to techniques as "navigational aids." Hundreds of CB techniquesare available for helping patients with psychological and behavioral prob-lems. In fact, entire texts have been devoted to describing these techniques(e.g., Leahy, 2003; McMullin, 2000).

Leahy (2003), in Cognitiue Therapy Tecbniques: A Practitioner'sGuide, organizes techniques into the following categories: eliciting thoughtsand assumptions, evaluating and challenging thoughts, evaluating assump-tions and rules, evaluating worries, information processing and logicalerrors, putting things in perspective, schema-focused therapy, emotionalprocessing techniques, examining and challenging cognitive distortions,modifying need for approval, and challenging self-criticism. In the McMul-lin (2000) text, CB techniques are organized as follows: teaching the ABCs,finding beliefs, categorizing beliefs, countering beliefs, perceptual shifting,historical resynthesis, and practice strategies. Interested readers are encour-aged to refer to these texts for detailed descriptions of these techniques.

Most standard CB techniques are useful in the treatment of addictivebehaviors, because they promote the acquisition of coping skills. In the fol-lowing sections, selected CB techniques relevant to additive behaviors are

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described. After presenting these techniques I recommend when they mightbe used, with whom, and under what circumstances.

Cognitive Techniques

Cognitive techniques focus on core beliefs and automatic thoughts that leadto addictive behaviors. Perhaps the most basic CB skill involves the iden-tification and differentiation of core beliefs, automatic thoughts, emotions(i.e., feelings), and behaviors. Patients come to therapy with naive viewsof their addictive behaviors. For example, they may attribute a relapseto unknown forces, exclaiming, "I don't even remember how I ended upsmoking. One moment I felt myself get angry and the next moment I waspuffing on a cigarette." They may not understand the subtle differencesbetween thoughts and emotions. S7hen asked, "How did you feel?", theymay report what they thought (e.g., "I feel like she hates me" rather than"I feel worried that she hates me").'When patients are not able to define ordifferentiate between thoughts and emotions, therapists teach about thesedifferences and explain the rationale for differentiating between them (so

they can begin to control them).After patients learn the differences between thoughts, emotions, and

behaviors, they can benefit from increasingly complex cognitive techniques.The daily thought record (DTR; Figure 10.5) involves listing situations,emotions, automatic thoughts, alternative thoughts, and outcomes in col-umns, so that each can be systematically considered. The DTR functionslike a journal, though rather than merely listing thoughts and emotions as

one does in a journal, each maladaptive thought is challenged with an alter-native thought. Patients are taught that they should complete a DTR eachtime they experience strong emotions. They may feel tense, anxious, angry,frustrated, or they may have psychological or physical urges to use drugs.IWhen these feelings occur, patients list the time and date in the first columnof the DTR. They then write the situation in the second column. In thethird column they write the emotion. In the fourth column they write theirautomatic thoughts. In the fifth column they write alternative thoughts.And in the sixth column they write the outcome, after they have replacedmaladaptive automatic thoughts with alternative adaptive thoughts. It is

recommended that patients initially complete DTRs several times a dayin order to become comfortable with them, and later complete them as

needed.Mary found DTRs to be helpful (see Figure 10.6). On May 10 at 4:00

P.M. Mary found herself at home, where she had been "cooped up" allday. George was due to return from work at 5:00 P.M., when he wouldexpect dinner. Mary wrote that she had no food in the house, so she wouldbe unable to prepare dinner. She wrote that she felt angry, frustrated, andirritated; she listed the following automatic thoughts: "He'll be pissed ifdinner's not ready," "I'm sick of him," "I need a cigarette and a beer," and

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Date andtime

Situation Emotions Automaticthoughts

Alternativethoughts

Outcome

Cogn itive-Behavioral Therapy

FIGURE 10.5, The daily thought record (DTR).

"I've got to get out of here." Fortunately, Mary was at the point in therapywhere she was able to list the following alternative thoughts to counterthese less productive automatic thoughts: "I can handle this," "It doesn'thelp to be angry back at him when he's pissed at me," "My anger only hurtsme," "I don't really want to smoke," and "I only get angrier when I drink,so I probably shouldn't." As a result of Mary's cognitive shift (to thesealternative thoughts), she was motivated to go shopping and buy food fordinner. In turn, George was not angry when he arrived home, and Marychose not to drink that night, which made her feel even better about herself.(Though this exercise helped Mary to feel better and make more adaptivechoices, it also highlighted Mary's, need to acquire more effective conflictresolution and interpersonal relationship skills.)

An effective technique for teaching rational decision making is theadvantages-disadvantages analysis, which may be used whenever any deci-sion is under consideration. This technique is introduced by drawing a

four-quadrant square (see Figure 10.7). Patients are instructed to write theadvantages and disadvantages of making certain choices versus not makingthose choices. John completed an advantages-disadvantages analysis forcontinued use of cocaine versus quitting cocaine (see Figure 10.8). He listedapproximately the same number of advantages and disadvantages for each

choice, but it became clear that the dire consequences (i.e., disadvantages)of continued use outweighed the advantages.

243

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Engaging in addictivebehavior

Not engaging in addictivebehavior

Advantages

Disadvantages

Cognitive-Behavioral Therapy

FIGURE 10.7. Advantages-disadvantages analysis.

Behavioral Technioues

Behavioral techniques are structured activities designed to modify unhealthybehaviors. Relaxation training, physical exercise, assertiveness training,and activity scheduling are just a few examples of behavioral techniques.As Mary became more effective at regulating her emotions, she was alsotaught to use behavioral techniques to reinforce healthy cognitive changes.For example, Mary's therapist advised her to begin scheduling activities, sothat she would no longer feel "cooped up" at home throughout the day. Heasked, "Have you ever considered using a calendar to keep track of yourdaily activities?" Mary laughed and said, "I wouldn't have anything to puton a calendar." She added, "I haven't owned a calendar in years. I don'tremember the last time I owned a calendar." The therapist pointed out thatMary had a calendar on her cell phone, and he offered to teach her to use rt.

Mary was receptive to this and began to use her calendar to schedule activi-ties she and the therapist agreed upon. For example, Mary had projects she

had always wanted to do at home. They worked together to establish smallsteps toward completing these projects.

Mary also benefited from assertiveness training. She had establishedpassive-aggressive and avoidant strategies for dealing with her husband, soMary's therapist taught her to be more constructively assertive with him.At first, she took small steps. For example, she suggested that they shop forgroceries together, so George could choose more of the foods he likes. Heagreed to do so, and shopping together became a regular activity. Next,

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Using cocaine Quitting cocaine

Advantages

Using cocaine is mg onlgrelief after busting Mg assall dag.

I won't have to sufferthrough withdrawal.l'll get to do what l want

I t'wight feel better aboutwrgself if I quit.l'vvr sure it will be better forvng health.l'd save sovwe twoneg,

I wouldn't be risking mg life.

Disadvantages

l'vvr a(wags paranoid, aboutgetting caught.

I know deep down thatusing isn't good for vve-

l'll continue to five a lie.

Sovwe dag l'll get caughtand lose evergthing ortheg'll Find vne dead in acrack house.

It's wrg onlg relief Frovntension.Mg tife will be all work andno plag.

l'll be bored and restless athovwe and take it out on vngfamilg.I vwight hate vug life.

FIGURE 10.8. John's advantages-disadvantages analysis.

Mary asserted that she would like to cook dinners with George when he

got home from work. Much to Mary's surprise, George agreed, and theyfound themselves shopping and cooking together, which gave Mary hopethat they could actually begin to address their marital problems.

John's therapist speculated that he would benefit from increasedphysical activity to reduce his tension and anxiety. He taught John variousrelaxation techniques. First, he had John focus on his breathing, empha-sizing the importance of taking slow, deep breaths when he experiencedsymptoms of stress. Next he instructed John to visualize and insert himselfinto a comforting scenario (e.g., a warm sunny beach). Eventually, John'stherapist taught him to imagine situations in which he might feel urgesto use cocaine. As expected, John began to crave cocaine in session. Histherapist helped him recognize these cravings and "urge surf" by shiftinghis thinking to more adaptive and calming scenarios, while controlling hisbreathing.

Choosing CBT Techniques

Various factors influence the choice of CB techniques, including the patient'sreadiness to change, psychological mindedness, familiarity with the CBTmodel, psychological resilience, the quality of the therapeutic relationship,and more. These factors are assessed during the case conceptualization.

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Carefully developing an accurate case conceptualization increases the like-lihood of choosing the most appropriate techniques.

Readiness to change is among the most important factors in the thera-pist's choice of techniques. A patient in the precontemplation stage is notlikely to respond well to an in-depth lecture about the differences betweenthoughts, emotions, and behaviors. A patient in the contemplation stage ofchange might potentially benefit from an advantages-disadvantages analy-sis, because it might influence him or her to prepare for action. A patientin the preparation stage might benefit from behavioral techniques thatreinforce an addiction-free lifestyle, for example, by starting an exerclseprogram. Individuals in the maintenance stage might benefit most fromreinforcement of their success.

Patients who are psychologically minded might benefit most frominterventions that address thoughts and feelings, which are abstract con-cepts. Patients who are not psychologically minded might benefit frommore concrete, specific behavioral changes (fitness workouts, etc.). Patientswho are new to CBT might benefit most from elementary explanationsof the CBT model, while those who are familiar with CBT might benefitfrom the simple question "How else could you have thought about thissituation?"

In these examples, the techniques chosen for John and Mary werebased on not only their readiness to change but also their strengths andweaknesses. John was guided to use the advantages-disadvantages analy-sis, because his therapist viewed him as being ready to seriously considerquitting cocaine. John was also encouraged to begin a regular exercise andrelaxation program in order to reduce his tension and anxiety. John's thera-pist realized that he used cocaine to feel more capable, and he believed thatJohn might feel more capable by strengthening his body through exercise.He also knew that John's tension would be reduced through the effectiveuse of relaxation. ..)-"

Mary was taught to use DTRs;'because her therapist understood theywould help her gain control over her emotions and make more deliberatechoices. He knew she would benefit from identifying her automatic thoughtsand generating alternative thoughts, which in turn would help her to regu-late her moods and decrease her need for alcohol. Mary's therapist alsorecommended that she use her cell phone for scheduling activities since, indoing so, she would organize her time to feel less bored, lonely, and restless,which, historically, had led to gambling, smoking, and drinking.

Lessons Learned When Practicing CBTin the "Real World"

For more than 30 years addicted individuals have been treated with CBT.Over these years, through thousands of successes and failures, many

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lessons have been learned about the effective delivery of CBT (Liese &Franz, 1,996). The following is just a sampling of these lessons:

1. In working with addicted patients, a collaborative therapeuticrelationship is essential. When therapists and addicted patients functioncollaboratively, techniques, education, and structure are most likely to be

effective. The key to collaboration is empathy. Therapists who work withaddicted patients sometimes fail to empathize with them when they relapseor engage in self-destructive behaviors. CB and addictions therapists areurged to maintain empathy toward their patients, regardless of their choicesor readiness to change.

2. All clinicians working with addicted patients, regardless of theo-retical orientation, should be knowledgeable about the full range of chemi-cal and behavioral addictions. They should be familiar with all addictionresources in their communities (12-step programs, Self-Management andRecovery Training [SMART], inpatient and outpatient facilities, smokingcessation programs, eating disorder programs, methadone clinics, etc.).

Even the most expert clinicians are at a disadvantage in treating addictivebehaviors without this knowledge. One of the best ways to learn aboutaddictive behaviors and community resources is by communicating andlearning as much as possible from other addiction specialists.

3. It is important to understand the role of self-medicating in addictivebehaviors. Many people with addictions use their addictive behaviors to getrelief from emotional discomfort. It is important to offer patients alterna-tive CB skills for dealing with discomfort. A benefit of CBT treatment ofaddictive behaviors is that CBT is, and always has been, focused on skillsdevelopment.

4. Recognize therapeutic ruptures and repair them as soon as pos-sible. When therapeutic ruptures are not resolved, therapy is compromised.Individuals with addictions are likely to struggle with interpersonal rela-tionships. Their interpersonal struggles might result from the impairmentcaused by their addictive behaviors, or they might be a result of the shameor secrecy that often accompanies addictive behaviors. Regardless, addictedindividuals may struggle with the very therapists trying to help them. Afterall, the therapist's aim is to assist the patient in making healthy, thoughsometimes unwanted, changes.

5. It is well established that many addicted people have serious diag-nosable, coexisting mental disorders. 'lfhen this is the case, it is importantto treat the mental disorders and addictive behaviors simultaneously. Suchmental disorders should be identified as part of the case conceptualization.Some mental disorders (e.g., schizophrenia and mania) are best treated withpharmacotherapy, while others (e.g., social anxiety, personality disorders)can be treated most directlv with CBT.

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6. It is essential for therapists to conduct a thorough family historyof addictive behaviors. Doing so will help them understand the depth andcomplexity of an individual's addictive behaviors. For example, in somecases, a strong family history of addictive behaviors might reflect a moresevere, treatment-resistant addiction.

7. On occasion it might be necessary to confront addicted patients.Technically speaking, confrontation involves pointing out discrepancies,for example, between beliefs and objective evidence (e.g., "You say you'vequit smoking, but I can smell cigarette smoke on your breath") It is impor-tant to understand that confrontation should not be an aggressive process.Rather, it should reflect a sincere therapeutic effort to help an individualrecognize discrepancies and resolve them.

B. Stay focused in sessions, and do not get distracted or sidetracked.Many patients with addictive behaviors have complicated or even chaoticlives. At times it is likely that this chaos will find its way into the therapysession. Rather than present problems in a systematic, organized fashion,the patient might present problems in a scattered manner. When this hap-pens it is the therapist's responsibility to keep the patient on task, unless,of course, the tangent is about a more important issue requiring immediateattention.

9. Use CB techniques appropriately and sparingly. The majority ofa CBT session should be spent guiding the patient toward understandingproblems and their solutions. Among the most common mistakes madeby CB therapists is putting techniques before relationships. Guided dis-covery itself is the process of asking questions and listening carefully toanswers, in order to help patients discover problems and their solutions.Techniques are helpful, but not until the time is right. Among the mostimportant CBT skills is knowing when the time is right for structuredtechniques.

10. Remember that addictive behaviors are complex, and relapse is

common. As a result there are obstacles and pitfalls that must be addressedalong the way. To the extent that these obstacles and pitfalls are treated as

learning opportunities, CBT will be effective (Marlatt et aL.,2012).

Conclusion

CBT with addicted individuals has the potential to be deeply rewarding.It is not uncommon for addicted individuals to demonstrate extraordinarycourage, insight, wisdom, and discipline as they overcome their addictivebehaviors. Therapists who work well with addicted patients are likely tofind this work very satisfying given that much can be learned from thosewho overcome addictions.

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References

Beck, A. T.,'!7right, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitiue therapyof substance abuse. New York: Guilford Press.

Connors, G. J., DiClemente, C. C., Velasquez, M.M., & Donovan, D. M. (2013).

Substance abuse treatment and tbe stages of cbange: Selecting and planninginteruentions (2nd ed.). New York: Guilford Press.

Hayes, S. C., Strosahl, K. D., &'Wilson, K. G. (2012). Acceptance and commit-ment therapy: The process and practice of mindful change (2nd ed.). NewYork: Guilford Press.

Leahy, R. L. (2003). Cognitiue therapy tecbniques: A practitioner's guide. NewYork: Guilford Press.

Leahy, R. L., Tirch, D., & Napolitano, L. A. (2011). Emotion regulation in psycho-therapy: A practitioner's guide. New York: Guilford Press.

Liese, B. S., & Beck, A.T. (1,9971. Back to basics: Fundamental cognitive therapyskills for keeping drug-dependent individuals in treatment. In L. S. Onken,J. D. Blaine, & J. J. Boren (Eds.), Beyond the therapeutic alliance: Keepingdrug-dependent indiuidual in treatment (NIDA Research Monograph No.165). Rockville, MD: U.S. Department of Health and Human Servrces.

Liese, B. S., & Franz, R. A. (1995). Treating substance use disorders with cogni-tive therapy: Lessons learned and implications for the future. In P. Salkovs-kis (Ed.), Frontiers of cognitiue therapy (pp. 470-508). New York: GuilfordPress.

Mahoney, M. J. (1991). Human change processes: The scientift.c foundations ofpsychotherapy. New York: Basic Books.

Manuel, J. K., Hagedorn, H. J., 6c Finney, J. I7. (2011). Implementing evidence-based psychosocial treatment in specialty substance use disorder care. Psy-cb o lo gy o f A d di ct iu e B e h au i or s, 2 5 (2), 22 5 -237.

Marlatt, G. A., Larimer, M. E,, & Witkiewitz, K. (Eds.). (201.2). Harm reduction:Pragmatic strategies for managing high-risk bebauiors (2nd ed.). New York:Guilford Press.

McMullin, R. E. (2000). Tbe new handbook of cognitiue therapy techniques. NewYork: Guilford Press.

Moyers, T. 8., & Miller, W. R. (2012). Is low therapist empathy toxic? Psychologyof Addictiue Behauiors. IEpub ahead of print]

Norcross,J. C., Krebs, P. M., & Prochaska,J. O. (2011). Stages of change. Journalof Clinical Psychology: In Session, 67(Z),143-1,54.

Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work:lI. P sy ch oth erapy, 4 8 (l\, 4 -8.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1,9921.In search of howpeople change: Applications to addictive behaviors. American Psychologist,47(9), tr02-1.r't4.

Prochaska, J. O., & Norcross, J. C. (2001). Stages of change. Psychotherapy,3S(4),443-448.

Segal, Z. V., .Vfilliams,

J. M. G., & Teasdale, J. D. (Eds.). (201,21. Mindfulness-based cognitiue tberapy for depression (2nd ed.). New York: Guilford Press.

Wenzel, A., Liese, B. S., Beck, A. T., & Friedman-Wheeler, D. G. (2012). Groupcognitiue tberapy for addictions. New York: Guilford Press.

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