3 The Value of Cognitive- Behavioral Strategies

Archie: When the Client Says "No" to Abstinence -Gary Dayton and Frederick Rotgers

I treated my first alcohol-using client at the psychotherapy clinic at the City College of New York, where I received my Ph.D. The training program oriented its students in a theoretical approach based in psychoanalysis. In keeping with that tradition, I worked with this man by exploring the meaning of his drinking and its relationship to his painful emotional and personality issues. The psychotherapy was somewhat helpful in promoting an increased awareness of the sources of his anxiety and related difficulties, as well as the connection between these issues and his drinking. While this greater awareness contributed to a decrease in his anxiety and a lessening of feelings of intense internal pressure, it did not help him to stop drinking. For that he found Alcoholics Anonymous.

This outcome seemed to describe the limitations of using a completely exploratory approach to psychotherapy for people struggling with excessive substance use and other related kinds of problems. After having several similar experiences with substance-using clients during my training, I found a clinical position that introduced me to a broad spectrum of more active interventions. These techniques combined with psychoanalytic approaches gave rise to a more well-rounded and effective way of working. I'd been hired by the Division of Drug Abuse Research and Treatment of the New York Medical College. In this research-oriented clinic, I managed groups and saw clients in individual psychotherapy. In remembering my experiences of failure with substance-abusing clients I had treated in the past, I realized that I needed to become open to learning and incorporating more active behaviorally oriented modalities into my work. While I did not want to abandon the psychoanalytic perspective that perceives suffering as a meaningful process in human development, I knew that this alone was insufficient. This research-oriented clinic was an exciting incubator for training because it offered different modalities for treating the full spectrum of drug and alcohol problems among an impressive group of experienced and competent counselors. The staff combined techniques from Alcoholics Anonymous with an educative cognitive-behavioral counseling approach. As I began to integrate these approaches into my work with clients, I immediately began to achieve greater success in stopping or modifying their use of substances.

During the years since those first experiences, I have come to believe in the necessity of integrating cognitive and behavioral elements into psychotherapy with clients who have problems with substance use. I have also come to understand the use of these techniques as consistent with harm reduction.

The cognitive-behavioral approach emerged from the seminal work of behavioral theorists such as Pavlov, Skinner, and Bandura, and the fathers of the school of cognitive therapy, Albert Ellis and Aaron Beck. From the classical behavioral point of view, habitual behavior can be understood in terms of stimuli or triggers that have acquired the power to stimulate the specific behavior and by the consequences that have rewarded or rein- forced the behavior. Bandura's social-learning contribution was that an individual didn't actually have to have direct experience of the behavior being rewarded to make it part of his or her repertoire. At certain moments in cognitive development, a child may observe a compelling behavior performed by a respected figure, the rewards for the behavior may be attractive, and therefore the behaviors are copied and learned as the child witnesses the experiences of an elder. The cognitive perspective ...

...The case of Archie, the illustrative story for this chapter, is an example of a pure cognitive-behavioral harm reduction approach to the treatment of excessive drinking. Archie was treated at the Program for Addictions Consultation and Treatment, the training clinic of the Rutgers Center of Alcohol Studies in New Brunswick, New Jersey. The therapist was Gary Dayton, a Ph.D. candidate in clinical psychology at Rutgers, working under the supervision of Dr. Fred Rotgers. Fred is a psychologist with a long, very active involvement in the cognitive-behavioral treatment of people with substance use problems. Archie's story describes a man with a serious drinking problem that was related to accompanying psychiatric problems. After his life condition worsened due to an abstinence-only approach, this cognitive-behavioral harm reduction treatment was successful in helping Archie to achieve stable moderation of his drinking as well as in helping him with depression and an obsessive compulsive disorder. This treatment particularly illustrates the harm reduction and cognitive-behavioral synthesis and the specific value that cognitive-behavioral techniques can have for helping people change their behavior.

Archie: When the Client Says "No" to Abstinence by Gary Dayton and Frederick Rotgers

Archie was an alcohol-dependent client with serious accompanying psychiatric problems who sought treatment with the goal of moderating his drinking. He was treated by Gary Dayton under the supervision of Frederick Rotgers at the Program for Addictions Consultation and Treatment (PACT), a training clinic of the Rutgers Center of Alcohol Studies in New Brunswick, New Jersey.

For many readers, Archie's treatment will not be seen as successful. We disagree. Prior to seeking help with Gary , Archie had been in a near-constant battle with his psychiatrist and other treatment professionals about his drinking. This battle left him even more anxious, depressed, and discouraged than he was when he first sought treatment for social anxiety and depression as well as obsessive-compulsive habits of hand washing and ordering of objects. During this period, Archie's drinking had been increasing, and his anxiety and depression weren't responding to either pharmacological or psychotherapeutic interventions. Although Archie was by no means completely free of psychiatric symptoms at the end of the treatment period described here, those symptoms had substantially reduced, despite the fact that Archie continued to use alcohol. We view this as a successful outcome, although Archie is by no means "cured."

Archie is a 37 -year-old, single Korean American who immigrated to the United States approximately twenty years ago after first living in Japan for nine years. He lives with his brother and his brother's family in a home located above the family business in a suburban New Jersey community. He was referred by his psychiatrist to PACT for assessment and treatment of alcohol addiction.

Archie was appropriately dressed, neat and well groomed for our first meeting. He was alert and well oriented. His speech was normal, with a moderate pace. He spoke articulately with no impediments but with a distinct accent (Archie is multilingual, speaking fluent Korean, Japanese, and English). Archie was attentive during the initial interview and cooperative, quietly deferring to the interviewer. Archie expressed a full range of emotions but with a dominant depressive tone. His reasoning and problem-solving abilities seemed intact with no apparent difficulties in concentration or higher-order thinking during therapy sessions. It is clear, however, that obsessive compulsive disorder symptoms interfere with Archie's ability to concentrate and to remain on track and complete tasks expeditiously. His memory appears sound with no difficulty in recall.

Archie reported no current medical problems, complaints, or symptoms. He is under the care of a psychiatrist and gets periodic medical check-ups by a primary care physician. In 1983, Archie was hospitalized for ten days resulting from a motor vehicle accident. There are no ongoing problems as a result of this accident. Archie is physically fit and trim, at 5 feet 6 inches and about 140 pounds.

Archie was an anxious, painfully shy young man who had great difficulty interacting with others. Archie fully understood English, but his ability to express himself in English was much less developed than his comprehension. At the time of the referral, Archie was being treated pharmacologically for obsessive compulsive disorder (OCD) by a psychiatrist. Archie is a college graduate in computer science from an eastern university, but because of chronic OCD, bouts of major depression, and alcohol problems, he has been chronically underemployed. He is currently unemployed. He had worked as a partner in the family-run convenience and grocery store until nine months ago when his partnership with his brother was dissolved. Although Archie has significant difficulties with OCD, depression, and alcohol, his motivation for treatment was high.

The early sessions with Archie were mainly focused on assessing the nature and extent of his problems with alcohol, gathering a personal history , and exploring the relationship between Archie's emotional problems and his drinking.
Archie sampled his first beer at the age of 12. "It tasted bad," he recalls. At 16 years old, Archie began to drink with regularity, but without any negative consequences. He reports drinking two or three beers once or twice a week at this age, mostly on weekends with friends and at family gatherings. Alcohol did not ...

Although his therapist was skeptical at first about Archie's ability to manage his drinking and change from being alcohol dependent to a moderate drinker, Archie has made substantial progress toward this goal, as well as toward other goals of reducing depression and anxiety symptoms. He has not quite "perfected" controlled drinking, yet it is clear that he has come a long way toward reaching it. As he continues in treatment and adds additional support for his goal by joining, for example, the Moderation Management group, we expect he will be able to achieve his goals.

Archie was explicit in his desire to control his drinking. Importantly for Archie, achieving stable moderation as opposed to abstinence reflected a tacit acknowledgment of his unrelenting standards schema: "Quitting drinking for me is like quitting a favorite food. If I know I can have a little, I can do this. I feel I am under control with moderate drinking. If I set too high a standard and can't reach it, well, I feel very bad." Attempting to achieve sobriety and failing increases the risk of feeling weak, incompetent, and worthless. "If I can't quit alcohol then what can I accomplish? I blame myself."

Had the treatment goal been abstinence it is likely that Archie would have initially met it and any subsequent failure to achieve perfect abstinence would have been another confirmation that he was incompetent and worthless. Requiring abstinence would have been a barrier for effective treatment with Archie and it is likely that he would have dropped out of treatment altogether.

Sobell and Sobell ( 1995) have concluded that goal choice may matter in consumer appeal. Moderation approaches may be a key to encouraging problem drinkers to access services as well as a means of reducing the harmful consequences of problem drinking.

Self -selection of treatment goals may better enable clients to achieve their own goals because they may be better motivated, better able to assume responsibility for their behavior, and, importantly, they may under- stand themselves better than their therapist (Sobell, Sobell. Bogardis. Leo, and Skinner, 1992). Requiring abstinence may magnify the drinker's problems with alcohol and pose a barrier to treatment (Cunningham. Sobell, Sobell, Agrawal and Toneatto, 1993). Archie's psychiatrist told him that he could resolve his alcohol problem only by admitting to alcoholism and by em- bracing the goal of abstinence. Had that been his only option it is likely that Archie would have continued drinking and possibly have progressed into a severely dependent alcoholic.

In summary , Archie has made significant progress in coping with a variety of debilitating psychiatric problems. During the course of his treatment it was clear that some of his problems (or at least the exacerbation of them) arose directly from the stance his psychiatrist took toward Archie's drinking. Archie is a man whose core belief about himself is that he is ineffective and incompetent. By working with Archie, allowing and supporting his own goal choice with respect to his drinking, and providing a setting in which he could develop increased self-efficacy with respect to his drinking, the stage was set for Archie to also experience an alleviation of many of his depressive symptoms. Although Archie is by no means problem- free, he has been able to make significant progress as a result of a therapeutic approach that respected him as a human being who was capable of making decisions for himself and setting reasonable treatment goals.