Short communicationEnhancing brief cognitive-behavioral therapy with motivational enhancement techniques in cocaine users☆
Introduction
The effectiveness of CBT for improving treatment outcomes among cocaine-using populations has been documented (Carroll et al., 2000, Carroll et al., 2004, Rawson et al., 2002, Rohsenow et al., 2000). Although CBT's effects are comparatively durable, a relative weakness of CBT is that its effects on early retention are mixed and it does not strongly address the individual's motivation and engagement, aspects more specifically targeted in motivational enhancement therapy (Miller and Rollnick, 2002). MET has demonstrated efficacy comparable to other standard substance abuse treatments (Burke et al., 2003, Project MATCH Research Group, 1998, Stephens et al., 2000) and has been conceptualized as an adjunctive or preparatory treatment, particularly for more severe drug use disorders (Miller et al., 2003, Rohsenow et al., 2004).
An emerging treatment strategy is to combine empirically supported therapies (or their components) to address their relative strengths and weaknesses. Although some studies have found support for the effectiveness of CBT–MET combinations (MTP Research Group, 2004), few empirical evaluations have examined whether standard approaches such as CBT are improved by combining components from other approaches and whether such combinations work in the manner hypothesized (Kazdin, 1986, Kazdin, 2004, Kazdin and Nock, 2003). The standard evaluative strategy is to conduct full-scale randomized clinical trials (Jacobson et al., 1996), which is costly and time-consuming. An alternate, and potentially more efficient strategy is to conduct smaller highly focused trials evaluating the effect of specific components on treatment outcome (Kazdin, 1986, Kazdin, 2004, Kazdin and Nock, 2003).
Using a short-term intervention paradigm, participants were randomized to two treatment entry interventions prior to standard substance abuse treatment: CBT only, and MET + CBT to evaluate whether the addition of MET to CBT improves treatment outcomes. Changes in treatment motivation, treatment satisfaction, and retention were evaluated as primary outcomes, with cocaine use a secondary outcome given the brief nature of the protocol interventions and the anticipated effect of MET on process measures.
Section snippets
Sample
Participants were recruited through an outpatient substance abuse clinic. Seventy-four eligible individuals who met current criteria for cocaine abuse (11%) or dependence (89%) were randomly assigned to one of two treatment conditions; MET + CBT (n = 38) or CBT (n = 36). Exclusion criteria included current opiate abuse or dependence, a lifetime diagnosis of bipolar disorder or schizophrenia, current suicidal or homicidal plans and intent, or a pending legal case.
Intervention conditions
Both brief introductory interventions
Sample description
There were no significant differences in demographic characteristics or pre-treatment motivation across therapy conditions (Table 1). Assessment of past 30-day drug use indicated greater frequency [F(1, 66) = 6.93, p < .05] and quantity [F(1, 66) = .51, p < .10] of cannabis use in the CBT condition.
Treatment retention
Mean sessions completed (CBT = 2.19, S.D. = 1.14; MET + CBT = 2.39, S.D. = 1.00) and percentage of participants completing all three sessions (CBT = 61%, MET + CBT = 68%), were comparable across conditions (p > .05). There
Discussion
This study examined whether enhancing CBT with MET would primarily increase client participation, engagement, and commitment to abstinence, and secondarily decrease cocaine use during the initial phase of substance abuse treatment. While there were no differences in completion rates for the three therapy sessions, participants who received MET + CBT attended more treatment sessions during the follow-up period. This finding is consistent with a number of emerging studies suggesting that
Conflict of interest
Drs. O’Malley and Carroll are members of Applied Behavioral Research, LLC, which develops and evaluates clinician-training strategies for a range of empirically supported therapies.
Acknowledgements
Authors O’Malley, Carroll, and Sinha designed the study. Author Robinson was the project director and supervised study therapists. Author Cavallo coordinated the study. Authors Nich and McKee undertook the statistical analysis. Author McKee wrote the first draft of the manuscript. All authors contributed to and approved the final manuscript.
References (30)
- et al.
Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study
Drug Alcohol Depend.
(2006) - et al.
A general system for evaluating therapist adherence and competence in psychotherapy research in the addictions
Drug Alcohol Depend.
(2000) Evidence-based treatments: challenges and priorities for practice and research
Child Adol. Psych. Clin. North Am.
(2004)- et al.
Assessment of client/patient satisfaction: development of a general scale
Eval. Program Plann.
(1979) - et al.
Developing a prototype for evaluating alcohol treatment effectiveness
- et al.
Factors associated with lapses to heroin use during methadone maintenance
Drug Alcohol Depend.
(1998) - et al.
The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials
J. Consult. Clin. Psych.
(2003) A Cognitive-Behavioral Approach: Treating Cocaine Addiction (NIH Publication 98-4308)
(1998)- et al.
Efficacy of disulfiram and cognitive-behavioral therapy in cocaine-dependent outpatients: a randomized placebo controlled trial
Arch. Gen. Psychiat.
(2004) - et al.
Preparing patients for alcoholism treatment: effects on treatment participation and outcomes
J. Consult. Clin. Psych.
(2002)
Brief motivational feedback improves post-incarceration treatment contact among veterans with substance use disorders
Drug Alcohol Depend.
Treatment and follow-up variables discriminating abstainers, controlled drinkers and relapsers
J. Stud. Alcohol
Commitment to abstinence and acute stress in relapse to alcohol, opiates, and nicotine
J. Consult. Clin. Psych.
Effects of commitment to abstinence, positive moods, stress, and coping on relapse to cocaine use
J. Consult. Clin. Psych.
A component analysis of cognitive-behavioral treatment for depression
J. Consult. Clin. Psych.
Cited by (56)
Inhibitory-control training for cocaine use disorder and contingency management for clinic attendance: A randomized pilot study of feasibility, acceptability and initial efficacy
2020, Drug and Alcohol DependenceCitation Excerpt :Another study showed cocaine overdose rates in Black men and women are comparable to opioid overdose rates in non-Black men and women in the United States (Shiels et al., 2018). Behavioral therapies are considered the “standard of care” for cocaine use disorder, but relapse rates are high (Covi et al., 2002; Higgins et al., 2004; McKee et al., 2007; Vocci and Montoya, 2009). Despite the conduct of more than 100 blinded, randomized, fully placebo-controlled studies of over 60 compounds, the Food and Drug Administration (FDA) has not approved a pharmacotherapy for cocaine use disorder (Czoty et al., 2016).
Treating Cocaine Addiction With Motivational Interviewing
2017, The Neuroscience of Cocaine: Mechanisms and TreatmentMotivational tools to improve probationer treatment outcomes
2015, Contemporary Clinical TrialsCitation Excerpt :Another review of MI in health settings concluded that MI had a “significant and clinically relevant” effect in three of four studies, and outperformed traditional advice-giving 80% of the time [35]. Some evidence suggests that adding MI components to the beginning of a treatment sequence increases treatment effects [19,36–39]. In addition, when MI is used alongside personalized feedback, individuals respond more positively to treatment seeking and readiness (see the “Check-Up” format discussed by [40]).
Impaired Bayesian learning for cognitive control in cocaine dependence
2015, Drug and Alcohol Dependence
- ☆
Funding for this study was provided by National Institute on Health grants P50DA09241, K02AA00171, K05DA00457, and K05AA014715; the NIH had no further role in the study design, in the collection, analysis and interpretation of data; in the writing of the report or in the decision to submit the paper for publication.