Introduction
Drug abuse, or drug addiction, is over dependence on a medication or a drug, legal or illegal. When the mild use transforms into uncontrolled craving, it begins to cause serious problems. The overuse of the drugs begins to alter the way the body and the mind behaves (SAMHSA, 2009). The physical and mental health deterioration is a given, relationships are also affected and the law of the land can pose long-term consequences. The overall costs of drug abuse, including crime-related costs and productivity costs, in United States are estimated to exceed $600 billion annually (Drug Facts, 2012).
Among the population abusing drugs, the percentage of the teenagers using illicit drugs continues to rise. Their development and growth is affected by the consumption and abuse of the alcohol, tobacco and other drugs. The addict teenagers may find difficulties in building relationship skills and becoming emotionally stable. Drugs can also affect their memory and learning abilities. According to a report of a survey conducted at Columbia University, New York by National Center on Addiction and Substance Abuse (CASA, 2013), substance abuse by teenagers is a problem of bigger proportions than bullying, obesity or depression.
It is widely believed that the addiction to drugs is due to a flaw in the character and can be coped up with a change in the behavior. However, as opposed to the myth, this is a disease that needs more than will to overcome. The patients would commonly need to undergo a rehabilitation program accompanied by counselling and other therapy sessions. The counselling therapy that we will discuss in this paper is cognitive-behavior therapy, a program that has proved to be of a great help over time. This therapy aims at developing the awareness in a person in regards to how they interact with their environment, the people around them and how they function.
The Population Overview
Drug abuse among teenagers continues to be on the rise in the United States. The teenagers and the people living below the poverty line form the majority of the audience. In the situations of unavailability of drugs, pain relievers have often seen to be used when they were really not necessary, either due to dependence or an addiction to the drug.
The use of marijuana has become increasingly popular among the teenagers, primarily because of its easy availability and its low cost (SAMHSA, 2009). Marijuana has recently started to be perceived as a safe drug – a belief that the teenagers seem to have picked up too. The Monitoring the Future (MTF) Survey Report, 2013 points out that the teen audience of marijuana is on a rise involving about 7% of 8th graders, 18% of the 10th graders and 22.7% of the 12th graders (Drug Facts, 2014).
Drug Abuse as a Social Problem
Drug abuse among teenagers is an issue on a rampant rise in America. It may be an individual behavior, but it prevails within a larger social context. It usually starts as an experiment and slowly grips the person into its lifestyle. A person who grows up observing people on drugs is more likely to perceive that substance abuse is normal and acceptable (Fonseca, 2012).
Peer pressure is one of the most common and the most powerful forces to initiate the use of drugs during the adolescence. A person is more likely to pick up on drugs if he is in a company of a drug addict. Conversely, it can be said that a person on drugs can easily influence his friends to experiment with the drugs. Moreover, the teenagers with similar habit, i.e. drug use, are more likely to form friendships with each other. Therefore, it is extremely important for the guardians to monitor the associations of the children with the others who consume drugs, and their perception about the extent to which their friends use drugs. In today’s times, adolescents of U.S. have a high degree of exposure to illicit drugs among their peers, even if they don’t consume them themselves (Monitoring the Future Study Volume – I, 2014).
Drug abuse leads to major health problems, which increases the government spending on health care services, affecting every community in America. Major diseases that can be directly or indirectly linked to drug abuse are cancer, heart diseases, HIV/AIDS (as a result of consuming drugs by injection or sex with injection drug users) among many others. Many social problems such as violence, child abuse, stress and drugged driving are directly linked to the over-abuse of drugs, which impact the society as a whole, directly or indirectly. Drug abuse has the potential of destroying the whole families (National Institute on Drug Abuse Report, 2005).
Group Intervention – Cognitive Behavioral Therapy
Cognitive Behavioral Therapy, or CBT, was initially developed as a therapy for the prevention of relapse when treating the problem of drinking, but it was later adopted for drug – related issues as well (NIDA, 2012) Cognitive behavior interventions are built up on the theory that the beliefs and the interpretations of life events of an individual plays a crucial role in the development of the behavioral patterns, substance abuse being one of them (Gabour & Ing, 1991). Thus, the patients undergoing this treatment are made to learn different skills that help them identify and correct upon the problematic patterns in their behavior. This fixes the problem of substance abuse as well as the other problems accompanying it. This format of the treatment makes it universally applicable and it has went on to become one of the very few treatments that have been supported by American Psychological Association for many psychological disorders and other personality issues (APA, n.d.).
Drug dependence impacts almost all the areas on one’s life. Therefore, it is not uncommon that an addict seeks counselling for many other significant issues like relationship problems, employment issues, depression, finances, self-esteem concerns (Kinney & Leaton, 1995). Many group intervention and group therapy programs can be employed for the treatment of addiction to drugs. Out of all the models, cognitive behavioral therapy has proved itself to be most effective over time. Depending on the substance abuse being treated, some of the common variations of CBT used as treatments are motivational interviewing, skills training, contingency management therapies, and cognition – focused drug counseling (Carroll & Onken, pp. 1453 – 60).
As per the practitioner’s manual for the cognitive behavioral treatment published by National Institute on Drug Abuse, the primary reasons for recommending CBT are (NIDA, 1988, p.1) are:
- It is a short – term approach compatible with the most clinical programs
- It has been evaluated rigorously in various clinical programs and is backed by solid empirical support
- It is a structured and goal – oriented model, focused on immediate problems
- It is a flexible and individual – focused approach that can be adapted to a wide range of persons, settings and formats.
A counselor treating a patient for addiction often believes in starting where the patient is. It is extremely important for a patient to feel comfortable within this relationship of the patient – counselor. CBT is a collaborative form of treatment. The patient and the therapist mutually agree on the goals of the treatment, maintaining a focus on the problems identified by the patient, before beginning with the therapy. This approach helps in fostering a good working relationship between the patient and the therapist and assures that the treatment will be most relevant to the needs of the patient (NIDA, 1998, p.23).
When a person is fighting to overcome his addiction but in vain, it is common for him to develop the notion of self – blame and personal deficiencies. Therefore, the prime focus of the therapist is to challenge these negative views that may have contributed to the harmful addiction patterns, which, as per the CBT, should be a self – regulated change (Fisher, 1995, cited in Csiernik, 2003, p. 182). It is extremely important for a counsellor to form a bond of affection, acceptance and warmth with the patient. Once a patient is sure that his actions will be accepted without any judgments, he becomes free of the hesitation and opens up in front of the counsellor.
The first step in CBT is to perform a functional analysis of the behavior of a patient that is associated with the drug use, focusing on the frequency and the patterns of use (Csiernik, 2003, p. 182). During this analysis, the patient and the therapist work together to identify and explore the feelings, thoughts and circumstances associated with the substance abuse. This analysis is crucial to be undertaken at the beginning of the treatment itself, since it helps both the parties to identify the triggers for drug use. It is important that the therapist maintains a non-judgmental stance at all times during the treatment, since the drug abuse is majorly a coping mechanism for underlying issues. There is a huge possibility that by the time an individual seeks help of the addiction, the substance abuse is their only way of coping with their personal issues.
This makes the second aspect of CBT, skills training, absolutely mandatory. The primary assumptions behind the skills training are:
- The patient is not aware of the effective strategies for coping with life’s challenges
- If the coping strategies were ever acquired, they have now been lost with time
- A person’s ability of applying the learned coping strategies are hampered by other underlying issues (NIDA, 1998, p. 2 – 3).
Skill training places the patient in the role of a student and the therapist as a teacher. The goal of this training is to enhance the learning of the coping mechanisms. The patient is taught general coping styles that can be applied to life’s many challenging situations. The patient will learn and retain the skills even after the treatment has ceased, thus making it effective for a long run.
Rounsaville and Carroll (1992) presented five major tasks that must be accomplished for the program to be successful:
- Develop the motivation for abstinence from the drugs
- Teach generalizable coping strategies that can be applied to various situations
- Change reinforcement contingencies
- Develop skills for the management of pain
- Improve interpersonal function and social support
The fifth task is extremely crucial because, if no recognition is given to the social environment of a patient, the chances of relapse tend to increase. The treatment is bound to fail if the patient is sent back to the same environment from where he picked up the addictive behavior. Hence, understanding the patient’s society and environment becomes a priority during the treatment (Winters, Botzet, & Fahnhorst, 2011).
In order to achieve maximum results, the skills training is undertaken in a group of people suffering from the similar problems. Because addicts are a heterogeneous group and come together with a wide range of problems apart from the addiction, the purview of skills training is pretty broad (Burleson et al., 2006; Tanner-smith et al., 2012; Kaminer & Waldron, 2004).
The initial sessions of the training focus on the skills related to the control of drug use, i.e. identifying the high-risk situations that trigger the consumption of drugs, coping with such triggers, etc. Once the patients have attained a mastery over these basic skills, the training is broadened to include a plethora of other problems that a person may have difficulty in coping with e.g. social isolation, employment related issues, etc (Diamond et al., 2002).
Emotion regulation skills also train the patients for tolerating distress. Over the course of time, with various group exercises, the patient begins to find non-drug alternatives to distress. The patients begin to find various pleasurable sober activities. When reducing the consumption of drugs, the patients may feel some absence and it is important that void time with other pleasurable and goal – directed activities.
Various advantages have been pointed out of performing group interventions, rather than individual therapies (Miller & Hester, 1989):
- Training a whole group will allow all the members to share their experiences together, which will benefit everyone in the long run.
- Every group member can share their experience of trying the newly acquired skills.
- Role-playing activities can be easily taken in a group. This way, the patients can know in the session itself, what works for them and what does not.
- Treatment is more structured because the key ideas and skills can be imparted in a less individualized format.
- Results of some members improving will motivate the other members to perform better. It will maintain healthy competition in the group.
Outcome of the Cognitive Behavioral Therapy
During the course of CBT, the patient is trained to identify the situations in the social and environmental context that cause the craving for drug consumption. Once these causes are identified, the coping strategies that are taught to the patient during the course of the training help him stay away from the drugs. The training focuses on both the intrapersonal development (identifying the cause of the cravings) and the interpersonal development (to be able to refuse the offer of drugs) of the patient. An attempt is also made to improve their societal factors, because the training is bound to fail if, after the treatment, the patient is sent back to the same environment. The patients are made to understand the negative effects of drug consumption and the change is prompted from within the patient, rather than being forced from outside. Hence, the newly acquired skills are more likely to stay with the patient even after the treatment has ended and if completed with enough motivation, can change the life of a person forever.
Strengths of the Cognitive Behavioral Therapy
As a comparatively short – term intervention, CBT is often completed within twelve to sixteen weekly sessions. It is generally conducted in community outpatient settings, hence proving to be extremely cost – effective. Despite its structural format, it is flexible enough to be suited to the individual patient’s needs.
In addition to being a widely employed and empirically validated approach, it has demonstrated its effectiveness across various cultures (Iwamsa, 1996), with both adolescent and adult populations (Kaminer & Waldron, 2004), and in both community – based settings (Morgenstern, Blanchard, Morgan, Labouvie, & Hayaki, 2001) and individual and group contexts (Marques & Formigoni, 2001).
Addiction has been identified as bio – psycho – social mechanism and a combination of therapeutic approaches customized for individual patients are known to prove more effective than any therapy used alone (O’Brien, 1994, p. 1569). Other therapies with which CBT can be combined are self – help groups, family and couples therapy, parental skill training, pharmacotherapy, and vocational counseling (NIDA, 1998, p.6). The combination is more promising than any other individual therapy, since in the cases of addiction, the patients not only treatment, but social, environmental and emotional intervention to ensure that the support is received by every aspect of an individual’s personality. This combination of the patient’s social and emotional context into the CBT strengthens this therapy.
Limitations of the approach – Cognitive Behavioral Therapy
In an article published in The American Journal on Addictions in 2003, Dr. George Woody heavily criticized CBT and its related psychotherapies as a standalone treatment for the patients of substance abuse. He strongly argued that psychotherapy can and should be used as a treatment only second to drug counseling. It should not be used with the patients, who are not emotionally stable, do not have a stable housing or clients with any psychological disorders (NIDA, 1998, p. 5 – 6). Some critics even went on to say that the clinicians are holding a false belief that CBT is universally effective and that they use this therapy without understanding which mechanisms to use to achieve the desired results.
A primary limitation of this model is that it mandates a high level of motivation, commitment, cooperation and involvement from the patient (Ronen, 2004). Therefore, CBT is limited to committed and compliant patients and it should never be used with the unmotivated individuals.
Dr. Ronen also believes that this model relies too heavily on the patient to apply cognitive skills to bring about the change in the behavior and the aspirations are sometimes unrealistic, considering that some human behavior disorders cannot be modified (pp. 76 – 77).
A major concern revolves around the cost effectiveness of the CBT. Despite the belief that CBT is best applied on an individual basis, studies and research have shown that it produces equally effective results in both the individual as well as the group settings (Marques & Formigoni, 2001; Sharp, Swanson, & Power, 2004).
Implications of the Cognitive Behavioral Therapy as a Social Work Practice
The social workers who understand that the addiction is not merely a flaw in the character, but a complex bio-psycho-social phenomenon, have the advantage of ensuring that the treatment experience of the client is in line with the available resources. On the other hand, the therapists who lack this knowledge may quickly engage the patients with a treatment intervention, but they fail to deliver a treatment that is patient – focused. Such therapists may end up delivering a treatment that may be well-suited to the therapist himself and not the client, which violates the first and the foremost rule of CBT – the patient – centeredness.
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