Clinical and Research News
Computer-Based CBT Shows Promise in Substance Abuse Treatment
Psychiatric News
Volume 43 Number 14 page 21-22

Cognitive-behavioral therapy delivered via computer-based training appears to be a successful adjunct to treatment of substance use disorders, according to a report in the June American Journal of Psychiatry.

Patients receiving biweekly access to computer-based training in cognitive-behavioral therapy (CBT4CBT) skills in addition to standard treatment submitted significantly more urine specimens that were negative for any type of drugs than did patients who did not receive CBT4CBT. There was also a trend toward longer continuous periods of abstinence.

Moreover, outcome was more strongly associated with treatment engagement among the CBT4CBT patients, as demonstrated by the fact that completion of homework assignments in CBT4CBT was significantly correlated with outcome and was a significant predictor of treatment involvement.

"This study points to a means of delivering this form of CBT much more broadly and inexpensively, and with improved consistency, potentially 24/7 with remote access," lead author kathleen Carroll, Ph.D., told Psychiatric News. "Moreover, it can address the shortage of clinicians trained in CBT and can free up clinician time, and possibly even encourage more substance users to seek treatment.

"And because of the level of standardization afforded by computer-assisted delivery, we think it can encourage higher levels of skills acquisition as well as our researchers' ability to evaluate CBT's mechanisms with a higher level of precision." Finally, she noted, this method allows therapists to tailor CBT to patients' needs and progress, allowing them to move at their own speed.

She is a professor of psychiatry in the division of substance abuse at Yale University School of Medicine.

In the study, 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to standard treatment or standard treatment with biweekly access to CBT4CBT.

CBT4CBT consisted of six lessons, or modules, covering the following core concepts: understanding and changing patterns of substance use, coping with craving, refusing offers of drugs and alcohol, problem-solving skills, identifying and changing thoughts about drugs and alcohol, and improving decision-making skills.

The concepts were depicted in "movies" using actors and realistic settings in which an individual is offered drugs or had to cope with a challenging situation in which substance use was likely. Then the movie was repeated with a different ending to demonstrate the use of skills required to change the outcome.

Next, each module included an interactive assessment followed by a short vignette with an actor explaining how use of each skill had helped him or her avoid substance use and how each CBT principle could be applied to other problems. Finally, a narrator reviewed key points, and participants were given a practice assignment.

Standard treatment or "treatment as usual"—which was also available to those in the CBT4CBT group—consisted of weekly individual and group sessions of general drug counseling. Patients in both groups also met twice weekly with an independent clinical evaluator who collected urine and breath specimens, assessed recent substance use, and monitored other clinical symptoms.

The participants assigned to CBT4CBT submitted significantly fewer urine specimens that were positive for any drug and a lower proportion of urines that were positive for any drug. This was most marked for cocaine (28 percent for patients in the CBT4CBT group versus 44 percent for those in the treatment-as-usual group).

Patients in the CBT4CBT group had an average of 22 days of continuous urine-confirmed abstinence during treatment compared with 15 days for those in the treatment-as-usual group, a difference that fell just short of statistical significance.

The investigators also found that outcome in the CBT4CBR was strongly related to treatment adherence—indicated by the number of days retained in the treatment program, the number of individual, and group sessions attended, and homework completion—suggesting that the computer-based training was an integral part of the success of the treatment.

In contrast, in the treatment-as-usual group, outcome was more strongly related to the severity of substance abuse at baseline.

"Given the link between use of the program and outcome, more frequent access to and use of the CBT4CBT program... should be evaluated as a strategy to enhance the potential benefits of this approach," the authors wrote.

"Computer-Assisted Delivery of Cognitive-Behavioral Therapy for Addiction: A Randomized Trial of CBT4CBT" is posted at<http://ajp.psychiatryonline.org/>.

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