Dr. Mark McGovern responds to participants in his web conference on implementing cognitive behavioral therapy and the Dartmouth-Hazelden Co-occurring Disorders Program.
Q: I was wondering how culturally diverse your model of cognitive behavioral therapy is? Can you tell us a little more about the sample population in the field test and what were the lessons learned?
A: Dating back to its origins with Aaron Beck in the 1970s, cognitive behavioral therapy, or CBT, has been widely studied and implemented with numerous and diverse patient populations. It has been used with people who have different disorders or problem types at differing levels of severity, and it has been delivered by a range of clinicians. We at the Dartmouth Psychiatric Research Center have field tested our own version of CBT using the interventions at agencies in Middletown, Connecticut (Rushford Center); Hartford, Connecticut (Hartford Dispensary); Indianapolis, Indiana; (Gallahue Behavioral Health); Minneapolis, Minnesota (Fairview Behavioral Health); and Portland, Oregon (CODA, Inc). This version of CBT is in the curricula Integrating Combined Therapies and Cognitive Behavioral Therapy in the Hazelden - Dartmouth PRC Co-occurring Disorders Program, In addition, the Co-occurring Disorders Program is being used by the United States Navy in its addiction and mental health treatment programs.
The lessons learned are largely positive: CBT is effective, well tolerated, and beneficial to patients, and relatively easy for clinicians to learn and deliver. CBT poses some challenges for therapists who are used to a more "free form" or improvisational approach to their work. For some, using a guided curriculum may at first feel awkward. However, we have also found that for these therapists their own motivation to try the curriculum and see how it works is the best solution. The other important lesson learned is that CBT works best when used by therapists who are already good clinicians. That is, therapists who establish a therapeutic alliance are nonjudgmental and empathic, and who are steady and reliable in their approach to their work are the best practitioners of CBT. Of course, it is strongly recommended that clinicians be familiar with and have competence within the culture of their patients.
Q: Have you found that CBT works with Native American and other clients?
A: Since CBT is focused on helping individuals examine their beliefs and how these beliefs influence their own feelings and behavior, it is not particularly culture bound. I have heard case reports of Native American patients describing their beliefs about historical trauma and experiences with ancestors and elders. A clinician familiar with these beliefs and experiences and their impact can help an individual process them in such a way that the result is more liberating, adaptive, and connecting. This being said, more research is needed on using CBT with Native Americans, including studies on the potential for appropriate modifications or adaptations of CBT.
Q: Has this CBT curriculum, Hazelden Co-occurring Disorders Program, been used with adolescents? How appropriate is it for that population?
A: CBT has been widely used with adolescents. A version of CBT combined with Motivational Enhancement Therapy is one of the evidence-based practices studied in two, national, multi-site effectiveness studies funded by SAMHSA of thousands of youth across the United States. The five-session version of combined MET/CBT was particularly effective for youth with both substance use and mental health disorders. These studies included teens with both externalizing mental health disorders-such as conduct disorder, ADHD, and oppositional defiant disorder--and adolescents with internalizing disorders, such as mood, and anxiety disorders and trauma. The combined MET/CBT approach influenced our adaptation of CBT in the Co-occurring Disorders Program title Integrating Combined Therapies.
Q: Does CBT also work well with Borderline Personality Disorders?
A: The most established psychosocial treatment for persons with borderline personality disorder is Dialectical Behavioral Therapy (DBT), developed by Marsha Linehan at the University of Washington. A version of DBT-known as DBT-S-has been developed for persons with substance use problems. Like many "brand name" psychosocial treatments, DBT is primarily a cognitive behavioral approach. CBT and the Integrated Combined Therapies manual we developed focus on helping people regulate negative emotions and reduce negative affect and behavioral consequences, including substance abuse. These skills apply to people who have a variety of substance use and psychiatric disorders, including those with borderline personality disorder.
Q: Is there any evidence of the successful application of CBT to offender populations?
A: "Evidence" is subject to a variety of interpretations, of course. I am not aware of any studies specific to offender populations that test the use of CBT within a randomized, controlled trial design. (There may be some; I just don't know of them.). However, in our field studies of agencies implementing our intervention, we did find clients who were referred through the criminal justice system. For, instance the clientele at the Oregon and Connecticut agencies were predominantly people mandated by the criminal justice system--either through probation or parole or alternative sentencing at drug court--to seek treatment. These patients appeared to receive equivalent benefit from CBT as did the patients who were "self" referred or recommended by other sources.
Q: How do you see Motivational Interviewing and CBT fitting together in an agency practice?
A: Motivational Interviewing, or MI, fits together with CBT and Twelve Step Facilitation (TSF), This combination, modified specifically for persons with co-occurring disorders, brings together three of the most potent psychosocial treatments with the most established evidence-based practices. And it allows clinicians to consider the patient's stage of motivation when addressing his/her problems. MI or MET is most appropriate for the person just beginning to experience doubts about a problem and explore it using professional treatment as a solution. CBT is optimal for the person at the "Action" stage of treatment, someone who is seeking solutions, tools, and skills to deal with a problem. A person who wishes to maintain changes they have made, prevent relapse, and decrease reliance on treatment providers and increase their integration with their community and family is well-suited to TSF.
This is the approach we use in our curricula Integrating Combined Therapies. Agencies have been delivering Integrated Combined Therapies in individual and group formats. They recommend stage-specific treatments for patients, or they bring together patients at various stages in group therapy sessions that promote social learning. The integration of Motivational Interviewing with CBT and TSF is logical and maximizes a person's chances to benefit from the treatments.
Q: Can CBT work with clients with who have cognitive damage from severe drug use?
A: We have noticed that persons with significant cognitive impairment can still benefit from CBT. The approach has to be paced to the capability of the patient, and material should be less organized around reading and writing and more focused on discussion and role-play. Of course, repeating or practicing a new skill is critical to acquiring it. There are also a variety of new psychosocial therapies designed to promote cognitive remediation, and many draw upon the principles of cognitive behavioral therapy.