Cognitive Behavior Therapy: the Relationship Between Environmental Factors and Internal Features - Research Paper Example

 There is a multitude of reasons why people turn to drugs and alcohol and eventually become addicted to using them. Some people initially try them for social reasons or curiosity, but upon feeling the pleasurable effects, go back to it again and again until they realize they have become addicted to it. Uncontrolled use of drugs and alcohol may be considered substance abuse. Most people who fall into this state have much deeper psychological problems and use the drugs or alcohol as a crutch to cope with their difficulties. Many interventions are available for people seeking help for their problem of substance abuse. One of this is Cognitive Behavioural Therapy. This paper will critically evaluate the use of Cognitive Behavioural Therapy (CBT) in working with people with substance abuse problems. It will thoroughly discuss a case study of a woman named Rosa Lee, with severe drug problems, as diagnosed with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It is a real case, culled from the book of Leon Dash (1996). After studying Rosa Lee’s case, CBT will be discussed as to how it can be of use as an intervention to help her on her way to recovery from her serious psychosocial illness. Case Study: Rosa Lee Cunningham Rosa Lee Cunningham is a Black American woman who has lived a pathetic life being a victim of extreme poverty, child abuse and deprivation of love and nurturance from her mother. The traumatic experiences in her life has led to her addiction to a lifestyle that further degrades her as a person instead of rising from her unfortunate situation. Education was not given a priority in Rosa Lee’s growing years. Her mother, Rosetta, would prefer that work and chores were done well and schooling was not as important. She needed to chop wood, carry heavy things, scrub a room spotless and cater to her family’s every need. As an adult, being overly clean with the house became her way of coping with stress. Rosa Lee craved for her mother’s approval. When she learned to shoplift nice things to offer her mother, she would be reprimanded, but later, as her mother would inspect the merchandize, would throw her arms around her with appreciation. Such acts of intimacy were short-lived, as Rosetta did not hesitate to inflict physical harm at Rosa Lee whenever she displeased her. On the other hand, her father, an alcoholic, had better regard for her and indulged her with whatever coins he can spare for her whenever he was drunk. Her first shoplifting episode was borne out of her desire to be upgraded in terms of fashion to keep up with her peers. From then on, stealing became a way of life, and she became better and better at it until such time when she managed to subtly slip merchandize in her waiting bag or under her skirt. Rosa Lee fared poorly in school, not realizing that she was a slow learner. She was also a truant child and she did not develop her literacy skills to the fullest. This lack of reading skills proved to be disadvantageous to her. As she hungered to be loved, she became promiscuous feeling that sex was a way to get affection. This led to an early pregnancy at age thirteen. She had to stop schooling to have her first-born which her mother cared for. Soon after, she found herself pregnant again, and again and again, making her a mother of multiple children before she reached her twentieth birthday. Once, she succeeded in having a man marry her only because he was threatened by Rosetta, but a few months later, Rosa Lee found herself back in her mother’s house as she had no other way to go because her husband beat her. To feed her children, she had to resort to prostitution and selling illegal drugs. She always justified such ways of generating income as means of “survival” for her eight children. Her steady income came in the way of welfare checks which her mother had full control of. Because Rosa Lee had no credible role model for morality, she set her own standards, which unfortunately were easily bent. The only thing she was sure of is that she didn’t want to hurt them like her mother hurt her. She herself taught her children to steal clothes so they had something nice to wear or other things so they had something to sell to buy food. Later on, she would involve her children and grandchildren in the drug trade because policemen don’t usually go after young children. She never expected that they would get hurt in the process, but failed to consider that she was putting them at high risk. When Rosa Lee eventually became a drug addict herself, it became so natural to her and her children to share the illegal drug use. Their joint drug sessions impressed upon the children her tolerance of such a habit, making it convenient for them to justify it and even depend on their mother to supply it or money to get it from their drug dealers. This series of substance abuse shared by Rosa Lee and her six children merited them jail sentences and even acquiring the HIV virus for Rosa Lee and her two children she shared needles with. It is pathetic that Rosa Lee and her children do not learn from the consequences of engaging in their drug habit, since upon release from jail, they are soon at it again. Even the threat of the AIDS disease did not deter them from continued pursuit of the next high. Prolonged use of dangerous drugs, and her high level of stress have resulted in some physical illnesses in Rosa Lee as manifested by seizures, memory lapses and stomach pain. To manage it, she has been receiving her daily dose of Methadone at the community clinic. However, at times, such symptoms become too much to bear and she ends up confined in the hospital. Rosa Lee’s manifested symptoms may be diagnosed as Substance Abuse/Dependence. Under DSM-IV-TR (text revision of 2002). Following are the usual behaviors exhibited by substance abusers/ dependents: SUBSTANCE ABUSE:             Manifests one or more of the following behavior:  Failure to fulfill major obligations: Rosa Lee has been habitually tardy in settling her bills, resulting in cut-off of services. She is unable to manage her finances, as she misappropriates her budget to her and her children’s drug supply instead of food for everybody or payment of utilities. Use when physically hazardous: In spite of the threat of her HIV virus turning into a full-blast AIDS disease, or simply when she knows that her physical condition makes drug use lethal for her, Rosa Lee continues to indulge in drugs. Recurrent legal problems: Rosa Lee has been arrested several times for shoplifting or busted for selling or using drugs. Recurrent social or interpersonal problems: Rosa Lee is unable to control her children’s addictive behaviour. She continually supports their drug habit by handing them the money to buy drugs and then tries to save them whenever they get in trouble associated with their drug use. Personally, she is frustrated with how they treat her but she seems helpless as she keeps her feelings usually bottled up inside and occasionally pushed to the limit. Since she has vowed never to be like her abusive mother to her children, she instead indulges their whims even if it brings disastrous results for them.   “With SUBSTANCE ABUSE the user has a choice: he/she uses in spite of illegal, unsafe consequences, or inappropriateness of the drinking/drugging experience.” (DSM-IV-TR, 2002). With Rosa Lee’s history of drug use, she continues to use drugs despite her awareness of its consequences to herself or her family.  SUBSTANCE DEPENDENCE (ADDICTION/ALCOHOLISM)             Manifests three or more of the following behavior:  Tolerance: Rosa Lee tolerates the consequences that follow her drug use – pain, inability to function normally, even her children’s seemingly abusive behavior towards her. Withdrawal: Rosa Lee’s body responses to drug use withdrawal are usually associated to how she takes medication to control the accumulated and related symptoms that the use of dangerous drugs have caused. Since her reading skills are inadequate, she is not accurate in following the dosage of the prescribed medication, causing her body to react with seizures, memory lapses, etc. Large amounts over a long period: Rosa Lee’s intake of drugs/ illegal substances depends on its availability. The more drugs available for the taking, the more she can consume. This has gone on for most of her adult life. Unsuccessful efforts to cut down: Despite her numerous attempts/ announcements to stop and reform her life by avoiding drugs, she would usually fall back into the drug habit. Time spent in obtaining the substance replaces social, occupational or recreational activities: Rosa Lee’s numerous commitments have usually been missed due to her drug problem. Continued use despite adverse consequences: Rosa Lee has gotten herself in dire circumstances because of her substance abuse/ dependency. Her repetitive confinements in the hospital, the threat of AIDS, the risk of being hurt by drug dealers may force her to stop using drugs, but when a stressful event comes to her life, or when her defenses are down, she would weakly give in to the temptation of taking drugs when it presents itself. Proposed Treatment Plan In coming up with an appropriate treatment plan for Rosa Lee, many factors are to be considered. Like in most cases, treatment needs to combine psychological therapy with the treatment of the physical addiction. Before any treatment plan is attempted, Rosa Lee’s intrinsic desire to be reformed must be expressed. The decision to be healed of her addiction should help her commit to being cooperative with the concrete vision that she will indeed be free from the bondage of the addiction. To cleanse her body of the chemicals she has ingested, Rosa Lee needs to go through medical detoxification. “While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.” (National Institute on Drug Abuse, n.d.). As it is, Rosa Lee has been taking her doses of Methadone, a drug that helps her in stabilizing her life and reducing her illicit drug use. Her treatment plan must likewise include treatment and management of her HIV positive state to prevent it from becoming a full-blast AIDS disease. Priority should be helping Rosa Lee regain her physical vigor and feisty spirit. The most important element in the treatment plan is Rosa Lee’s psychological therapy. Managing the effects of her trauma from childhood entails getting to the root of it. Therapy must include her revisiting of the past and steps to achieve closure from the psychological pain inflicted by her overpowering mother and the prejudicial socio-cultural environment that exploited her dignity as a person. Cognitive Behaviour Therapy is thus recommended. Cognitive Behavour Therapy Cognitive Behaviour Therapy evolved from two therapeutic disciplines namely Behaviour Therapy and Cognitive Therapy (Shinebourne lecture, 2010). Behaviour Therapy was strongly influenced by the behaviourist movement in Psychology, particularly the Classical Conditioning theories of Pavlov and the Learning Theories by Thorndike and Skinner. Behaviourism was developed as a reaction against the prevailing Freudian psychoanalysis which focused on the workings of the mind, inclusive of the conscious, pre-conscious, unconscious and the concepts of id, ego and superego. It also put much emphasis on childhood experiences. It explains that most of the adult personality, coping and defense mechanisms are results of experiences that brought about strong emotions during childhood (Freudian lecture, 2010). However, behaviourism questioned Freud’s Psychoanalysis’ scientific basis and lack of empirical evidence. Also, behaviour therapy did not consider mental processes such as thoughts, beliefs, interpretations, imagery, etc. It was realized that behaviour and emotions are also strongly influenced by cognitions such as the thoughts, beliefs and interpretations that people make (Shinebourne lecture, 2010). Hence, the fusion of behaviourist and cognitive principles became Cognitive Behaviour Therapy. Aaron Beck claims that much of our psychological problems are caused by “cognitive distortions” due to our acknowledged human fallibility. “In depressed people, these belief systems, or assumptions, develop from negative early experiences such as the loss of a parent, rejection from peers, an unrelenting succession of tragedies, criticism from teachers, parents or peers, or even the depressed behaviour of a parent. These negative experiences lead to the development of dysfunctional beliefs about the world, which are triggered by critical incidents in the future.” (Field, 2000). Beck (1987) came up with the concept of “negative cognitive triad” that describes the pattern that triggers depression. In the first component of the triad, the client exhibits a negative view of himself. He is convinced that he is to blame for whatever pathetic state he is currently in because of his personal inadequacies. Secondly, the client shows negative view of the world, hence, a tendency to interpret experiences in a negative manner. He nurtures a subjective feeling of not able to cope with the demands of the environment. Third and lastly, the client projects a gloomy vision of the future. He can only anticipate failure in the future. Stallard (2003) contends that the aim of CBT assessment is to develop a cognitive formulation of the problem and establish the relationship between environmental factors and internal features. He enumerates the aims of CBT intervention as follows: to increase the client’s self-awareness; to facilitate a better understanding of himself and to improve his self-control by developing more appropriate cognitive and behavioural skills. In terms of using CBT with clients with problems with substance use (PSU), the specific aims are to help clients broaden their perspective on their dependence on substances such as drugs and alcohol either for pleasure and/or relief from discomfort. It also aims to reduce the intensity and frequency of the individual’s cravings or urges to get ‘high’ by lowering his beliefs in the substance use. CBT teaches the client techniques in managing his cravings in order to reduce the risk of relapse. Likewise, CBT helps combat depression, anxiety, anger and other negative emotions that usually trigger substance use (Maslin lecture, 2010). Using CBT with the case of Rosa Lee entails knowing the current substance use problem and its severity. The therapist should be aware of how her substance use problem is maintained and how it developed to be what it is today. To guide the therapist in analyzing her problem, Beck’s (1989) Cognitive Theory of emotional disorder may be used: Rosa Lee’s Early Life Experiences Suffered from poverty; physically and emotionally abused by her mother; did poorly in school; had a history of theft; promiscuity led to being an adolescent mother; borne 8 children by the age of 28. Core Beliefs/ Schemas “I am worthless. Others are better than me. The world owes me so much.” Conditional Assumptions/ beliefs/rules “If I give in to my children’s whims, then they would love me and not leave me. I should be a good mother by giving in to them. I must always say yes to them no matter the consequences since I don’t want to be treated like how my mother treated me.” Trigger Emotions: “I feel frustrated because I can’t give my family a better life”. Behaviour: “I need a high to forget all my problems, so I’ll find a way to score” Physiology: Prolonged use has led to Rosa Lee’s episodes of seizures, memory lapses and stomach pain. Since CBT fuses cognitive and behavioural techniques, the most appropriate ones shall be selected for Rosa Lee’s case. The cognitive techniques will address Rosa Lee’s substance related beliefs and negative automatic thoughts that push her to take the substance while the behavioural techniques will deal with those damaging beliefs that trigger drug use by teaching her skills to overcome them (Maslin lecture, 2010). The goal of therapy is to help Rosa Lee realize that reorganizing the way she views situations will call for a corresponding reorganization in her behavior. In therapy, clients are taught Thought Catching or the process of recognizing, observing and monitoring their own thoughts and assumptions and catch themselves especially their negative automatic thoughts when they dwell on it. Once they are aware of how their negativity affects them, they are trained to check if these automatic thoughts are valid by examining and weighing the evidence for and against them (Corey, 2005). Rosa Lee will learn to assess the advantages and disadvantages of her drug using behaviour as well as evaluate why she keeps holding on to her substance related beliefs. More importantly, therapy helps her distinguish her behaviour from her own person, that what she does is not necessarily a judgment of who she really is. A CBT therapist uses a variety of therapeutic strategies depending on what he decides will work on a particular client. He also delegates responsibility to his client by expecting him to do homework outside the therapy sessions. Homework or Task Assignment is aimed at positive behavior that brings about emotional and attitudinal change (Corey, 2005). Therapists also engage in Socratic dialogues with the clients, throwing questions that encourage introspection with the goal of the client arriving at his own conclusions. Reality Testing lets the client do tasks to disprove negative beliefs such as phoning a friend to disprove the belief that no one wants to speak to him. (Field, 2000). With substance abuse problems, cravings management is included in the therapy as the client understands why he craves drugs and manage it by identifying what triggers his craving and normalizing the craving until it ceases. Since the clients’ emotions play a key role in triggering and maintaining substance use, CBT helps in understanding and normalizing emotions, identifying links between emotions and substance use, identifying and labeling emotions and teaches strategies to manage emotions. For instance, when Rosa Lee feels threatened that her children will reject her if she does not give in to their coaxing her to do drugs with them, she goes ahead and does it. This feeling of “threat of rejection” may be identified as the trigger and the therapist may help her deal with it by making her understand that giving in to her children’s whims will only damage them all more instead of helping them live more productive lives if she decides to say NO to them. The therapist may draw a picture to Rosa Lee of the pros and cons of giving in to her children’s whim and letting her choose the better alternative. After undergoing intensive CBT, relapse prevention is essential. All throughout treatment, clients are encouraged to integrate the techniques they have learned in therapy in their daily lives with the goal of keeping CBT effective even when therapy ends (Roth, Eng and Heimberg, 2002). However, clients are also warned that they might still encounter difficult times in the future even after successful treatment but their newly acquired skills at dispelling negative thoughts and reactions must be at their disposal to use whenever they would need them and maintain the belief that a single difficult event is not a failure on their part. “An important goal of therapy should be to ensure that clients can apply cognitive and behavioral techniques on their own, with less reliance on the therapist over time, thus facilitating relapse prevention efforts.” (Roth, Eng and Heimberg, 2002, p. 453) CBT offers hope for the seemingly hopeless substance abusers who want to be free from their addiction and finally lead better, productive, clean and drug and alcohol-free lives. References Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1, 5-57. Beck’s (1989) Cognitive Theory of emotional disorder, as mentioned in the Shinebourne (2010) lecture Corey, G. (2005) Theory and Practice of Counseling and Psychotherapy, 7th ed. Brooks/Cole, a division of Thomson Learning Inc. Dash, L. (1996), Rosa Lee: A mother and her family in urban America. The Penguin Group DSM-IV-TR (text revision of 2002) Substance abuse, Retrieved on December 21, 2010 From:http://allpsych.com/disorders/substance/substanceabuse.html; http://dsmivtr.org/2-3changes.cfm Field, A. (2000) Cognitive Therapy, retrieved on December 19, 2010, from http://www.sussex.ac.uk/Users/andyf/depression.pdf Freud lecture (2010) (lecture for Introduction to Counselling and Therapy, 2010). Maslin, J. (2010) Cognitive-Behavioural Therapy for Substance Use Problems (lecture for Introduction to Counselling and Therapy, November 11, 2010) National Institute on Drug Abuse (n.d.)Principles of Drug Addiction Treatment: A Research-Based Guide. Retrieved on December 20, 2010 from http://www.whitehousedrugpolicy.gov/treat/bestpractice.html Roth, D.A., Eng, W. & Heimberg, R.G., (2002) Cognitive Behavior Therapy, Encyclopedia of Psychotherapy Vol. 1 Elsevier Science (USA). Shinebourne, P. (2010) Introduction to Cognitive Behaviour Therapy (CBT) (lecture for Introduction to Counselling and Therapy) Stallard (2003) as mentioned in the Maslin (2010) lecture Read More