Cognitive therapy of substance abuse

Book Reviews management. Use of intravenous haloperidol is discussed, as is frequent need for supplementation with a benzodiazepine such as lorazepam. The authors’ table on haloperidol usage is confusing, however. For example, the statement “once patient is calm, add the total milligrams of haloperido1 and administer same number of milligrams over the next twenty-four hours” is confusing. If 10 mg is needed to calm a patient over a 2-hour period, do we give 10 mg or 120 mg over the next 24 hours? Similarly, the unreferenced statement “oral dosage is twice the intravenous dosage” could lead the clinician who has used high doses of intravenous haloperidol to convert to a very high dose of oral haloperidol, a practice that could lead to significant extrapyramidal side effects. The remainder of the book consists of 13 other useful chapters on topics ranging from pain to geriatric psychiatry. The chapters on neuropsychiatry and cognitive impairment disorders are particularly well-written. Compared with the first edition (published in 1988), the book is significantly longer (300 vs 183 pages), with clearer tables and a number of new references. Updates include an expanded section on AIDS, inclusion of DSM-IV criteria, and discussion of some of the newer psychopharmacological agents (for example, selective serotonin reuptake inhibitors, but not clozapine). The ultimate test of a concise guide is its utility, and this book, although it has limitations, clearly serves its purpose. It is small, thorough, and provides a quick reference guide for common consultation problems. For the reader who wants more, the references are up-to-date and generally comprehensive. The interested reader should, of course, review such texts as the Mussachusetts General Hospital Handbook of General Hospital Psychiatry or Stoudemire’s and Fogel’s Medical-Psychiatric Practice for more detailed discussions of subjects beyond the scope of this guide. In a future edition, the authors could include a section referencing other relevant texts in consultation psychiatry. The “Additional Readings” section at the end of each chapter could also reference more comprehensive works relevant to the particular chapter, e.g., Wayne Katon’s Panic Disorder in the Medical Setting and G. Richard Smith’s Somatizafion Disorder in the Medical Setting. With increased emphasis on such comprehensive references, this useful pocket book would be a guide not only to psychiatric consulting, but to the field of consultation psychiatry. STEVEN

A.

EPSTEIN,

M.D.

Washington, D.C. 436

Cognitive Therapy of Substance Abuse. Edited by Aaron T. Beck, Fred D. Wright, Cory F. Newman, Bruce S. Liese. New York, The Guilford Press, 1993 ($35.00), 367 pp. This long-awaited textbook explicates and expands on Aaron Beck’s applications of cognitive therapy to the addictions with lucid, useful integration and a wide explanation of theory and practice. Along with his coauthors, Dr. Beck has produced a landmark work that will be widely read and will inform the practice of all therapists. Aaron T. Beck, Fred D. Wright, Cory F. Newman, and Bruce S. Liese cover a wide range of important issues relating to cognitive therapy for substance abuse. They describe the history of research and thinking about cognitive approaches to substance abuse, how to do cognitive therapy and its relationship to the treatment of comorbid conditions, such as anxiety disorder, depression, and personality disorders. Their major premise is that substance abuse patients can be helped through correcting erroneous core perceptions about self. The book begins with an overview of the significance of substance abuse, a brief history, and a description of the most commonly abused drugs. The relationship to polysubstance abuse, dual diagnosis, and relapse prevention is stressed. The cognitive model of addiction, including a description of work by Allen Marlot on relapse prevention, is discussed. In cognitive approaches to treatment, a modest goal of substance-use reduction is encouraged, though in the long run the authors strongly advocate that patients become drug and alcohol free. The degree of emphasis on a controlled substance-use approach is my way of treating a possible weakness; however, many experts and those in AA strongly emphasize the need for abstinence as a part of successful treatment. In my experience, even those who use controlled drinking as a goal often find that patients view this as unrealistic and decide to aim for abstinence. Beck et al. go on to review the literature on alcohol, drug, and smoking interventions. In Chapter 2, a cognitive model of addiction is presented. The importance of beliefs that drugs and alcohol will lead to pleasure and reduce the stress of life is a cognitive way of presenting a selfmedication hypothesis. A vicious cycle is created when problems with anxiety and mood lead to drug use, which then leads to worsening financial, social, and medical problems. Patients often have considerable denial about the way in which alcohol and drugs create problems. It is this core of dys-

Book Reviews

functional beliefs about drugs or alcohol use such as, “I can’t be happy unless I use,” that is the major target of cognitive approaches to treatment. Cognitive therapy aims at modifying faulty or erroneous thinking and maladaptive beliefs that underlie addictive behavior. Each selected case example carefully conceptualizes the basis of the person’s life history and demonstrates the therapist’s effort to actively build a collaborative relationship using open-ended questioning and a highly structured and focused format. Sequences of events leading to drug use are explored as are the patient’s basic beliefs about the value of alcohol and drugs. The patient is trained to evaluate and consider ways in which faulty thinking produces stress and distress, to modify thinking to make it more realistic, and to practice new ways to control craving. In Chapter 3, theory and therapy are described in more detail, emphasizing addictive beliefs derived from erroneous negative self-concepts that lead to drug-taking behavior. Chapter 4 is about as well-written a description of some of the important issues in the patient-therapist relationship as can be found. It clearly lays out some of the important sources in addicted patients of negative transference to the therapist and countertransference to the patient. Therapist attitudes and maladaptive beliefs about each other can interfere with constructing a positive therapeutic alliance. Management of the therapeutic relationship in cognitive approaches parallels that of psychodynamic approaches. In fact, many concepts, including an awareness of the importance of raising selfesteem, the need to self-regulate affect, efforts directed at self-care, and an attempt to build trust through directness, openness, and honesty have much in common with psychodynamic psychotherapy. Other aspects of the relationship include the value of setting limits to help patients gain selfcontrol, the value and importance of confidentiality, the need for the therapist’s credibility, flexibility, and tact, and the avoidance of colluding with the patient to avoid important issues. The therapist’s job is to work at helping patients build selfesteem. Useful tips on managing inevitable power struggles with patients are also provided. In summary, one has the feeling that the therapist-patient relationship is as central an issue in cognitive approaches to treatment as any other approach. Chapter 5 talks about case formulation, which entails getting a first-rate history with outside corroboration, the use of rating scales, a DSM-IV diagnostic formulation, development of presenting

problems and current functioning levels, a developmental profile, a cognitive profile, integration and conceptualization of cognitive and developmental profiles, and a description of the implications for therapy, including the therapist’s goals and predicted resistances, Chapter 6 describes a fairly well-structured approach to the therapy session that includes agenda setting, mood checks, bridging sessions, Socratic questioning, summaries, homework assignments, and feedback. Chapter 7 emphasizes the educational aspects of cognitive-behavioral approaches which appeal to patients who are looking for logical answers to their problems. Chapter 8 describes the importance of setting clear goals for patients regarding coping with life problems in addition to reducing drug dependence. Chapter 9 introduces a variety of techniques that enhance cognitive therapy, including reattribution of responsibility, a daily thought record, the use of imagery, activity monitoring and scheduling, behavioral rehearsal with role playing, relaxation training, problem solving, and the value of exercise. Chapter 10 describes the kind of craving and the various techniques that can be used to reduce or control craving. Chapter 11 describes the various ways in which false beliefs can cause problems and how assessing beliefs and modifying addictive beliefs can be useful. The effort to develop beliefs that addiction can be controlled and ways in which homework can be used to increase beliefs about controlling addiction in the face of high-risk stimuli are presented. Chapter 12 gives practical advice on sorting out how substance abuse can both lead to life problems and be caused by them, whether they relate to family and marital issues, work and socioeconomic problems, daily stressors, legal problems, or medical problems. Chapter 13 describes ways of intervening in crises related to overdose, suicidality, homelessness, when the patient is missing, when there is a loss of job, a loss of relationships, medical emergencies, or criminal involvement. How to deal with threats to the therapist is also covered. This is a well-written chapter on the management of crisis situations. Chapter 14,15, and 16 deal with the comorbidity of depression and anxiety along with alcoholism and concomitant personality disorders. As Dr. Beck’s work on cognitive-behavioral approaches has been applied to both disorders, the usefulness of the cognitive therapy approach in treating comorbid disorders is especially valuable. In fact, these three chapters are helpful in understanding 437

Book Reviews the psychiatric comorbidity of substance abuse that may need to be treated along with the substance abuse problem. Chapter 17 presents a cognitive model for relapse prevention and ways of identifying high-risk stimuli in order to predict and control relapse. It provides a cognitive model for relapse, including false beliefs that people have about situations that can lead to relapse, and a means of predicting and controlling relapse by trying to reduce situations and recognize conditions that might lead to it. There is an effort to develop beliefs that reduce vulnerability to lapses and relapses such as, “I don’t need drugs to have fun,” or “I can cope with unpleasant emotions without using drugs.” Efforts at keeping lapses from becoming relapses and the value of the social support network are emphasized. The book also has valuable appendices to help build positive skills on beliefs and substance abuse, craving beliefs, a relapse prediction scale, a checklist for dealing with ambivalence and lapses, patients’ reports of the therapy session, and reasons why patients do not complete their self-help assignments. The last chapter deals with relapse prevention. In summary, Cognitive Therapy of Substance Abuse is a lucid manual of theory and practice on treatment of substance abusers. The techniques recommended in this book need not be thought of as having to be applied in pure form and can easily be combined with other approaches. In fact, perhaps what is most valuable is the distillation of clinical wisdom of Dr. Beck and his colleagues. The techniques used are clearly described and can be used for treatment outcome research to validate the cognitive approach vs other approaches, and to look for subpopulations in which cognitive therapy makes special sense. For patients who tend to look for logical answers to their problems and those with clear cognitive distortions about themselves and substance abuse, this technique is especially indicated. If you haven’t read Beck’s other works on depression, anxiety, and personality disorders, this book will whet your appetite. RICHARD

J. FRANCES,

Hackensack,

M.D.

New Jersey

The Psychobiology of Mind-Body Healing: New Concepts of Therapeutic Hypnosis, Revised Edition. Edited

by Ernest Lawrence Rossi. Evanston, IL, W. W. Norton and Co., Inc., 1993 ($39.00), 380 pp. 438

Dr. Rossi’s new book sets several very ambitious goals. First, he seeks to present an empirically grounded framework for integrating mental and physical (body) phenomena. Secondly, he presents a series of hypnotic interventions to effect physical healing through psychological means. Although the overall plan and goals of this book are the same as for the first edition that was published in 1986, this revision has been extensively updated with new material and references that have strengthened his arguments. Many, but not all, of the points that seemed somewhat speculative in the first edition have subsequently been supported. The major thesis of this book is that information transduction is the principle by which mental processes lead to biological changes through routes that are traced through neurotransmitters, hormones, immunotransmitters, and neuromodulators (“information molecules”) to second messengers to genetic expression and the regulation of cells. Major sections of the book trace the paths of information transduction within the autonomic nervous system, the endocrine system, the immune system, and the neuropeptide system with the major connection between the brain and body linked through limbic, hypothalamic, and pituitary systems. Overall, a very solid, readable review of these systems is provided and few readers will come away without having learned a great deal. Dr. Rossi uses two major constructs to explain how environmental events and psychological processes lead to physical changes. The first is “statedependent memory, learning, and behavior.” States of arousal and emotional activation are learned at both a mental and physical level creating, at times, chronic states that may contribute to physical disorders and illnesses. The second is the concept of “ultradian rhythms.” Much attention is paid to time and various rhythms of alertness and rest, cycles that are tied to the time courses of various biological processes. Although both of these constructs have some empirical support, the applications given are somewhat speculative. For example, state-dependent memory, learning, and behavior is set forth as the central principle for all trauma-related and dissociative disorders. I would not be surprised if this turns out to be a better theoretical explanation than most, but at present, the discussions are somewhat speculative. The discussions of hypnosis and treatment rest heavily upon these two constructs, with accessing the problematic state-dependent problem through using the patient’s natural rhythms and healing