masbirt
Brief Treatment

Eric G. Devine
Deborah J. Brief
George E. Horton
Joseph S. LoCastro

Comprehensive Addiction Treatment
A cognitive-behavioral approach to treating substance use disorders

Boston T X.  Development and training.  Boston Center for Treatment Development and training. B C C T D T.

Comprehensive Addiction Treatment (CAT)
Therapist Manual
(V3)

Eric G. Devine
Deborah J. Brief
George E. Horton
Joseph S. LoCastro

Acknowledgements
The Boston Center for Treatment Development and Training gratefully acknowledges the following people for their contributions to the development of this manual: Mathew Biondolillo, David Clark, Kimberly Dequattro, Sherral Devine, Jillian Koplow, Courtney Richambault, Laurie Sickles, Emma Uwodukunda, and Emily Wolff.

Reproduction Notice
Copying, distribution, and using this manual for the provision of clinical care is unrestricted.  The sale of, marketing of, or other commercial use of this manual and accompanying CD-ROM is strictly prohibited.  Author’s written permission is required for all other uses (e.g., research, continuing education seminars, training workshops) outside of the provision of clinical care.  Duplication of the CD-ROM is prohibited.

Treatment Development
Portions of the materials developed for this treatment have been adapted from published public domain treatment manuals including the Combined Behavioral Intervention (Miller, 2004) and A Cognitive-Behavioral Approach: Treating Cocaine Addiction (Carroll, 1998).  Module 9 of this manual (Mood Management) has been reprinted from the Combined Behavioral Intervention Manual with only slight revisions.

Treatment Overview
Comprehensive Addiction Treatment (CAT) combines elements of empirically supported treatments for substance use disorders into a 14-module treatment program.  This includes elements of Motivational Interviewing, Community Reinforcement Approach, and Cognitive-Behavioral Skills Training.  The goal of CAT is to provide a manualized approach to delivering effective treatment for substance use problems, while retaining flexibility in how the treatment is applied with each client.

Treatment topics
Treatment topics are divided into two categories: Core Modules (Modules 1-3) and Skills Modules (Modules 4-14)

Core Modules
The Core Modules are essential components of treatment to be used with all clients.   These modules should be used in the order presented, but the length of time devoted to each can exceed a single session as needed.

Module 1: Enhancing Motivation for Change
The primary objective of this module is to bolster the client’s motivation for making changes in substance use.  Motivational Interviewing techniques and style are used to develop rapport, express empathic understanding, and elicit the client’s reasons for considering change.

Module 2: Decision Making
The primary objective of this module is to explore and resolve ambivalence about change.  Consistent with the spirit of Motivational Interviewing, this module is intended to help the client identify the pros and cons of changing substance use behaviors.  The therapist assists the client with exercises that serve to facilitate a decision on the part of the client with regard to whether they want to pursue change.

Module 3: Functional Analysis and Treatment Planning
The primary objectives of this module are to identify the individualized factors that maintain substance use for a client, and to formulate a plan for addressing deficits in coping.  A functional analysis is conducted to identify both the specific triggers for substance use and the desired effects or consequences of use for each client.  This information determines the focus of the client’s treatment plan and the modules that will be utilized in therapy.

Skills Modules
The Skills Modules are treatment topics that can be selected and used as needed to meet the individual needs of the client.  The order of module use, duration of time spent completing a module, and the combination of modules used, is flexible and should be decided through discussion with the client and consideration of identified coping deficits.

Module 4: Urges
The primary objectives of this module are to heighten a client’s awareness of urge triggers, and to develop coping skills for handing urges.  The first part of module, Recognizing Triggers and Urges, is focused on helping the client describe the experience of an urge and identify the specific triggers that elicit their urges.  The second part of the module, Coping with Urges to Use, helps the client identify appropriate coping strategies that can be applied to the specific triggers that challenge their achievement and maintenance of abstinence.

Module 5: Social Pressure
The primary objectives of this module are to help the client identify sources of social pressure, and develop strategies for coping with this pressure to use substances.  The module is presented in two parts, each of which is intended to take one full session.  The first part of the module, Social Pressure Part 1, is focused on enhancing awareness of the types of social pressure (indirect and direct) that clients encounter, and on developing skills for handling indirect pressure.  The second part of the module, Social Pressure Part 2, is focused on developing skills and planning strategies for handling direct social pressure.  Role-playing exercises are used to facilitate client competence to effectively refuse offers to use substances.

Module 6: Social Support
The primary objective of this module is to help clients identify and engage people who can help them achieve and maintain abstinence.  The module emphasizes developing a broad range of social support, beyond the traditional support offered by participation in 

self-help groups.  Clients are also provided with guidance and feedback on how to ask for support, and obstacles to obtaining social support are considered.

Module 7: Social/Recreational Counseling
The primary objective of this module is to help clients engage in a wide range of activities that provide pleasure, relief, and reward in daily life.  The module is focused on helping clients understand the importance of leisure skills in the maintenance of abstinence.  Emphasis is placed on acquiring skills for finding pleasure and relief in the moment, as well as skills for building a rewarding daily lifestyle.

Module 8: Risky thinking and decision-making
The primary objective of this module are to help clients identify, and change, patterns of thinking and decision-making that are associated with  an increased risk for using substances.  This module is particularly helpful when a client’s risky thinking and decision-making hinder progress towards achieving abstinence.  In addition, risky thinking and decision-making can be a warning sign that a client might return to substance use, and so would warrant time spent with this module.

Module 9: Mood Management
The primary objectives of this module are to teach clients a model for understanding the multiple determinants of mood, and to help them develop skills for challenging the distorted thinking associated with intense negative moods.  This module focuses o helping clients recognize the multitude of factors, beyond just the immediate situation, the influence mood.  Skills for challenging distorted thinking are emphasized, and clients are encouraged to exercise better control of their moods by practicing new ways of thinking.

Module 10: Sobriety Sampling
The primary objectives of this module are to enhance client motivation to try a period of abstinence, and to develop a detailed plan to achieve this abstinence.  Clients are encouraged to consider the potential advantages of a period of sobriety.  The module may be used with clients who report a non-abstinence goal as well as with those who need assistance initiating abstinence.

Module 11: Return to Substance Use
The primary objective of this module is to help clients recover from an episode of substance use when this is inconsistent with their stated goal.  The module is focused on understanding why clients return to using substances, and strategies for helping them limit the duration and severity of an episode.  The module can be used to address shifts in motivation, problems in coping, or cognitive-affective reactions to violating a commitment to abstinence.

Module 12: Referral for Medication
The primary objective of this module is to educate clients about the options for medication to treat substance use disorders.  This module is focused on understanding the client’s beliefs about medication for addiction and resolving any misperceptions or faulty 
information.  Clients are encouraged to make their own decisions about whether to seek a referral for a medication evaluation.  The therapist’s role is providing education and facilitating a referral as needed.

Module 13: Case Management
The primary objectives of this module are to identify, and ameliorate, deficits in psychosocial functioning the interfere with the ability of clients to achieve and maintain their desired changes in substance use.  The module is focused on assessing life problems (e.g., medical, psychiatric, legal, financial, vocational, family, and social) that may interfere with clients’ efforts to change their substance use, and developing a referral plan for resolving some of these problems.  Clients and therapists work together to prioritize needs that can be reasonably addressed within the context of treatment for substance use disorders.  The module can be used as a routine portion of the planned intervention or it can be used as needed to manage immediate crises that emerge during the course of treatment.

Module 14: Termination
The objectives of this module are to conduct a review of the positive changes clients have made over the course of treatment, and to ensure adequate follow-up plans are in place at the time of termination.  The module is focused on reviewing changes in substance use, but emphasis is also placed on other life changes.

Treatment structure and length
This manual has been developed for use in the Massachusetts Screening, Brief Intervention, Referral, and Treatment (MASBIRT) Project.  Clients enrolling in the MASBIRT brief treatment may receive six or twelve therapy sessions.  Given the number of treatment modules and the potential for using more than a single session to cove one topic area, treatment should be structured based upon the identified areas of skill deficits.  Clients should be aware of the time limitations within treatment and should be allowed the opportunity to adjust priorities in treatment planning if needed.  Structuring treatment to concentrate on specific skill areas critical to advancing client change is encouraged.  Concentrating time in a single module for the majority of treatment, however, may prevent clients from acquiring a broad base of skills that may be needed.

Readings to supplement this treatment manual
Therapists using CAT must have a good understanding of the principles of Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI).  Understanding these principles will enhance effective delivery of this treatment.  Therapists are encouraged to consult the following resources as supplements to this treatment manual:

Carroll, K.M. (1998) A Cognitive-Behavioral Approach: Treating Cocaine Addiction.  NIDA Therapy Manuals for Drug Abuse: Manual 1.  NIH Publication Number 98-4308. pp.

	Cognitive Behavioral Therapy: An Overview (pp. 1-12)
	Basic Principles of CBT (13-24)
Miller, W.R. (Ed.) (1999). Enhancing motivation for change in substance abuse treatment.  Treatment Improvement Protocol (TIP) Series, No. 35, Rockville, MD: Center for Substance Abuse Treatment.
	
	Conceptualizing Motivation And Change (pp. 1-22)
	Motivation and Intervention (pp. 23-38)
	Motivational Interviewing as a Counseling Style (pp.39-56)

References

Carroll, K.M. (1998) A Cognitive-Behavioral Approach: Treating Cocaine Addiction.  NIDA Therapy Manuals for Drug Abuse: Manual 1.  NIH Publication Number 98-4308. pp.

Miller, W.R. (Ed.) (2004).  Combined Behavioral Intervention Manual: A clinical research guide for therapists treating people with alcohol abuse and dependence.  COMBINE Monograph Series, (Vol.1).  Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.  DHHS No. 04-5288.

Author Correspondence
For more information about this treatment manual please contact the primary author:

Eric Devine, Ph.D.
Assistant Professor, Boston University School of Medicine
Doctor’s Office Building, Suite 1150
720 Harrison Ave
Boston, MA 02118-2391