COGNITIVE-BEHAVIOUR
COGNITIVE-BEHAVIOURTHERAPY AND PROBLEM DRINKING:A META-ANALYSISAndrew G . MatthewA thesis submitted in conformity with the requirementsfor the degree of Master of ArtsDepartment of Human Development and Applied PsychologyOntario Institute for Studies in Education of theUniversity of TorontoCopyright by Andrew G . Matthew 1997
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Acknowledgments1am deeply grateful to Dr.Barry H.Schneider for hisguidance and encouragement in the preparation of this manuscript.I am also grateful to Dr. Anthony Toneatto for his support andhelpful advice.Further, 1 wish to thank John G. Matthew for histhoughtful assistance in editing this manuscript.Finally, 1 would like to thank my family and friends for theirunending support and reassurance throughout the process of writingthis manuscript.
Cognitive-Behaviour Therapy and Problem Drinking:A Meta-analysisMaster of Arts, 1997.Andrew Glenday MatthewGraduate Department of Human Development and Applied PsychologyOntario Institute for Studies in Educationof the University of TorontoAbstractCognitive-behavioural theories have been proposed ta explainwhy, where, and how much people drink, and why most remain socialdrinkers while others experience problem drinking.Cognitive-behavioural treatment strategies focus on the cognitively mediatedvariablesbelievedtobeinvolvedmaintenance of problem drinking.inthedevelopmentandThe aim of this quantitativereview is to determine the overall effectiveness of CognitiveBehavioural Therapy (CBT) in the treatment of problem drinkingaccording to the literature to date.An English-language computerised literature search was used tolocate studies (n 12) reporting the results of controlled trials.The results from the original studies were statistically pooled toestablish the overall effect of CBT in the treatment of problemdrinking.CBT was found to be effective in reducing the alcoholintake of problem drinkers, atleast in the short term(meanwithin-group ef fect size - 5 0 ) , but there is little evidence tosuggest that it is superior to other forms of treatment.Specif icrecommendations are made with respect ta design methodology infuture research.
Table Of Contents.Abstract.List of Tables . . . . . . . . . . . . . . . . . . . . . .ListofFigures . . . . . . . . . . . . . . . . . . . . ral Models AndStrategies Of Problem Drinking.Efficacy of Cognitive-Behaviour Therapy.Meta-analysis . . . . . . . . . . . . . . . . . .II . Method . . . . . . . . . . . . . . . . . . . . . . .In The Treatment of Problem Drinking.Inclusion Criteria .Rationale . . .Data Extraction . . .Conventions Adopted .Methodological Quality . . . . . . . . . . . . .Statistical Analysis m . . . . . . . . . . . . .III . Results . . . . . . . . . . . . . . . . . . . . . . .Literature Search . . . . . . . . . . . . . . . .Study Characteristics . . . . . . . . . . . . . .Overall Effect Sizes . . . . . . . . . . . . . .Outlier Effect . . . . . . . . . . . . . . . . .Overall Effects . . . . . . . . . . . . . . . . .Literature Search.
Treatment Dropout.Different Methods Of Calculating Effect Size.From Non-Significant ResultsMethodological QualityRandom AssignmentIntegrity Control Of Treatment Delivered.Follow-Up IntervalIV .Discussion.ConclusionV.References.Appendix AMeSH Terms Employed In The ComputerisedSearch StrategiesAppendix 8.Authors Individually Searched InMedline and Psyclit. . . . . . . . . a . -.Descriptive Data Extracted FromAppendix D.Methodological Quality Scale . . . . . . . .Appendix E.References Of Studies That Did Not Meet TheAppendix CIndividual StudiesInitial Screening CriteriaAppendix F.References Of Studies That Did Not Meet TheFinal Inclusion Criteria.
List Of TablesTable1.Table2.Table3.Subject Characteristics . . . . . . * . . .Effect Sizes For Individual Studies . . . .Table4.Comparison Of Cognitive-Behaviour TherapyExperimental CharacteristicsWith Different Types Of Controls: WithinGroup Mean Effect Size At Follow-UpTable5.Comparison Of Cognitive-Behaviour TherapyWith Different Types Of Controls: BetweenGroup Mean Ef fect S i z e At Follow-UpTable6.Effect Sizes (At Follow-Up) ControllingFor Treatment DropoutTable7.Re-calculated Between-Group Effect Sizes(At Follow-Up) Including Different EstimatedEffects for Non-significant ResultsTable8.Effect Size (At Follow-UP) AndMethodological QualityTable9.10.Effect Sizes (At Follow-UP) ControllingFor Random AssignmentTable.Effect Sizes (At Follow-Up) ControllingFor Integrity Control Of Treatment.
List Of FiguresFigure1.Between-Group Mean Effect Sizes For ComparisonOf Cognitive-Behaviour Therapy With DifferentTypes of Controls Across Follow-Up Periods.52
Cognitive-Behaviour Therapy1Cognitive-Behaviour Therapy and Problem Drinking:A Meta-analysisIntroductionCognitive-Behavioural Therapy (CBT) is a form ofpsychotherapy that combines cognitive-based and behaviour-basedtechniques in an effort to effect behaviour change (Beck, 1970;Ellis, 1962; Meichenbaum, 1977).Unfortunately, this simpledefinition falls short of being useful in practical application.Many practitioners and theorists have had difficulty throughoutthe evolution of CBT in defining the scope of CBT using thissimple definition (Dobson&Block, 1988).The difficulty is notsurprising since, according to some sources, CBT blurs thedistinction between behaviour theory and cognitive theory(Grossberg, 1981; Phillips, 1981)- To distinguish CBT from otherfornis of therapy, the theoretical origins of the techniques mustbe understood.Proponents of classical behaviour therapy (BT) believe thatbehavioural theory explains and already incorporates intotreatment the basic tenets of cognitively-based theories(Phillips, 1981).The behaviourists' claim that cognition hasalways been an integral part of BT has been expressed as follows:.cognitionis unavoidable in behaviour therapy, as itis in any form of psychotherapy and indeed, in almostal1 kuman activities.Ifbehaviour therapists bavenot made a point of such things, it is because to do sois as redundant as to mention, when recording that a
Cognitive-Behaviour Therapy2patient received an intravenous injection, that asyringe was used.(Wolpe, 1978, p. 442-443) as citedin Grossberg 1981, p , 27.These cognitive behaviours, however, are not believed to befunctionally different from other behaviours, and thus, do notrequire different treatment (Phillips, 1981).As a consequence,proponents of BT describe cognitive-based theories and therapiesas "retrogressive, misleading and even anti-s ientific.' (seeSweet, 1991, p. 159).On the other hand, advocates of cognitive-based theoriesbelieve that their focus on the modification of maladaptivethoughts to bring about both cognitive and behaviour change usingverbally-based therapies distinguishes cognitively-basedtheories, including CBT, from the mainly nonverbal means of BT(Miller&Berman, 1983).It is this focus on the alteration offaulty cognitions through cognitive restructuring (CR) thatdistinguishes CBT as a psychological treatment (Rachman1980)&Wilson,.In a comparative review examining the degree of beneficialoutcornes associated with BT versus CBT, Sweet (1991) chose todefine CT and BT as separate entities, and combine the twodefinitions in an effort to define CBT.Referring to CT, Sweet(1991), states that:.theessential identifying factor was that putativecognitions, cognitive processes, core beliefs, selfstatements, attitudes, attributions, schema, etc,, were
Cognitive-Behaviour Therapy3being therapeutically addressed in a verbal fashion. Thecentral assumptions of cognitive therapy is that thepatients* wilful modification of these phenomena (viatherapist instruction and assistance) yields significantchanges in behavioural and physiological dependent variablesas well as the cognitive variable themselves.( p - 161),and continued by defining BT as:. .those procedures regularly andfrequently calledbehavioural in the literature.systematicdesensitization. applied relaxation, behaviouralrehearsal, stimulus control, guided and unguided exposure invivo, flooding.social skills training andassertivenesstraining, actively scheduling, self-monitoring, behaviouralhomework practice, response cost, contingent positivereinforcement, participant modelling, taken economies, timeout, covert conditioning and self-management strategies.(P. 161)Finally, the definition of CBT was simply stated by Sweet (1991),as CT combined with any one or more components of BT.In contrast, Miller (1983) states that defining CBT as acombination of cognitive and behavioural techniques istheoretically sound but practically inappropriate. He maintainsthat many V B T " treatments found in the research literature failt o report their behavioural components specifically.Hence,Miller (1983) proposed to define and identify CBT treatments asany form of treatment that includes the examination of
Cognitive-Behaviour Therapymaladaptive beliefs.In discussing Miller's4(1983) meta-analysis, Dush (1983), subsumed al1 cognitive-behaviouraltechniques reported in the overview under the label "cognitiverestructuringl'.Dush (1983), distinguishes self-statementmodification (SSM) from CR, and includes SSM in CBT's quiver oftreatment techniques.In a meta-analysis reviewing the efficacyof self-statement modification, Dush (1983) describes Ellis'rational-emotional therapy, Meichenbaumls self-instructionaltherapy and Beck's CT as forms of CBT, "each emphasiz(ing) theimportance of covert self-verbalizations and suggests that 'selftalkl or private monologues can influence performance of a widevariety of tasks.lm (p. 409).This 'self-talk' refers to adaptiveor maladaptive self statements which are believed t o bemodifiable.The common theoretical component apparent in each of theoperational definitions of CBT is the modification of maladaptivethoughts.This focus on maladaptive thoughts seems to be thecomponent that distinguishes CBT from BT according to many if notal1 attempts at definition.In this meta-analysis, we havedefined CBT as a therapy that involves the assessment of excessesin maladaptive thoughts or deficits in adaptive thoughts, and themodification of these self-statements by means of verbalconsultation with a therapist, either through restructuring ofthe cognitions (challenging, disputation, replacement, correctionof distortions) or through covert self-verbalization (rehearsal),combined with a BT treatment component such as systematic
Cognitive-Behaviour Therapy5desensitization, relaxation, rehearsal, stimulus control,exposure in vivo, flooding, social skills training,assertiveness training, scheduling, self-monitoring, behaviouralhomework practice, response cost, reinforcement, modelling, tokeneconomies, time-out, covert conditioning or self-managementstrategies.This definition and its focus on maladaptivethoughts reflects the core theoretical proposition of cognitivebased theories: that behaviour change is mediated by cognitiveprocesses.Counitive-Behavioural Models And Stratesies Of Problem DrinkinqCognitive-behavioural theories have been proposed to explainwhy people drink, where they drink, how much they drink and whymost remain social drinkers while some fa11 victim to alcoholabuse and dependence (Wilson, 1987a).Although, many sourcesdiscuss the etiology of problem drinking in terms of genetic andbiological factors, research evidence also supports the role ofcognitively mediated variables in the development and maintenanceof problem drinking (Wilson, 1987a).The cognitive-behavioural models most often cited in theliterature are the Tension-Reduction Theory and the ExpectationTheory (Nathan, 1985; Oei, Lim, & Young, 1991; Wilson, 1987a;Wilson, 1987b).These theories are not unrelated.The basict e n e t of the Tension Reduction Theory is that alcohol dependenceis initially motivated by the need to reduce tension or stress(Oei, Lim,&Young, 1991; Wilson, 1987a).It is widely believedby problem drinkers themselves that alcohol reduces tension and
Cognitive-Behaviour Therapy6that by consuming alcohol the tension and stress will bedecreased (Wilson, 1987b).However, studies over the pastfifteen years suggest that alcohol consumption does not alwaysresult inLim,&emotional or physiological tension reduction (Oei,Young, 1991; Wilson, 1987a; Wilson, 1987b).Thepharmacological effects of alcohol have a variable impact onanxiety state (Wilson, 1987a).The occasional tension-reducing effects of alcohol mayproduce reinforcement for drinking behaviour because the tensionreduction occurs on an intermittent schedule of reinforcement(Oei, Lim, & Young, 1991).Hence, problem drinking results fromthe learned expectation (Expectation Theory) that stress andtension reduction may ensue, rather than from the actualphysiological and affective effects of alcohol consumption.Peoples' expectations or beliefs regarding outcome are oftenbetter predictors of later behaviour than the actual consequencesof their behaviour (Wilson, 1987b).Under the Expectation-Theorymodel, the problem drinker has learned a contingencyrelationship, expecting alcohol to reduce his or herpsychological stress and physiological arousal (Oei, Lim,Young, 1991).&It is this tension-reduction expectation that isbelieved to be one of the major cognitive mediational componentsof alcohol consumption.The cognitive-behavioural treatment strategies used by thestudies examined in this review center upon cognitiverestructuring techniques (changing cognitive distortions)
Cognitive-Behaviour Therapycombined with various behavioural procedures. The7cognitivecomponents of treatment focus on issues of self-efficacy,attributions (interna1 versusexternal) and outcome expectations(Wilson, 1987a; Wilson, 1987b).The cognitive procedures includetechniques designed to increase patients' awareness of their ownautomatic thoughts (self-talk). They provide methods of alteringdistortions in an effort to replace them with more adaptivethoughts.The behavioural components are used to produce furthertherapeutic change (Wilson, 1987a; Wilson, 1987b).Theperformance procedures provide practice situations in which theproblem drinker can gain experience and increased believabilityin his or her new, more adaptive cognitive responses (Greenberger&Padesky, 1995).Over time, the problem drinkers are believedto gain more confidence in these beliefs allowing them to replacepreviously held maladaptive cognitions, resulting in healthierbehaviour.Efficacv Of CBT In The Treatment Of Problem DrinkinqOver the past two decades there has been a proliferation ofliterature on the efficacy of CBT in treatment generally (Miller&Berman, 1983; Dush, Hirt,&Schroeder, 1983; Sweet & Loizeaux,1991; Phillips, 1981; Ledwidge, 1978; Kendall & Hollon, 1979) andin the treatment of problem drinking (Emrick, 1975; Emrick, 1974;Costello, Biever, & Baillargeon, 1977; Bien, Miller, & Tonigan,1993; Saunders, 1989).These narrative and quantitative reviewsdo not, however, include an appreciable examination of theefficacy of CBT in the treatment of problem drinking, but focus
Cognitive-Behaviour Therapy8mainly on the treatment of depression and anxiety (Miller &Berman, 1983).The reviews on problem drinking examine theefficacy of other forms of therapy (Agosti, 1995), or comparisonsof b r i e f versus extended treatment (Bien, Miller, & Tonigan,1993).This lack of attention to problem drinking in CBTefficacy reviews is not surprising, because primary studiesevaluating the effectiveness of CBT in the treatment of problemdrinking have only entered the literature over the past 15 years.Recently, however, a feu reviews have been published thatdirectly or indirectly explore the CBT and problem drinkingresearch.Oei, Lim and Young (1991) reviewed 13 empirical studies ofCBT and substance abuse; 11 problem drinking studies and 2methadone maintenance studies.therapeutic approach.CBT was found to be an effectiveMoreover, in reviewing studies whichi n c l u d e d CR as a treatment component, Oei et al. (1991) concludedthat CR, in particular, was effective in the treatment of problemdrinking.The review was originally designed as a meta-analysis,and criteria for including CBT papers were developed followingcriteria listed in Dush, Hirt and Schroeder (1983), and Millerand Berman (1983).A literature search produced 13 studies thatfulfilled the requirements.The authors concluded, for nospecified reason, that the combined sample was insufficient toconduct a meta-analysis.Therefore, their review was aqualitative review of 13 studies.Furthemore, Oei et al. (1991)included Social Skills Training (SST) and Stress Management
Cognitive-Behaviour TherapyTraining(SMT)9under the scope of CBT treatments (defining SSTand SMT as forms of treatment that "focus" on patient'smaladaptive beliefs).Consequently, only 4 of the 11 problemdrinking studies reviewed utilized CR as a component of therapy.Hence, the overall finding that CBT is effective in the treatmentof problem drinking is based on 11 studies, 7 of which employeither SST or SMT as the only CBT treatment component, and thesecondary finding that CR is particularly beneficial is based ona qualitative review of a small sample of four studies.However,as detailed below, many more relevant studies have since beenconducted.In a recent publication, Miller, Brown, Simpson, Handmaker,Bien, Luckie, Montgomery, Hester and Tonnigan presented acomprehensive review of outcome literature relating to alcoholtreatment.The systematic search produced 211 studies whichreported outcomes relating to alcohol treatment.Thirtydifferent treatment modalities (each represented by 3 or morepapers) were compared.No distinction is made by the authorsbetween CT and CBT; they subsume both forms of the therapy underthe treatment modality CT.modality.Seven papers were grouped under thisMiller et al. (1995) found that l'Cognitive Therapy"ranked tenth (out of 30) when compared to other therapies in thetreatment of problem drinking, and conclude that this result isllencouraging'' (p. 24).Miller's extensive review is interesting and, at the veryleast, innovative.However, it is not a meta-analysis.The
Cognitive-Behaviour Therapy10basic methodology of the review follows a meta-analytic approach,but the final analysis or combining of outcomes does not observemeta-analytic procedures for statistical pooling principles.Thedrawback of the approach used by Miller et al. (1995) is thatalthough the treatment modalities are rank ordered, no data areprovided regarding the size of difference in efficacy among thetreatment modalit
Cognitive-Behaviour Therapy 1 Cognitive-Behaviour Therapy and Problem Drinking: A Meta-analysis Introduction Cognitive-Behavioural Therapy (CBT) is a form of psychotherapy that combines cognitive-based and behaviour-based techniques in an effort to effect behaviour change (Beck, 1970; El
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Health-seeking behaviour practice is recognised as an essential tool to prevent the menace of hypertension. The association among health and human behaviour is a major area of interest in public health. Kasl and Cobb 1966 identified three types of health behaviour: preventive health behaviour, illness behaviour, and sick-role behaviour.
The link between children‘s non-attendance and behaviour 78 Evidence from research 78. Playground behaviour – practical ideas 84 Playtime 84 Buddy schemes 85 . The more attention the teacher gives to a child‘s behaviour the more likely it is that that behaviour will be repeated. 8 Practical approaches to behaviour management in the .
Introduction. Mark Papworth. Learning objectives o understand the fundamental principles of cognitive behaviour therapy (CBT)T and low intensity cognitive behaviour therapy (LICBT). o know the historical context of the development of CBT and LICBT.T o be aware of systems of step
Cognitive Therapy, and Cognitive Behaviour Therapy as we know it today was born. In the years since Ellis and Beck developed REBT and Cognitive Therapy psychologists have made further refinements to the techniques, giving additional attention to t
The Allen Cognitive Level Screen (ACLS) can help you identify the Allen Cognitive Levels of clients with Alzheimer’s disease, dementia, and other cognitive disabilities. Also referred to as the leather lacing tool, this cognitive assessment tool measures global cognitive processing capaci
organisational behaviour concepts and philosophies that influence behaviour P4 Apply concepts and philosophies of organisational behaviour within an organisational context and a given business situation. M4 Explore and evaluate how concepts and philosophies of OB inform and influence behaviour in both a positive and negative way. in the work place.
English/Language Arts 4. Grade Level i. Ninth grade 5. Length of Class Time i. 90 minute class 6. Length of Time to Complete Unit Plan th i. The unit on Non-fiction began on March 8 and was competed on March th 30 . The class had instruction on the topic everyday of the week. Student population Contextual/Environmental Factors Source Implications for Instruction and Assessment Rural School .
