How do we know if psychological treatments are effective?
To answer the question “Is cognitive-behavioral therapy effective as a standalone treatment for substance use disorder?”, we must first answer the following: “How do we delineate effectiveness from non-effectiveness in evaluating psychological treatments?” In other words, how do we know if a given psychosocial treatment is effective for a given mental disorder? Luckily, Division 12 of the American Psychological Association (APA) has an answer for us! Enter: the APA’s “Tolin Criteria.”
Given the inherent harms of providing treatments that have weak efficacy, don’t work, or, even worse, are iatrogenic, the Society of Clinical Psychology (Division 12 of the APA) has long been evaluating the empirical basis of psychological treatments. Through this effort, Division 12 has played a key role in disseminating empirically-supported treatments for psychological disorders. In 2015, Division 12 revised and updated its criteria for evaluating the efficacy of psychological treatments by adopting what has since been referred to as the “Tolin Criteria.” The most notable update to the Tolin criteria includes establishing efficacy based on various meta-analyses, which statistically combine the results of multiple scientific studies rather than individual studies alone. This update to criteria allows for a more comprehensive and rigorous evaluation of the existing evidence for a given treatment’s efficacy (for more information on what makes the Tolin Criteria unique, see Tolin et al. [2015]).
Why is it important to identify effective treatments for substance use disorder?
When it comes to substance use disorder (SUD), effective treatments that can reduce substance-related harms are imperative. Not only is heavy and prolonged substance use associated with harmful physical and mental health consequences, but it can also impact all aspects of one’s life, including social, employment, and recreational functioning. As such, it’s essential to examine the empirical bases of psychosocial treatments to improve the overall quality of life for individuals and communities and ensure that those experiencing challenges with substance use receive the most effective treatments possible.
Cognitive Behavioral Therapy (CT) for SUD (sometimes referred to as Relapse Prevention or Coping Skills Training) is one of the most well-supported and commonly practiced treatments for SUDs in the United States and abroad. CBT is a psychosocial treatment used to treat a variety of mental disorders. CBT specifically targets cognitive, behavioral, affective, and environmental risks of substance use when used in the treatment of SUD. CBT aims to provide individuals with the skills to reduce, moderate, or abstain from substance use, depending on the goal of the individual seeking treatment.
Presently, CBT has only been established as an empirically-supported treatment for SUD by Division 12 when used in conjunction with Motivational Enhancement Therapy. There have been no evaluations of CBT as an effective standalone treatment for SUD, nor an evaluation of CBT as an effect standalone treatment for SUD per the Tolin Criteria – until now!
In the present study, we sought to review the existing literature on CBT for the treatment of SUD and apply Division 12’s Tolin Criteria to examine the efficacy of CBT as a standalone treatment. After an initial review of 44 potential meta-analyses, five met criteria for evaluation. After extracting, coding, and rating the quality of each of the eligible meta-analyses, we examined the effectiveness of CBT compared to minimal treatment (e.g., waitlist, psychoeducation), specific (e.g., Motivational Interviewing, Contingency Management) and non-specific-treatments (e.g., treatment as usual, drug counseling), and for its overall efficacy concerning substance use outcomes, such as frequency and quantity of use. Additionally, we examined the effectiveness of CBT immediately following treatment, at early follow-up, and late follow-up.
What does the current state of the literature say about CBT as a standalone treatment for SUD per the Tolin Criteria?
First, we must note that only one meta-analysis of the five we reviewed was of sufficient quality to be deemed as having “moderate” rigor per the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR2), which helps in the evaluation of critical (e.g., using a comprehensive literature search strategy) and non-critical (e.eg., performing study selection and data extraction in duplicate) weaknesses of systematic reviews. The other four meta-analyses that met the criteria for evaluation were deemed as having “Low” or “Critically Low” rigor per the AMSTAR2. Thus, only one meta-analysis was used to estimate the main effect size, but all meta-analyses were used for supplementary analyses.
Overall, the present review found strong support for CBT as a treatment for SUD. We found that CBT is moderately more effective than minimal treatment (e.g., waitlist, psychoeducation) and non-specific treatments (e.g., treatment as usual, drug counseling) in impacting substance use outcomes but equivalent when compared to other specific treatments (e.g., Motivational Interviewing, Contingency Management). Additionally, we found that CBT was most effective at follow-up assessments shortly after treatment (especially when compared to inactive or minimal treatment), with diminishing treatment effects found over time. Furthermore, we found some evidence that CBT improves psychosocial and functional outcomes beyond improvements in substance use – though this finding comes from an outdated and “critically low” quality review per the AMSTAR2.
Taken together, the current status of the literate merits a “strong” recommendation of CBT as a treatment for SUD per the Tolin Criteria. Given APA Division 12 has yet to examine CBT as a standalone treatment for SUD, this review provides a much-needed evaluation of its efficacy and may help encourage further dissemination of and training in CBT.
Finally, evaluating treatment efficacy via the Tolin Criteria is intended to be an iterative process in which treatments are continually re-examined as the literature grows. As such, future research must examine the efficacy of CBT for SUD among historically marginalized communities, and among racially and ethnically diverse people. Likewise, future research should explore how CBT may be culturally tailored to serve diverse communities and how technology-delivered CBT can be leveraged to reach a greater number of patients.
Target Article
Boness, C. L., Votaw, V., Schwebel, F. J., Moniz-Lewis, D. I., McHugh, R. K., & Witkiewitz, K. (2022). An Evaluation of Cognitive Behavioral Therapy for Substance Use: An Application of Tolin’s Criteria for Empirically Supported Treatments.
Discussion Questions
- What are your thoughts about updates to the Tolin Criteria? Do you think these updates provide a more comprehensive and rigorous set of criteria to evaluate psychosocial treatments compared to the previous Chambless Criteria?
- In the present evaluation, we focused on substance use quantity and frequency outcomes in evaluating CBT for SUD. What other outcomes should be evaluated to further support the efficacy of CBT for SUD?
- How can the active ingredients and mechanisms of change within CBT inform cultural adaptations for the treatment of SUD?
- How might the formal designation of CBT for SUD as an empirically supported treatment inform research on and the dissemination and implementation of CBT for SUD?
About the Authors
David “Ikela” Moniz-Lewis is a Clinical Psychology Ph.D. graduate student at the University of New Mexico. His research and clinical interests include mindfulness-based treatments for substance use disorders, particularly among historically marginalized and underserved populations, as well as delineating and applying idiographic mechanisms that lead to person-centered recovery. For more information on his work, please visit: https://abqresearch.org/ikela-lewis/
Victoria (Tori) R. Votaw is a NIAAA F31 predoctoral fellow and Clinical Psychology Ph.D. candidate at the University of New Mexico. Tori’s research interests include precision medicine for substance use disorders, and her clinical interests are in cognitive-behavioral and third-wave treatments for substance use and emotional disorders. For more information on her work, please visit: https://abqresearch.org/tori-votaw/
Cassandra (Cassie) L. Boness is a licensed clinical psychologist and Research Assistant Professor at the University of New Mexico Center on Alcohol, Substance use, And Addictions. Dr. Boness is interested in the factors that cause and maintain addiction as well as ways to improve measuring those mechanisms with research-based tools. For more information on her work, please visit: www.bal.unm.edu
References Cited
Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317.