Dr. Kathleen Carroll

Drug addiction is notoriously tough to treat, but now research is showing a fresh way to tackle the problem. It’s called computer-based training for cognitive-behavioral therapy (CBT4CBT), an innovative program developed by Yale University School of Medicine’s Dr. Kathleen Carroll and her colleagues. She recently visited NIH to discuss her research with a full house at Executive Plaza’s Neuroscience Bldg. Her talk was part of OBSSR’s Behavioral and Social Sciences Research Lecture Series.

“When I began [my research, funded by NIDA],” Carroll said, “it wasn’t clear which therapies were effective or how they worked.

We had to get very serious if it was going to be taken seriously in some of the same ways as pharmacotherapy.”

Cognitive-behavioral therapy (CBT) is a kind of “talk therapy” that focuses on patterns of thinking, the beliefs that underlie them and how they influence behavior and emotions. It tends to be goal-directed rather than open-ended.

“The building blocks of CBT are beautifully generalizable,” Carroll explained. “First, we work with basic issues such as coping with craving, skills for refusing offers of drugs, thoughts about drug use in ways that can be useful with managing powerful emotions, acting effectively and assertively and solving problems.” The point is to modify attitudes and increase ability to handle stressors, as in the triggers for substance use.

So she had an idea: Why not deliver CBT by computers?

The stakes are huge. According to NIDA, in 2006, 21.2 million people (8.6 percent of the population age 12 and older) needed treatment for an illicit drug or alcohol use problem but did not receive it. Even after long periods of abstinence, addictive relapses can occur at rates similar to other chronic diseases like diabetes, hypertension and asthma. The cost of illicit drug abuse is $181 billion per year.

That’s the cost to society. The human cost—to addicted individuals themselves, families and friends—is incalculable.

Carroll and her team designed a clinical trial in which 77 individuals seeking outpatient treatment for substance dependence were randomly assigned to standard treatment (“therapy as usual,” as in a group setting) or standard treatment with biweekly access to the CBT4CBT computer program.

“Access” here means a computer-based, interactive program that her team designed, said Carroll, playing a module to illustrate. Some features:

• Interactive videos show characters (portrayed by professional actors) openly struggling with real-life situations. The user can play a clip, and then stop it at will. Narrators appear, addressing the user, who can replay the story and/or change the ending, depending on choices the user makes.
• The program has seven modules, 1 hour each.
• It’s user-friendly and doesn’t require any experience with computers, with very little text.
• There are many interactive exercises and quizzes.

“[Our program] is distinguished by its staying power and its greater durability,” said Carroll. “We’re really teaching people skills and strategies they seem to be able to use.”

There’s also homework, or practice exercises, Carroll said. “Homework correlates with skill acquisition and with drug use outcomes. At the end of therapy, the quality of response increases; it also increases the resourceful variety of alternative coping behaviors. It’s a nice clear relationship.”

Not only did it teach valuable coping skills, said Carroll, “The patients loved it. We got a high satisfaction rating.

“It’s only 77 people and we need to replicate the study and refine the program,” she continued, “but if this were a medication it would be good news.”

Indeed it is good news: those assigned to the CBT4CBT program showed significantly more negative (“clean”) urine specimens and, on follow- up, stayed abstinent longer than those who received standard treatment.

“It’s a sleeper effect,” said Carroll. At 6-month follow-up, CBT individuals continued to improve, while the “therapy-as-usual” cohort was edging back to pre-treatment levels.

And since it’s cost-effective, the computer-based program may provide an important means of making such therapy more broadly available.

Although cognitive therapy makes good scientific and economic sense, in the real world it’s rarely implemented because of therapy trends and staffing constraints in community settings. In addition, only a small fraction of addicts seek therapy. That’s where computers come in.

“Computers with multimedia can show skills,” Carroll stressed. “It’s not just clinicians explaining concepts in an abstract way.” Anyway, busy clinicians, especially in group therapy settings, may lack time to give much individual attention.

NIDA already uses an HIV risk-reduction CBT program. Using the same methodology, across different studies, the CBT program has enormous possibilities: “Broadening the base,” Carroll stressed, “is where I’m hoping we can really have an effect. We can actually deliver CBT via the web, and begin to have impact on prevention.

“[Our program] is distinguished by its staying power and its greater durability,” said Carroll. “We’re really teaching people skills and strategies they seem to be able to use.”