Cognitive-Behavioural Integrated Treatment (C-BIT): A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems


This treatment manual assists clinicians with clients who have co-existing severe mental health and substance abuse problems, may not be motivated to tackle their drug/alcohol problems, and are poorly engaged with treatment services. It provides a framework that is structured but flexible, in which the interrelationship of mental health and drug and alcohol abuse problems can be tackled.

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This treatment manual assists clinicians with clients who have co-existing severe mental health and substance abuse problems, may not be motivated to tackle their drug/alcohol problems, and are poorly engaged with treatment services. It provides a framework that is structured but flexible, in which the interrelationship of mental health and drug and alcohol abuse problems can be tackled.

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Editorial Reviews

From the Publisher
“…an outstanding integrated treatment manual that is current, empirically supported and attractive to therapists and their clients…” (Addiction, June 2004)

“…extremely well written and presented…” (Mental Health Nursing, July 04)

“...The two most striking characteristics of this excellent book are its authenticity and its usefulness...”  (Clinical Psychology, No.45, January 2005) 

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Product Details

  • ISBN-13: 9780470854389
  • Publisher: Wiley
  • Publication date: 12/22/2003
  • Edition number: 1
  • Pages: 318
  • Product dimensions: 6.69 (w) x 9.59 (h) x 0.67 (d)

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Cognitive-Behavioural Integrated Treatment (C-BIT)

A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems
By Hermine L. Graham

John Wiley & Sons

ISBN: 0-470-85438-3

Chapter One



Although there has been an increasing awareness of problem substance use in clients with severe mental health problems (that is, "dual diagnosis"), it continues to be underrecognised in the psychiatric population. Even when treatment providers correctly identify substance misuse, the treatment response has often been inappropriate and ineffective. The result of inadequate assessment and ineffective treatment of these clients is a poor course of illness, including more frequent relapses and rehospitalisations, the increased costs of care and containment being borne by families, clinicians, law enforcement, society and the individual.

Effective treatment of this client group and improvement of their long-term prognosis rests with clinicians and treatment providers working in collaboration with clients and their careers. Clinicians thus need to be familiar with current knowledge about alcohol and drug use in the psychiatric population.

Prevalence of Problem Substance Use

The Epidemiologic Catchment Area (ECA) study of over 20 000 people inthe USA found that 47 per cent of those with a diagnosis of schizophrenia and 60.7 per cent of those with bipolar disorder had substance use problems in their lifetime compared with 16.7 per cent in the general population (Reiger et al., 1990) found lifetime prevalence rates of alcohol use disorder of 43 per cent among clients with a diagnosis of schizophrenia, and higher rates for those with schizoaffective disorder (61 per cent), bipolar disorder (52 per cent) and major depression (48 per cent). Studies in treatment settings in the UK have tended to look at 1-year prevalence rates. For example, Graham et al. (2001) found that 24 per cent of clients with a severe mental health diagnosis were identified by their keyworkers as having used substances problematically in the past year. Menezes et al. (1996) identified a 1-year prevalence rate of 36.3 per cent among clients with a functional psychosis. Studies in the USA, have typically found recent rates of substance misuse in this population of 25-35 per cent.

Studies of the prevalence of substance use problems in people with severe mental health problems have shown significant variations. A number of contributory factors have been highlighted (Weiss, Mirin & Griffin, 1992; Warner et al., 1994). These include variations in the method used to assess substance use, the time period used (for example, problematic use in the past year versus problematic use over the course of the lifetime), diagnostic criteria for mental health and substance use problems, and the setting where substance use is assessed. Nonetheless, the studies all point to higher rates of problematic use of alcohol and drugs (abuse and dependent use) among those with mental health problems than the general population.

Types of Substances Used

The substances typically misused by people with severe mental health problems include alcohol, cannabis and stimulants (cocaine/crack and amphetamine). The question of whether people diagnosed with certain mental health problems are more prone to misusing particular types of substances has been the topic of much debate. Early reviews suggested that people with schizophrenia were more likely to use stimulants problematically than clients with other mental health problems (e.g., Schneier & Siris, 1987). However, more recent and larger studies of the prevalence of specific types of substance misuse in clients with a variety of severe mental health problems, including the ECA and the National Comorbidity Survey (NCS) (Kessler et al., 1996), have failed to replicate this finding (Kessler et al., 1996; Regier et al., 1990). The evidence suggests availability is the primary determinant of which specific substances are misused (Mueser et al., 1992), as opposed to the subjective effects. It is important not to overlook the fact that a very high proportion of clients with severe mental health problems smoke tobacco (de Leon et al., 1995; Hall et al., 1995; Hughes et al., 1986; Postma & Kumari, 2002). Due to the limited information currently available about the use of tobacco in this population or its interaction with mental health problems, tobacco use will not be addressed in this manual.

Demographic and Clinical Correlates of Substance Use Problems

Understanding which clients with severe mental health problems are most likely to have problems with alcohol/drugs can facilitate the early recognition and treatment of these clients. A number of reviews of the demographic, clinical and historical factors associated with this client group have been carried out (e.g., Dixon, Goldman & Hirad, 1999; Drake & Brunette, 1998; Mueser et al., 1995). A number of demographic characteristics are correlated with substance misuse. In the main, the same characteristics that are related to problem substance use in the general population are also related to problem substance use in people with severe mental health problems. These include being male, young and single, and having lower levels of education. The clinical correlates include poor engagement and adherence with treatment. Additional correlates related to the personal history of individuals that have been identified include initial better pre-morbid social functioning, antisocial personality disorder (ASPD), family history of substance use problems, trauma and post-traumatic stress disorder.

The Impact of Substance Use Problems on Severe Mental Health Problems

It has been suggested that people with severe mental health problems who use substances problematically often experience greater adverse social, health, economic and psychological consequences than those who do not. These consequences are said to be exacerbated by the problematic use of substances (Drake & Brunette, 1998; Mueser et al., 1998a). Problematic substance use can lead to an increased risk of relapse and rehospitalisations (Hunt, Bergen & Bashir, 2002; Linszen et al., 1996; Swofford et al., 1996). The strongest evidence linking symptom severity and substance use is the effect of alcohol on worsening depression. The risk of suicide is significantly increased in persons with a primary substance use problem (Meyer, Babor & Hesselbrock, 1988), as well as in individuals with schizophrenia, bipolar disorder and major depression (Drake et al., 1985; Roy, 1986). This risk is compounded in persons who have severe mental health problems and use substances problematically (Bartels, Drake & McHugo, 1992; Torrey, Drake & Bartels, 1996).

Substance use problems among this population are associated with increased "burden" on family members, as well as interpersonal conflicts with relatives and friends (Dixon, McNary & Lehman, 1995; Kashner et al., 1991; Salyers & Mueser, 2001). Financial problems often accompany chronic substance use, as clients spend their money on drugs and alcohol rather than essentials such as food, clothing and rent. In addition, substances or craving for substances can contribute to disinhibitory effects that result in aggression and violence toward family, friends, treatment providers and strangers (Steadman et al., 1998; Swartz et al., 1998; Yesavage & Zarcone, 1983). The combined effect of problematic substance use on family burden, interpersonal conflict, financial problems, and aggression and violence often renders these clients highly vulnerable to housing instability, homelessness and exploitation (Drake, Wallach & Hoffman, 1989; Pickett-Schenk, Banghart & Cook, 2003). Furthermore, problematic substance use can result in illegal behaviours (such as possession of illegal drugs, disorderly conduct secondary to alcohol/drug use, or theft or assault resulting from efforts to obtain drugs), leading to high rates of incarceration (Mueser et al., 2001). In addition to the clinical, social and legal consequences of problem substance use, severe health consequences are also common. Substance misuse may contribute to risky behaviours, such as unprotected sex and sharing needles, that are associated with HIV and hepatitis infection (Cournos et al., 1991; Razzano, 2003; Rosenberg et al., 2001a,b).


As we have previously mentioned, people with severe mental health problems are at much greater risk of developing problems with alcohol/drugs than people in the general population. What accounts for the higher rates? Understanding the factors that contribute to the high rate of comorbidity may provide clues useful in the treatment of this client group.

Kushner and Mueser (1993) have described four general models that might account for the high rate of comorbidity between substance use and severe mental heath problems. These models include the common factor model, the secondary substance abuse model, the secondary psychopathology model and the bidirectional model. These models are summarised in Figure 1.1. For a more in-depth review, see Mueser, Drake and Wallach (1998), and Phillips and Johnson (2001). For disorder-specific reviews, see Blanchard et al. (2000) on schizophrenia, Kushner, Abrams and Borchardt (2000) on anxiety disorders, Strakowski et al. (2000) on bipolar disorder, Swendsen and Merikangas (2000) on depression and Trull et al. (2000) on borderline personality disorder.

Common factor models propose that one or more factors independently increase the risk of both mental health and substance use problems. That is, there are shared vulnerabilities to both disorders. Three potential common factors have been the focus of some research-familial (genetic) factors, ASPD and common neurobiological dysfunction-although many other factors are possible. If genetic factors, ASPD or some other factor was found independently to increase the risk of both mental health and substance use problems, this would support the common factor model.

Secondary substance abuse models posit that high rates of comorbidity are the consequence of primary mental health problems leading to substance use problems. Within this general model, three different models have been suggested: psychosocial risk factor models (that is, clients use substances to "feel better"; this includes the self-medication, the alleviation of dysphoria and the multiple risk factor models), the supersensitivity model (that is, psychological vulnerability to mental health problems results in sensitivity to small amounts of alcohol and drugs, leading to substance use problems) and iatrogenic vulnerability to substance abuse.

The secondary psychopathology model of comorbidity is the exact opposite of secondary substance abuse models. Secondary psychopathology models posit that substance use problems lead to or trigger a long-term psychiatric disturbance that would not otherwise have developed.

The bidirectional models propose that severe mental health and substance use problems interact to trigger and maintain each other. For example, substance use problems trigger severe mental health problems in a vulnerable individual. The severe mental health problems are then subsequently maintained by continued substance use due to socially learned cognitive factors such as beliefs, expectancies and motives for substance use (Mueser, Drake & Wallach, 1998).

The available research evidence suggests that there are many possible explanations for why clients with severe mental health problems are so vulnerable to substance use problems. No single model can explain this, and it is likely that multiple models contribute to the coexistence of these two problems, both within and across clients. Thus, in summary, different theories have been proposed to address the high rates of coexistence of severe mental health and substance use problems. Two models have the greatest empirical support: the supersensitivity model (that is, biological vulnerability to mental health problems lowers the threshold for experiencing negative consequences from relatively small quantities of substances) and the ASPD common factor model (that is, ASPD independently increases the risk of developing a severe mental health problem and a substance use problem). However, it is important to note that common social and personal factors (for example, socio-economic factors and deprivation) may also increase the likelihood of ASPD, thereby, in turn, increasing the likelihood of the development of coexisting mental health and substance use problems. The self-medication model (that is, high comorbidity is due to clients' attempts to treat their own symptoms with substances) does not appear to explain the high rate of substance misuse in clients with severe mental health problems, although there does appear to be an association between dysphoria and increased rates of substance use problems.


When clinicians attempt to engage and offer treatment to clients with severe mental health problems who use alcohol/drugs problematically, they often encounter a number of obstacles to change. Some of these may be due to motivation, cognitive deficits and social factors that are directly related to experiencing severe mental health problems (Bellack & Gearon, 1998; Drake et al., 2001). In working with this population, it is important to take these factors into consideration.


People in the general population who use substances problematically often experience fluctuating motivation to change. However, among those with severe mental health problems, motivation is often confounded by a number of additional factors. These include low self-efficacy, primary negative symptoms of severe mental health problems, such as loss of motivation, energy and drive, apathy and difficulty in experiencing interest or pleasure, and secondary negative symptoms, such as depression and the side effects of medication. Such factors serve generally to reduce motivation among people with severe mental health problems; however, the presence of substance use problems often exacerbates this. Clients may minimise problems related to substance use and focus solely on the perceived positive benefits associated with using substances in the absence of other positive, powerful reinforcers. Thus, motivation often waxes and wanes.


Cognitive functioning is important in making and sustaining changes in behaviour, particularly substance use. People with severe mental health problems, notably schizophrenia, experience significant cognitive impairment (Bellack & Gearon, 1998), some of which may be due in part to the side effects of medication.


Excerpted from Cognitive-Behavioural Integrated Treatment (C-BIT) by Hermine L. Graham Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

About the Authors.

Aims of the Book.



1. Issues in Working with those with Coexisting Severe Mental Health Problems Who Use Substances Problematically.

The Nature of Coexisting Severe Mental Health and Alcohol/Drug Problems.

Models of Comorbidity.

Obstacles to Treatment and Behaviour Change.

Treatment Needs.

2. Overview of C-BIT Approach.



How to Know When to Move on to the Next Phase.

Treatment Sessions.

3. Overview of C-BIT Theory and Techniques.

Brief Introduction to Cognitive Therapy.

Cognitive Therapy Techniques in C-BIT.



4. Assessment Phase: Screening and Assessment.

Clinical Assessment of Drug/Alcohol Use.

Assessment and Screening Tools.

Case Formulation.

Treatment Planning.

5. Treatment Phase 1: Engagement and Building Motivation to Change.

Strategies to Increase Engagement.

How to Put Drug/Alcohol Use on the Agenda.

Building on Motivation for Change.

Dealing with Resistance.

Identifying Social Networks Supportive of Change.

Finances/Money Management.

6. Treatment Phase 2: Negotiating Some Behaviour Change.

Identifying and Setting Achievable Harm-Reduction Goals.

Working with Resistance to Goal Setting.

Identifying Activities of Interest.

Engaging the Client’s Interest in the Activity.

How to Build Social Networks Supportive of Change.

Strategies to Increase Awareness of Problematic Links Between Mental Health and Substance Use.

7. Treatment Phase 3: Early Relapse Prevention.

Formulating Problems: Cognitive Model of Substance Use.

Relapse Prevention: Helping Your Clients Manage Their Substance Use.

Relapse Prevention: Including Social Network Member(s).

Coping with Cravings and the Abstinence-Violation Effect.

Relapse Prevention: For Substance Use and Its Links with Mental Health.

8. Treatment Phase 4: Relapse Prevention/Relapse Management.

Including Social Network Member(s) in Relapse Prevention.

Identifying a Relapse Signature to Psychotic Relapses and Role of Substance Use.

Developing a Comprehensive Relapse-Prevention/Relapse-Management Plan.

Using a Comprehensive Relapse-Prevention/Management Plan—Relapse Drill.


9. Coping with Different Moods: Anxiety.

The Role of Substances in Creating or Maintaining Anxiety.

Starting Out: Assessing Anxiety.

Strategies to Manage Anxiety.

10. Coping with Different Moods: Anger and Impulse Control.

The Role of Drugs/Alcohol in Creating/Maintaining Anger.

The Role of Psychosis in Creating/Maintaining Anger.

Starting Out: Assessing Anger.

Strategies to Manage Anger.

Impulse Control.

11. Coping with Different Moods: Depression.

The Role of Drugs/Alcohol in Creating and Maintaining Depression.

The Role of Psychosis in Creating/Maintaining Depression.

Starting Out: Assessing Depression.

Strategies to Manage Depression.

12. Communication: Social Skills.

Social Skills.

Social Skills Training for Mental Health Problems and Substance Use.

Social Skills Training.

Applying Social Skills to Specific Situations.


Assertiveness Training.

Strategies to Tackle Lack of Assertiveness.

Applying Assertiveness Skills to Specific Situations.

13. Self-Esteem.

Effect of Low Self-Esteem on Mental Health and Drug/Alcohol Use.

Effects of Psychosis and Drugs/Alcohol on Self-Esteem.

Starting Out: Assessing Self-Esteem.

Strategies to Improve Self-Esteem.

14. Lifestyle Balance.

Strategies to Encourage Lifestyle Balance.

Increasing Activity Levels.

Time Management.

Money Management.


15. Working with Families and Social Network Members.

Provision of Psychoeducation.

Encouraging Involvement.

Practical Coping Strategies and Skills.


16. Implementation Issues.


Implementation Obstacles and Solutions.

Training and Supervision (Capacity Building).

Organisational Factors.

Overview of the Evidence Base and Future Directions for Research.




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