Increasing Substance Use and Mental Health Treatment Engagement Using a Cognitive Behavioral Intervention
Barriers to treatment engagement
There is a significant treatment gap for substance use disorders (SUD), with approximately 10% of individuals in need of treatment attending it.1 This gap is pronounced in rural communities due to a variety of barriers such as lack of knowledge about existing treatment, issues with access to and availability of treatment, and provider stigma.2 Among individuals with SUD, thoughts or beliefs about treatment can also serve as strong barriers to treatment engagement.3 Negative beliefs about SUD and mental health treatment can be common, including in rural communities. Additionally, shame or embarrassment may come from stigmatizing beliefs about SUD and its treatment.4
Addressing beliefs as a barrier to SUD treatment
This program seeks to overcome barriers to engagement (i.e., treatment initiation and retention) including lack of information or negative beliefs about treatment. It aims to equip rural providers to help their patients identify negative or stigmatizing beliefs and see treatment from a different perspective.
Cognitive-behavioral interventions have shown the most promising results in increasing treatment initiation and retention.5 Cognitive-Behavioral Therapy for Treatment Seeking (CBT-TS) is a one-session, 45-minute intervention delivered via telehealth. In the session, a provider works with an individual to identify thoughts that are serving as barriers to treatment and then helps them modify those thoughts through cognitive restructuring to increase the likelihood that they will seek treatment. CBT-TS has been tested across numerous randomized clinical trials and among various clinical populations and has demonstrated consistent results in increasing treatment initiation and retention and improving clinical outcomes. This intervention has been utilized for individuals with depression, post-traumatic stress disorder (PTSD), and alcohol use disorder and for individuals reporting suicidal thoughts. It has consistently been shown to increase treatment initiation and the number of sessions attended relative to providing education (e.g., basic information about treatment options).6
CBT-TS training and ongoing support
Dr. Lisham Ashrafioun at UR Medicine Recovery Center of Excellence has partnered with his collaborator Dr. Tracy Stecker at the Medical University of South Carolina, who developed CBT-TS. Dr. Stecker is leading provider training for CBT-TS. Supporting its feasibility for busy providers in rural communities, the training is one session lasting about an hour, and it can be completed in person, by phone, and/or by video call. This single session can help equip a provider to expand their role7 in enhancing treatment-seeking among their patients through relatively brief conversations. The training is suitable across settings (e.g., primary care, mental health clinic, SUD clinic) and health care disciplines, including nurses, social workers, psychologists, physician assistants, physicians, pharmacists, as well as trainees and others.
Understanding the important role that peers can play in recovery as well as the already heavy caseload of many SUD and mental health treatment providers, the center can also provide peer training. This training is typically more intensive and involves instruction on: (1) conveying empathy, effective listening, and observation skills, (2) addressing logistical issues, and (3) delivering the treatment content and using CBT skills needed for the intervention.
In addition to training, we provide ongoing consultation to answer questions about the intervention, address related questions and concerns, and help providers navigate difficult cases.
For interested organizations, we can also assist with implementation of CBT-TS including navigating care coordination, health care system complexities, provider stigma, and limited resources. We can also facilitate patient outcome tracking, including treatment initiation and retention as well as clinical outcomes such as substance use and mental health symptoms.
In the toolkit on this page, we have included a brochure for providers that summarizes what CBT-TS is, how it can help, evidence supporting its utility, and other ways this program can provide support. A brochure for patients that clinics, centers, and/or programs can share is also available upon request through Program Assistance.
Lisham Ashrafioun, PhD, Assistant Professor of Psychiatry, University of Rochester Medical Center; Health Science Specialist, VA Center of Excellence for Suicide Prevention
Dr. Ashrafioun is an Assistant Professor in the Department of Psychiatry at the University of Rochester and a Research Investigator at the VA Center of Excellence for Suicide Prevention at the VA Finger Lakes Healthcare System. His research interests and experiences have spanned across distinct and overlapping areas of chronic pain, suicide prevention, and substance use, particularly opioid misuse.
Tracy Stecker, PhD, Assistant Professor, School of Nursing, Medical University of South Carolina; Co-Research Director, VA Center of Excellence for Suicide Prevention
Tracy Stecker is the Co-Research Director of the Center of Excellence for Suicide Prevention at the VA Finger Lakes and an Assistant Professor in the College of Nursing at the Medical University of South Carolina. Dr. Stecker is a psychologist and mental health services researcher who focuses on help-seeking behavior in individuals with mental illness. She has received funding from the National Institute of Mental Health, the National Institute of Alcoholism and Alcohol Abuse, the Department of Defense, and the Department of Veterans Affairs to develop and test cognitive-behavioral interventions to increase mental health treatment seeking among individuals with symptoms of PTSD, substance use, and suicidality.
Sarah Szafranski, MA, Program Coordinator/Therapist, Medical University of South Carolina
Sarah Szafranski is a Licensed Professional Counselor. She has worked as both a research coordinator and therapist on research funded grants at the Medical University of South Carolina and with the Ralph H. Johnson VA Medical Center. Her primary areas of expertise are evidence based interventions for PTSD, anxiety, and depressive disorders.
 Lipari, R. N., Park-Lee, E., & Van Horn, S. (2016). America’s need for and receipt of substance use treatment in 2015. The CBHSQ report. SAMHSA.
 Rural Health Information Hub. (2020). Rural prevention and treatment of substance use disorders toolkit. Retrieved January 6, 2023.
 Maisto, S. A., Aldalur, A., Abar, B., Stecker, T., Chiang, A., & Conner, K. (2022). Heterogeneity in alcohol-related severity and interests in going to treatment in community adults with alcohol use disorder (AUD). Substance Use and Misuse, 57(10), 1626–1632.
 Rural Health Information Hub. (2020). Barriers to preventing and treating substance use disorders in rural communities. Rural prevention and treatment of substance use disorders toolkit. Retrieved January 6, 2023.
 Vogel, E. A., Ly, K., Ramo, D. E., & Satterfield, J. (2020). Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies. Drug and Alcohol Dependence, 212, 108065.
 Stecker, T., McGovern, M. P., & Herr, B. (2012). An intervention to increase alcohol treatment engagement: A pilot trial. Journal of Substance Abuse Treatment, 43(2), 161–167; Stecker, T., McHugo, G., Xie, H., Whyman, K., & Jones, M. (2014). RCT of a brief phone-based CBT intervention to improve PTSD treatment utilization by returning service members. Psychiatric Services, 65(10), 1232–1237.
 Chipp, C., Dewane, S., Brems, C., Johnson, M. E., Warner, T. D., & Roberts, L. W. (2011). "If only someone had told me…": Lessons from rural providers. Journal of Rural Health, 27(1), 122–130.