What is Cognitive Behavioral Therapy for Addiction Treatment

Last updated on November 4th, 2019

Cognitive Behavioral Therapy (CBT), which was introduced in the 1970s, is an effective therapy for the treatment of substance addictions and/or other mental health disorders, such as anxiety, depression, and eating disorders.1,2 It can be used alone or in conjunction with other types of therapy to help addicted individuals achieve and maintain sobriety.2 This type of therapy, which is useful in both individual and group settings, focuses on the connection between thoughts, emotions, and behaviors and provides patients with the coping skills necessary to resist triggers and avoid relapse.1[/content-overview


What Is CBT?

close-up of therapist writing on clipboard with patient blurred in background during cognitive behavioral therapy sessionCBT, which combines aspects of behavioral theory and cognitive theory, is a goal-oriented therapeutic approach that aims at rectifying maladaptive thought patterns and behaviors in order to improve emotions and promote positive change.3 It is collaborative by nature; the therapist works closely with the patient to instill a set of skills, with treatment plans being customized for each individual.1,4 Because CBT is personalized for each patient and focuses on the patient’s worldview and belief system, CBT has the advantage of being culturally sensitive.1

CBT differs from “talk therapies” in that it doesn’t merely involve discussion between the therapist and the patient. CBT sessions involve skill-building, and after the sessions, patients are required to complete homework on their own time.4 In this manner, therapists who utilize CBT act as teachers in addition to therapists.

Before CBT can benefit the patient, a strong therapeutic alliance must be formed to promote trust and cooperation.3 It’s vital to the working relationship that the patient provide the therapist with feedback so that the treatment plan can be adjusted according to the patient’s needs.4 Many patients find CBT appealing because they can take the strategies they learn in therapy and apply them to real-life situations.1

What Role Does It Play in Addiction Treatment?

While enrolled in an addiction treatment program, a patient may receive CBT, which encompasses several therapeutic strategies, on an individual or group basis or both.2 This form of therapy is brief and focuses on empowering the individual, encouraging them to rely on themselves and their own abilities, as opposed to depending upon the therapist.1 Ideally, once an individual completes their substance abuse treatment program, they will carry over the skills learned in CBT to avoid relapse and live a healthy and sober life.

Ideally, once an individual completes their substance abuse treatment program, they will carry over the skills learned in CBT to avoid relapse and live a healthy and sober life.CBT for the treatment of alcoholism and drug addiction focuses on reducing or eliminating substance-using patterns and replacing them with healthier alternative behaviors. One meta-analytic review of 34 randomized clinical trials revealed, overall, a moderate treatment effect associated with CBT—with the improved treatment response (measured, for example, by clean toxicology screens) seen not just during therapy but far past the end of treatment.2 Within the review, the most robust treatment response was seen to result from CBT for cannabis abuse, followed by cocaine and opioids.2

CBT within an addiction treatment program aims to help patients recognize trigger situations, devise ways to avoid these triggers, and learn healthier ways to deal with emotions and situations that once led to drug or alcohol abuse.3

How Does It Work?

The first meeting entails orienting the patient to CBT, educating them on what it entails, and inquiring about their substance abuse history. This initial meeting may also consist of making a list of target behaviors that the patient would like to focus on and fix. The therapist evaluates the patient’s thought patterns by asking how they perceive him or herself, others, and the future. This is followed by assessing behaviors, emotions, and thoughts that can trigger or worsen the patient’s problems. All of this information is gathered in order to create an individualized treatment plan.4

Once the treatment plan is created, progress can be made with a number of strategies, such as:4

Goal Setting

The therapist and patient come up with specific outcomes that the patient would like to achieve related to drug abuse and any other problematic behaviors. The goals are measurable and observable, as well as achievable. If the goals are set too high, the patient may become discouraged, which is why it’s important to set small goals at first. Goals are a means for the therapist to assess progress within CBT.

Agenda Setting

The therapist and patient collaborate in order to devise a plan for how session time will be spent. Each individual suggests what they’d like to cover and prioritize in pursuit of achieving treatment goals.

Relaxation

These techniques decrease anxiety, stress, and tension and can be chosen based on what works best for the patient. These relaxation techniques are invaluable when faced with stressors that may lead to relapse.

Problem-Solving

The patient and therapist identify coping strategies that can be utilized to deal with problems associated with drug use, stress, and other triggers. These strategies that are put in place increase the patient’s confidence and feeling of control over issues that may arise.

Behavioral Activation

close-up of woman holding cup of coffee and reading a book in an attempt to change her behavior and moodThis includes a set of strategies used to influence a person’s mood and emotions. Just as thoughts and emotions influence behaviors, the opposite is true. This method focuses on re-introducing enjoyable activities into a person’s daily routine with the goal of improving mood and decreasing negative thought patterns.

Homework Assignments

These may consist of practicing skills, behavior monitoring, and readings. Homework assignments help the patient to continue to do work and build skills outside of therapy sessions.

Relapse Prevention

Naturally, relapse prevention is one of the main focuses of CBT. Therapists educate patients on how to anticipate problems and label them as “high-risk situations” associated with a potential for them to return to substance abuse. Therapists assist patients in building coping skills to utilize in these high-risk environments.

Relapse prevention can be facilitated in an individual or group setting, with role-play and practice being main elements of skill-building. Playing out potential situations in a safe and controlled setting is an opportune way for patients to build the confidence they need to avoid relapse when faced with stress or drug-using triggers.3

Relapse prevention strategies tend to have a few common elements. A patient in CBT for substance abuse must:3

  • Have a wide variety of coping strategies in place to handle high-risk situations.
  • Make the appropriate lifestyle changes that reduce the desire for mind-altering substances.
  • Increase the amount and frequency of healthy activities.
  • Be ready for minor lapses so that they don’t result in full-blown relapses.
  • Practice relapse prevention skills in the event of a relapse as opposed to giving up.

Once a patient nears the end of their rehab program, the therapist will create a plan for them to maintain the changes they achieved during therapy. End-of-treatment planning is collaborative, just as CBT is, and the goal is to prepare the patient to apply the skills post-treatment. The therapist and patient review the relapse prevention and coping strategies learned in therapy, and the patient is free to express any fears or concerns they may have related to returning to their everyday lives.4

Since the relapse rate for substance abusers is between 40% and 60%, it’s important that a patient receive ongoing support after they are discharged from the recovery program.5 Ending a substance abuse treatment program doesn’t necessarily mean a patient can no longer benefit from CBT in a formal setting. Many people in recovery attend individual therapy once or twice a week following the completion of a recovery program to build upon the progress made in rehab.

What Are Cognitive Distortions?

One of the main focuses of CBT is that of re-wiring a patient’s negative and unhealthy thought patterns, also referred to as cognitive distortions. This is because, according to theory surrounding CBT, patients who are addicted to drugs or alcohol have distorted views of themselves and their environment, and thus these thoughts are the source of drug-seeking behaviors.3

This re-wiring process is referred to as “cognitive restructuring.” During cognitive restructuring, the patient expresses a belief related to their personal drug or alcohol use and the therapist, through counseling, works to replace that thought with a constructive one.1,3

For instance, a patient may tell the therapist, “I can only socialize when I am drunk.” The therapist will work with the patient to replace that thought with something more positive, such as “It can be uncomfortable to socialize without drinking, but people do it all the time.”3

Rectifying that statement can provide the patient with the confidence necessary to cope with uncomfortable or stressful situations without resorting to mind-altering substances. Eventually, the patient learns to restructure their own thoughts and beliefs, an important skill they can utilize once treatment has ended.

The above is just one example of a cognitive distortion. There are many categories of maladaptive thoughts that can influence and perpetuate the cycle of alcohol and drug abuse. Below are some more examples of cognitive distortions:4

Man standing with head down portraying someone who is dealing with cognitive distortion
  • All or nothing thinking: The person views situations as black or white; they fail to acknowledge that things exist on a spectrum or continuum.
    • Example: “If I do drugs, I am a bad person.”
  • Catastrophizing: Predicting solely bad outcomes for the future.
    • Example: “If I lose my job, I will die.”
  • Disqualifying positives: Minimizing the positive things that happen.
    • Example: “I’ve been sober a week, but I’m sure I’ll relapse at some point.”
  • Emotional reasoning: Allowing emotions to overshadow hard facts.
    • Example: “Even though I feel depressed the next morning, I know that drinking helps my mood.”
  • Labeling: Assigning a label to someone or an event without learning all of the facts about the person or event.
    • Example: “My dad would never understand my need to use drugs or alcohol.”
  • Magnification: Playing up the negatives of a situation.
    • Example: “I had a minor slip-up with drugs, so I know I’ll relapse and be an addict forever.”
  • Mental filter/tunnel vision: Seeing only the negatives of a situation without acknowledging the positives.
    • Example: “My husband says he wishes I would stop drinking, so I must be the worst wife ever.”
  • “Should” and “must” statements: Having solid ideas of how people should act.
    • Example: “I must not have any relapses to be considered a success.”

Changing Cognitive Distortions

There are a few techniques utilized to challenge these cognitive distortions. The therapist encourages the patient to counter their own dysfunctional thought patterns. The counter-statements work best when the therapist uses information presented in the therapy session to enhance the believability of the new thoughts and behaviors.4

Socratic questioning is the name for the nonjudgmental technique in which the therapist asks open-ended questions that can help guide the patient into identifying their negative cognitions and beliefs associated with drug or alcohol abuse, as well as any emotional problems.4

The Dysfunctional Thought Record (DTR) is a written way to keep track of distressing situations or events and the maladaptive thoughts and negative emotions resulting from those situations. The flow of the record occurs as follows:

  • The person rates how believable the negative thoughts are.
  • They rate the emotions that result from the dysfunctional thought.
  • They come up with evidence for and against the thought.
  • They create a new thought based on evidence.
  • They rate how believable the new thought is.
  • Finally, they rate the new emotion that results from the new thought.

The Socratic questioning technique and DTR are 2 methods that are useful in changing the thought patterns and behaviors of people who abuse drugs and alcohol, particularly if they are continually practiced once therapy has commenced.

Co-Occurring Disorders

Substance abuse commonly co-occurs with other mental health disorders, such as depression, anxiety, bipolar disorder, schizophrenia, and post-traumatic stress disorder (PTSD). In fact, nearly 8 million people in the United States had co-occurring disorders, or dual diagnoses, in 2014.6 Without proper treatment, people who have dual diagnoses have an increased risk of experiencing physical illnesses, suicide, homelessness, incarceration, and early death.6

Additionally, cognitive distortions are typically more severe with patients who have co-occurring disorders than with substance abuse patients. For example, a patient with anxiety and alcoholism may experience adverse effects to a particular anti-anxiety medication, which in turn could lead to a claim that all anti-anxiety drugs are harmful.3 This pattern of thinking can impair the treatment process.

Woman sitting outside with head down suffering from co-occurring disordersAlthough there is significant evidence for using CBT as treatment for substance use disorders and mental health disorders in isolation, there is less evidence surrounding CBT for the treatment of co-occurring disorders. For instance, one review of the literature, consisting of 16 studies, found that CBT was highly effective for the treatment of generalized anxiety disorder, panic disorder, social phobia, PTSD, and depression on their own without co-occurring substance abuse.7

One moderate-sized study analyzed the effectiveness of CBT and Motivational Interviewing (MI) for substance abusers with psychotic disorders. There was little evidence to support the benefits of the CBT specifically; there were no significant improvements in drug or alcohol use at the 1-year follow-up assessment and no notable differences in abstinence rates between control and treatment groups. That being said, there were short-term improvements in depressive symptoms, general functioning, cannabis use, and amphetamine use among those who received the CBT and MI intervention.8 More research must be conducted to verify the utility of CBT for the treatment of dual diagnoses.

Someone can additionally be said to have co-occurring disorders if they are addicted to or dependent on two different substances, a situation also referred to as polysubstance addiction or dependence. Abusing two different substances can complicate recovery, just as having co-occurring mental health and substance use disorders can. According to a review of 34 randomized controlled studies evaluating the efficacy of CBT for various substance addictions, CBT had the least impact on users who struggled with polysubstance dependence.2 As with co-occurring disorders, more research is needed to confirm the use of CBT.

Some people with co-occurring disorders may have experienced trauma, such as physical, emotional, or sexual abuse, in their pasts. One useful coping skill instilled through CBT is called “grounding.” These patients may experience overpowering feelings associated with the trauma, which can be triggered by relatively miniscule events or interactions. These strong reactions may compel a person to abuse drugs or alcohol to cope. Grounding, which changes the patient’s focus from inward to outward, helps soothe patients who are in great distress so they can return to reality and be present.3

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), CBT for treating co-occurring disorders can be adjusted to improve outcomes. A few ways to adjust the treatment include:3

  • Using visual aids, such as mapping of patterns and illustrations.
  • Engage in role play to prepare for expected triggers and unexpected situations.
  • Provide feedback on applying the skills learned.
  • Utilize lists that specifically mention the behavioral learning goals.
  • Assess for the acquisition of knowledge.
  • Use memory enhancement aids, such as mnemonic devices, tapes, and notes.

Group in chairs portraying individuals participating in integrated treatment Due to the complex nature of co-occurring addictions and mental health conditions, CBT may be more effective when combined with other interventions, which is referred to as integrated treatment. Integrated care involves the combination of multiple interventions in order to reduce substance abuse and improve mental health symptoms.3

A few examples of integrated interventions include:3

  • Integrated evaluation and screening procedures.
  • Dual diagnosis recovery support groups.
  • Co-occurring disorder self-help meetings.
  • Motivational enhancement modalities that address both disorders.
  • Group interventions for special populations, such as homeless, or triple diagnosis of addiction, mental condition, and trauma.
  • Combined therapy and pharmacological interventions.

Next Steps

If you or someone you care about is struggling with an addiction to drugs or alcohol, help is available. It’s never too late to make a positive change. There are many rehab centers that use CBT to help patients get clean and continue to stay sober in the long run.


References

  1. Brooks/Cole. (2009). Student Manual for Theory and Practice of Counseling and Psychotherapy (8th). Belmont, CA: Cengage Learning.
  2. McHugh, R., Hearon, B., Otto, M. (2011). Cognitive-Behavioral Therapy for Substance Use Disorders. The Psychiatric Clinics of North America, 33 (3), 511-525. 
  3. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
  4. Cully, J., Teten, A. 2008. A Therapist’s Guide to Brief Cognitive Behavioral Therapy. Department of Veterans Affairs. South Central MIRECC, Houston.
  5. National Institute on Drug Abuse. (2014). Drugs, Brain, and Behavior: The Science of Addiction-Treatment and Recovery.
  6. Substance Abuse and Mental Health Services Administration. (2016). Co-occurring Disorders.
  7. Butler, A., Chapman, J., Forman, E., et. al. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review 26, 17-31.
  8. Baker, A., Bucci, S., Lewin, T., et. al. (2006). Cognitive-behavioural therapy for substance use disorders in people with psychotic disorders. The British Journal of Psychiatry, 188 (5), 439-448.
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