Cognitive Behavioral Therapy for Substance Use Disorders

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Cognitive behavioral therapy, or CBT for short, is a specific psychotherapeutic approach often used in the treatment of substance use disorders.  CBT focuses primarily on helping individuals identify and change negative thoughts and beliefs that play a role in their substance use.  By doing so, individuals who struggle with substance abuse and addiction can learn more effective ways to manage negative moods, urges, and cravings in order to stay clean and sober.

What is CBT?

Cognitive behavioral therapy is based on the premise that our thoughts, feelings, and behaviors are interconnected and stem from underlying core beliefs.  For example, negative feelings are fueled by negative thoughts and frequently lead to unhealthy or blatantly self-destructive behaviors (e.g. drinking or using to escape).  The self-destructive behavior, in turn, can further fuel the negative thoughts and feelings, creating a vicious cycle.  Learning to intervene in and change our negative thoughts to healthier, more positive thoughts can help create more positive feelings and lead to more positive behaviors.

An example of all this in play would be an alcoholic who has the underlying belief, “I’m worthless”.  Life situations that involve any type of perceived rejection or abandonment – which everyone experiences from time to time – trigger an array of negative automatic thoughts related to this belief, such as “Why bother, nobody cares anyway”, “Everyone always leaves”, and, “Nothing I do is ever good enough”.  Those beliefs trigger negative feelings, which the alcoholic knows will go away – at least temporarily – after a few drinks, which is the self-destructive behavior.  Each time alcohol provides an escape the behavior is reinforced, leading to more negative thoughts about being worthless and a failure due to the drinking.  Cognitive behavioral therapy can help the alcoholic learn ways to intervene in and stop this vicious cycle.

Reframing Perception

Cognitive behavioral therapy helps individuals change their perception of situations by thinking about those situations differently.  For example, if the alcoholic individual (in the example above) experiences a relationship break-up, she can use cognitive behavioral techniques to change her perception of the situation from, “I’m worthless; no one will ever love me, and everyone eventually leaves” to “I have a lot to offer the right person.  This wasn’t the right relationship for me and, although it will hurt for a while, the end of this relationship isn’t a reflection of my worth as a person”.  The first perception causes distress and increases the likeliness of using alcohol to cope.  The second “reframed” way of looking at the situation decreases distress and bolsters more positive feelings and behaviors.  

Features of CBT

There are several features of cognitive behavioral therapy that make it a valuable component in the treatment of substance use disorders:

  • CBT is focused on addressing a specific problem
  • It’s goal-oriented and collaborative. Client and therapist work together to reach the mutually agreed-upon treatment goal
  • It’s a short-term treatment, typically lasting 16 to 20 sessions
  • Therapy typically includes homework assignments to be completed in between therapy sessions and discussed at the next session
  • The therapist takes an active role in the treatment process
  • It’s geared more towards helping clients learn healthy coping skills they can start practicing and using right away rather than helping them gain insight into deeper, underlying issues

Key Elements of CBT

There are several key elements of cognitive behavioral therapy, which are identified and addressed throughout the therapy process.  They include:

  • Automatic Thoughts
  • Cognitive Distortions
  • Self-Talk
  • Thoughts Feelings Actions Triangle
  • Core Beliefs

CBT Elements Explained

 

Automatic Thoughts

American psychiatrist Dr. Aaron Beck, who originated cognitive behavioral therapy over 50 years ago, noticed his depressed patients seemed to struggle with a stream of spontaneous negative thoughts.  These “automatic thoughts” fueled and exacerbated their depressed mood.  CBT helps individuals identify and challenge their negative automatic thoughts by looking at evidence that contradicts them. 

Cognitive Distortions

Negative thoughts and beliefs come in a variety of forms known as cognitive distortions or “thinking errors”.  Cognitive distortions are irrational and flawed.  They’ve been found to play a role in anxiety, depression, substance abuse and addiction, and a variety of other psychological problems.

Common Cognitive Distortions

 

  • All-or-nothing thinking (also called black-and-white thinking) (e.g. “If I don’t get this job then there’s no point in continuing to look”; “This entire week was a complete loss!”)
  • Catastrophizing (e.g. “I relapsed again; my life is ruined”)
  • “Should” statements (e.g. “I should do everything perfectly”)
  • Overgeneralization – typically includes “always” or “never” (e.g. “I always screw up everything”)
  • Disqualifying the positive – (e.g. “The only reason she went out with me is because she didn’t have anything better to do”)
  • Labeling (e.g. “I’m worthless (or a loser, a failure, etc.)”)
  • Blaming (e.g. “I wouldn’t be an addict if I’d had a better childhood”)
  • Filtering – Focusing on any negative aspect of something, such as yourself or a situation, while dismissing or ignoring any positive aspects
  • Mind reading (e.g. “My friend didn’t return my call so he’s obviously mad at me”)
  • Personalizing (e.g. “I didn’t get that promotion because my boss doesn’t like me”)
  • Emotional reasoning – making decisions based on feelings not values (e.g. “I’m not going to my NA meeting because I don’t feel up to it”), or assuming something is true based on how you feel (e.g. “I feel like an idiot so I must be an idiot”).

Cognitive behavioral therapy helps individuals recognize their cognitive distortions and learn to replace them with healthier, more rational ways of thinking.

 

Self-Talk

Self-talk is something we all engage in throughout the day.  It’s the internal commentary we have about ourselves, other people, and events or situations.  Individuals who struggle with depression, for example, often have a lot of negative self-talk.  Examples include thoughts like “Nothing will ever get better”, “I’m such a loser”, and “Why bother trying, nothing ever works out for me so I might as well keep using”.

Thoughts Feelings Actions Triangle

The thoughts-feelings-actions triangle concept in CBT  demonstrates the connection between our self-talk/automatic thoughts, our feelings, and our actions – which comprise the three corners of the triangle. Each one affects the other two.  CBT helps individuals learn to notice their distorted, negative thoughts and stop them, challenge, and replace them with thoughts that are more rational and positive.  Doing this helps create a positive shift in their emotions and actions.

Core Beliefs

Our “core beliefs” about ourselves, others, and the world form the basis of our thoughts, feelings, and actions.  All of us have a unique combination of core beliefs.  Cognitive behavioral therapy helps individuals identify and challenge their distorted and irrational core beliefs.  It’s these problematic beliefs that underlie unhealthy choices and self-destructive behaviors, such as abusing substances.

Techniques used in CBT

Therapists use a variety of techniques in CBT.

CBT: Common Therapeutic Techniques

 

Keeping a Thought Diary

In addiction recovery treatment it can be helpful to keep a diary or record of negative thoughts and self-talk.  This provides an ongoing opportunity to critically evaluate each thought (and underlying beliefs) by considering objective evidence that contradicts it as well as supports it. 

Behavioral Experiments

This CBT technique involves testing the validity of our thoughts (e.g. assumptions we tend to make) and beliefs.  These experiments can also help determine which thoughts support more desirable behaviors. 

Situation Exposure Hierarchies

This technique involves creating a list of distressing situations or activities and ordering the items on the list based on which causes the least distress to which causes the most.  Then, start by facing the first (least distressing) item on the list several times over a period of a few days until the distress decreases by at least half.  Therapists frequently use exposure techniques to treat anxiety and related disorders (e.g. PTSD and OCD).  They may be especially useful to individuals who frequently drank or used when feeling anxious.

Pleasant Activity Schedule

One of the most effective ways to create more positive emotions is to do something you enjoy.  Scheduling at least one fun activity each day helps individuals with substance use disorders have fewer negative thoughts and feelings, which in turn decreases the urge to drink or use as an escape.

Imagery Based Exposure

This CBT strategy involves purposely remembering a distressing event that triggered intense negative feelings and, subsequently, an unhealthy coping response (e.g. the urge to get drunk or high). Individuals are instructed to continue vividly picturing the incident until the amount of distress it elicits is at least 50% less than it was initially.  Whenever the memory resurfaces in the future it’s much less painful, thus greatly reducing the need to self-medicate.

Benefits of CBT

Cognitive behavioral therapy has been well-researched over the years, and the potential benefits have been well-documented.  It can help individuals:

  • Communicate more effectively
  • Learn to manage painful emotions in a constructive, rather than self-destructive, manner
  • Process and heal from trauma
  • Learn to stop negative thoughts and rumination
  • Address and resolve challenges in their relationships with others
  • Develop healthy ways to cope with stress, loss, and difficult situations
  • Reduce their symptoms of depression, anxiety, and other psychiatric disorders
  • Identify and change flawed beliefs and negative thought patterns that perpetuate self-destructive behavior and interfere with positive change

Cognitive behavioral therapy can play a significant role in reducing the likeliness of relapse.  It’s almost impossible for someone with an addiction to stay clean and sober without addressing the underlying flawed thought patterns and beliefs, and without instilling healthy new coping skills to manage the painful emotions that are an inevitable part of life.

Why CBT is an Ideal Component of Substance Abuse Treatment

Cognitive behavioral therapy fits well into drug and alcohol treatment because:

  • It helps individuals identify the underlying flawed beliefs that lead to self-destructive behavior.
  • The concepts are practical and relatively easy to understand
  • It usually involves completing homework between sessions, which enhances the therapy process
  • It’s easy to start applying the concepts in one’s daily life
  • CBT is based on a collaborative effort between the individual and the therapist
  • It’s a time-limited, relatively short-term therapy, usually lasting between 10 and 25 sessions (16 total sessions are common)
  • It’s effective in both group settings and individual settings
  • It’s effective in the treatment of substance use disorders and many other psychiatric disorders, which makes it a valuable part of any dual diagnosis treatment program

While there’s no “one-size-fits-all” approach to therapy, CBT has helped countless individuals on their journey to establish a substance-free lifestyle.  Although CBT can be quite effective on its own, it’s generally the most effective when combined with other forms of treatment for anyone with a substance use disorder as well as individuals requiring dual diagnosis treatment.