Cognitive Behavioral Therapy (CBT) is a type of talk therapy that is a combination of both behavioral therapy and cognitive therapy. It helps clients focus on how they learn and how they think about and interpret things in their lives. While traditional therapies focus on the cause of clients’ mental illness or substance abuse, CBT focuses on what they are feeling at that point in time. Cognitive Behavioral Therapy has become a very effective type of therapy, and research has shown that clients will use the skills they have learned long after their treatment has ended.
Although CBT is most widely used to treat depression and anxiety, it is also effective in helping those who struggle with drug and alcohol dependency. There are options as to how it is provided – either on an individual, group, or couples/family basis. It is often used as part of a larger treatment program that may incorporate other types of therapy as well.
There are different forms of CBT, but all forms have the same premise: that clients’ thoughts and behaviors both play a role in the emotions they experience. In addition, CBT helps clients anticipate problems and increase their self-control capacity, so they can avoid reverting to substance use.
Evaluations of CBT have shown that this therapy has, in fact, worked for many mental health disorders as well as to treat drug and alcohol dependency. It is currently one of the most effective treatment models used in addiction treatment, per NIDA.
One of the most important criteria for CBT is that the practitioner and client have a good working relationship. This type of therapy should only be applied if the practitioner is skilled in CBT and if CBT is appropriate for the specific client.
How Cognitive Behavioral Therapy Works
In Cognitive Behavioral Therapy, therapists and clients cooperate to determine which of the clients’ thought processes or behaviors are not helpful. They also examine how clients’ thoughts and behaviors can impact their feelings and cause symptoms such as anxiety to occur. Therapists may use different exercises to help clients successfully change those thoughts and behaviors into healthy and helpful ones. In short, as explained by the National Institute on Drug Abuse, CBT helps clients recognize, avoid, and cope in the following ways:
- Recognize the situations in which they are most likely to use drugs or alcohol
- Avoid such situations when appropriate
- Cope with problematic behaviors related to drug or alcohol dependence
Each session will include homework. Clients will learn about a skill in their weekly session and be given an assignment to complete – usually applying what they learned to life outside of therapy – before their next session. Often, clients will work with their therapists to determine the assignment that will be completed. The goal of homework is to help clients learn different ways to cope with their emotions and behaviors, which is best achieved by practicing the learned skills repeatedly. If the homework is not completed successfully, then clients will not be able to use the skills they have learned in an unexpected situation where they would need them the most.
There are five critical tasks that are essential to CBT as it applies to drug and alcohol dependence and recovery:
- Foster the motivation for abstinence. Performing an analysis that shows clients what could be lost – or gained – by continued drug or alcohol use can help further motivate individuals to stay sober.
- Teach coping skills. As described, clients must learn which situations are the riskiest for relapse and how to properly manage them.
- Change reinforcement contingencies. Clients will substitute drug-related behaviors with more appropriate behaviors and activities that have positive rewards.
- Foster management of painful emotions and situations. Clients must learn skills to handle cravings for drugs and alcohol, as well as other strong emotions, such as anger, anxiety, and depression.
- Improve interpersonal functioning and enhance social support systems. This helps clients build a stronger support system with relationships that promote a drug-free lifestyle.
There are many effective interventions that therapists can utilize while practicing CBT. However, when related to drug and alcohol dependence, there are six essential interventions that are unique to substance use disorders:
- Functional analyses on drug or alcohol abuse
- Individualized training in recognizing and coping with cravings, managing thoughts about drug or alcohol abuse, problem solving, emergency planning, recognizing decisions that may seem irrelevant, and refusal skills
- Examination of clients’ cognitive processes in relation to drug or alcohol abuse
- Identifying and exploring past and future high-risk situations
- Encouragement and review of implementation of skills outside of sessions
- Practicing skills within sessions
There are also interventions that are recommended for drug- and alcohol-related cognitive behavior, but that are not required, including:
- Monitoring use and cravings of drugs or alcohol
- Monitoring clients’ general functioning
- Including loved ones in up to two sessions
- Exploring both the positive and negative consequences of drug or alcohol use
- Exploring clients’ ambivalence about abstinence, if needed
The purpose of the required functional analysis is to help both clients and therapists understand why clients are dealing with drug or alcohol dependence. It also helps determine which coping skills are most important for clients to learn on a personalized basis. An examination filled with open questions, given by therapists, can help to provide the information needed. Questions should fall into each of the following categories:
- Deficiencies and obstacles
- Has the client been able to achieve brief periods of abstinence?
- Does the client have comorbid psychiatric diagnoses or other problems that may impair their learning ability?
- Skills and strengths
- Has the client been able to maintain employment or positive relationships?
- How does the client spend time when not engaged in drug-related behaviors?
- Determinants of drug or alcohol abuse
- What triggers their drug or alcohol use?
- How do they obtain the money used to buy drugs or alcohol?
CBT, when applied to substance abuse disorders, was first used to prevent relapse when treating clients who were dependent on alcohol. Since then, it has been adapted to apply to individuals with not only alcohol dependencies, but drug dependencies as well. There is a theory that the processes involved in learning – mainly reinforcement and conditioning – play a role in the development of behaviors related to addiction. Clients will learn several skills that will be used to identify and change those behaviors, so they will be able to successfully stop using drugs or alcohol.
How CBT Addresses Relapse
If clients relapse during a CBT course, they can then work with their therapists to analyze their feelings, thoughts, and circumstances both before and after the relapse. This exercise can help individuals better determine what feelings led them to relapse, so they can learn which feelings they need to work through and what situations they need to avoid, if applicable.
These skills, although learned in therapy sessions, must be repeated in order for the client to learn how to successfully utilize them, states the Anxiety and Depression Association of America.
A publication by the University of Connecticut lists some of the coping skills clients should learn:
- Intrapersonal skills
- Managing thoughts and drug or alcohol cravings
- Managing negative thinking
- Planning for emergencies
- Developing decision-making skills
- Developing problem-solving skills
- Learning to manage anger
- Using activities that are not related to drugs or alcohol
- Learning relaxation techniques
- Interpersonal skills
- Refusing drugs or alcohol
- Handling criticism
- Enhancing support system
- Refusing requests from others
- Improving communication skills
- Improving general social skills (how to start a conversation, how to use nonverbal behavior, etc.)
If a mood disorder, such as depression, has also been diagnosed, the therapist will begin by educating the client about depression, any symptoms the client may be experiencing, and how those symptoms relate to depression. The therapist and the client will coordinate their efforts to any negativity the client holds, as this may be a contributing factor to the client’s feelings. Structure, which is important to depression, is also practiced in CBT. Each session will revolve around a plan that was approved by both the client and the therapist.
The Importance of Client Involvement
Clients are actively involved in CBT, from start to finish, with the goal being for them to learn new ways of coping that they will use even after treatment has ended. They will be able to use these coping skills when confronted with situations or events that they relate to drug or alcohol use so they can successfully maintain sobriety.
A very important goal for both practitioners and clients is education. Generally, the first session involves setting a treatment plan that both parties will follow to keep treatment focused. Clients may also be given handouts with their homework assignments that can help them learn more about their diagnosis. This also applies in another way; clients get out what they put in, meaning that if they do not put in an effort to learn these skills, they will not see a pronounced benefit in their situation. If the client does not show a strong motivation to change, then little change should be expected.
The length of treatment varies between individuals; however, it is generally short-term, with clients seeing benefits around 12 weeks after beginning treatment. Depending on the severity of the problem that requires treatment, clients can expect to commit to anywhere from 5-20 sessions.
If a client experiences a problem after treatment has ended, the therapist may offer what could be called booster or refresher sessions. These sessions can help clients to maintain the skills they have learned in therapy and to help with any problems that may arise. This will help address the problem before the person experiences significant emotional trauma. Once the skills are learned that the person was lacking, structured therapy sessions will give way to the person using the skills outside of the therapy setting.
Cognitive behavioral therapy is most frequently performed on an outpatient basis. This provides clients with the ability to develop – and practice – coping skills related to drug and alcohol use in their daily lives. It also allows family members and friends to participate in the recovery process, as they can promote healthy, drug-free behaviors.
One of the most beneficial qualities of CBT therapy is that it is easily adaptable to each client’s treatment needs. After an initial assessment, the practitioner will develop a personalized plan for the client that may involve other therapeutic techniques.
When CBT Is Not the Right Choice
Although CBT has been praised, there are still situations where this option may not be in the best interest of the client. A skilled therapist will know how to adapt CBT to best fit each client’s needs. In some cases, this type of therapy may not benefit the client at all, and the therapist may need to find a different approach. An assessment of each client should be performed so the therapist can choose the treatment model that the client needs – if the treatment model is inappropriate, the therapist risks the client either resisting treatment or leaving treatment before it has been completed.
It is also argued that Cognitive Behavioral Therapy is not the best option for certain clients. In such situations, the therapist will be able to identify this during an assessment so the appropriate treatment model can be applied. This may be the case when individuals exhibit intense emotional reactions. It is said that if individuals are highly emotional, they may struggle with the focus on changing thoughts and behaviors. If CBT isn’t ideal, there are a bevy of other treatment options to choose from that may be more appropriate.