Cognitive-Behavioral Therapy CBT Therapy for Addiction
One of the best treatments for mental health disorders—including substance use disorders such as addiction to alcohol or drugs—is cognitive-behavioral therapy (CBT).
Developed in the 1960s, CBT is a form of talk therapy or psychotherapy that teaches individuals to identify and replace false or negative thoughts—characteristic of mental health disorders such as major depression—and behaviors with healthier ones.
CBT is also a part of almost every modern science- or evidence-based treatment for substance use disorders (SUDs). It is versatile—adaptable to one-on-one, group, and family therapy—and applicable to many different mental health disorders.
CBT can also help when someone has a dual diagnosis: a SUD and another mental or emotional disorder—such as depression, stress, anxiety, or trauma—at the same time. Between 40% and 60% of people with a mental illness have a co-occurring addiction.
How CBT is Different from Other Psychotherapies
Several things distinguish cognitive-behavioral therapy from other types of talk therapies.
CBT takes less time. CBT is not meant to be an open-ended process that can last years or the client’s entire life. CBT is designed to be short-term, with an average of 12-to-20 weekly sessions, sometimes biweekly. The goal is for the client to complete therapy, learn new and effective coping skills, and then carry on with these skills in their lives. In some cases, there are even briefer versions, with only six-to-eight sessions.
CBT is a collaboration. In CBT, the client is an active participant, working with the therapist. Together, they determine what the problem is, what are the goals, and how best to accomplish them. How therapy proceeds depends on both of them. Not every therapist will be a good fit for every client, just as CBT may not be the best treatment. CBT requires dealing with emotional issues. Clients must decide if they need a different therapist or a different treatment.
CBT is about the present. That is, CBT is mainly concerned with fixing the current problem, by modifying current thoughts and behaviors. For example, substance abuse disorder can start as an attempt to cope with a mental health issue, or vice versa (known as dual diagnosis).
CBT can be used with other therapies. Therapists often encourage the use of other types of therapies with CBT, including medication-assisted treatment (MAT), contingency management, and long-term psychotherapy.
How Cognitive-Behavioral Therapy Works for Addiction
Once addiction starts, overcoming it requires clients to change their behavior. CBT can help.
Addiction is a flawed or defective reaction to a problem or situation, such as irrational negative feelings caused by trauma or other mental health issues. What’s needed is for the client to identify these harmful feelings and learn new and better ways to cope with them.
Addiction is sometimes referred to as a habit, something that is done repeatedly almost without thinking. Breaking an addiction or a habit requires that clients modify their attitudes and behaviors related to drug use. CBT does this by examining the relationships among thoughts, feelings, and behaviors.
The basics of CBT as a substance abuse treatment are:
- Functional analysis. Identifying the things or situations that lead to substance abuse.
- Coping skills training. Learning healthier and more effective ways to cope with such situations and feelings.
- Relapse prevention. Finding ways to avoid triggers (people, places, situations) for their substance use.
Is Cognitive-Behavioral Therapy Effective for Treating Addiction?
According to most addiction specialists, CBT is now the gold standard for substance abuse treatment because of the extensive research showing its efficacy.
One 2009 meta-analysis study of CBT for alcohol and illicit drug use shows that, by itself, CBT reduces substance abuse by 79% over no treatment.
The best outcomes with CBT were on marijuana use, followed by cocaine and opioids. In a 2010 study of CBT use in cocaine users, 60% still tested clean after 52 weeks.
It also works well in conjunction with other therapies, such as methadone medication-assisted treatment abd contingency management.
What Happens in CBT Therapy?
CBT counselors strive to avoid judgment. They are teachers, not law-enforcement officers or judges. The goal is understanding and solving problems, not punishing violations. It is a warm relationship, not an adversarial one.
First, the client and therapist agree on an agenda: What are the clients’ desired goals? These goals should be as specific as possible, something that can be measured (such as cutting drug or alcohol use), and can be realistically accomplished in a limited amount of time.
Once the goals are established, the CBT counselor should come up with an estimated timeline for treatment, how long it should take. Therapy sessions usually take place for 30-to-60 minutes, once a week (sometimes every two weeks), usually for a year or less.
A session may include asking whether the clients abused any substances since the last session? If so, how much and how often, and under what circumstances?
The client agrees to attend regularly and do “homework”—reading about and doing exercises related to applying new coping skills to issues in their lives—between sessions.
Therapists and clients also review the previous session’s lessons and agree on homework for the following session.
For example, the clients may be asked to record their thoughts and feelings just before substance use. This may help the clients become aware of why they use alcohol or drugs. One of the chief benefits of cognitive-behavioral therapy is clients retain the skills they learn during treatment. That’s important because addiction has no cure. According to the best current science, once addiction begins, relapse will be a risk for the rest of the individuals’ lives. A one-time substance use decades after recovery may reawaken addiction. Worse, because the individuals have lost their tolerance, or the substances may have become or been replaced with stronger ones, the risk of a fatal overdose is greater. The lessons learned with CBT, however, can remain with individuals long after therapy and peer support group attendance have ended.
Benefits of CBT
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One of the chief benefits of cognitive-behavioral therapy is clients retain the skills they learn during treatment. That’s important because addiction has no cure.
According to the best current science, once addiction begins, relapse will be a risk for the rest of the individuals’ lives. A one-time substance use decades after recovery may reawaken addiction.
Worse, because the individuals have lost their tolerance, or the substances may have become or been replaced with stronger ones, the risk of a fatal overdose is greater.
The lessons learned with CBT, however, can remain with individuals long after therapy and peer support group attendance have ended.
Cognitive-Behavioral Therapy Techniques
Some specific CBT techniques include:
- Cognitive restructuring. Instead of assuming the worst will happen, clients reframe the thought in a less negative way that acknowledges the limitations in thinking this way.
- Guided discovery. The therapist asks questions designed to challenge the clients’ negative beliefs and see things from other perspectives.
- Exposure therapy. Clients gradually face fears until they can cope.
- Journaling. Writing down negative thoughts and behaviors, positive alternatives, and lessons learned in therapy sessions.
- Activity scheduling. Listing activities that they keep putting off on a calendar and resolving to do them that day.
- Behavioral experiments. If certain activities lead clients to expect the worst, they are asked to write down what they think will happen in advance. When the worst doesn’t happen, they will dread it less over time.
- Relaxation and stress reduction techniques. Clients are taught deep breathing exercises, muscle relaxation, and guided visualization (imagining a less stressful situation).
- Role-playing. By acting out scenarios before they happen, clients can work out possible problems ahead of time.
- Successive approximation. Also known as decomposition and “chunking,” this is a process of taking a difficult or seemingly impossible task and breaking it down into a series of smaller, more achievable “chunks.” The client gains confidence with each completed chunk.
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