With the most recent revision (Fifth Edition) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), addictions are included in a larger category of Substance-Related and Addictive Disorders. Substance use disorders (SUDs) are now subcategorized into three levels of severity (mild, moderate, and severe). The specific criteria individuals must meet has remained similar, with recurrent legal problems no longer serving as a criterion, and craving/urge to use being added as an additional criterion. Somewhat more stringent minimum criteria have been established for mild SUD (2–3 criteria vs. 1 or more for the old criteria of substance abuse), with 4–5 criteria needed for moderate SUD and 6 or more criteria for severe SUD. A withdrawal syndrome has also been added for cannabis within the newest version of the International Classification of Diseases (ICD-10).
Cognitive behavioral therapy (CBT) has proven to be an effective psychotherapeutic treatment for psychiatric disorders such as mood and anxiety spectrum disorders, as well as SUDs. It is an individualized, collaborative approach to psychotherapy that emphasizes the importance of thoughts, feelings, and expectancies and also incorporates more traditional behavioral approaches that utilize counterconditioning and contingency management in addressing the problem of addiction.
CBT is based, in part, on social learning theory. Thus an underlying assumption of cognitive and behavioral therapies is that learning processes play an important role in the development and maintenance of SUDs. These same learning processes can be used to help individuals reduce their drug and alcohol use through modification and substitution of existing patterns. CBT is also based on stress and coping theories. These theories promote that life stressors are likely to trigger the use of avoidance or emotion-focused coping strategies such as substance use in individuals who have low self-efficacy and poor problem-solving coping skills in an attempt to avoid experiencing distress. As such, CBT focuses on challenging individuals’ positive expectancies about substance use, enhancing their self-confidence and self-efficacy to resist substance misuse, and improving their overall and specific skills for coping with life stress.
When applied to the addicted population, CBT helps a client change his or her drug or alcohol use as well as risky attitudes and beliefs. CBT combines two very effective kinds of psychotherapy—cognitive therapy and behavioral therapy. CBT for SUDs focuses on helping clients in two major behavioral ways. The first is to help reduce the intensity and frequency of their urges to use, by undermining their underlying beliefs or cognitions about using. The second is to teach the clients specific techniques for controlling or managing their urges to use or drink. In other words, the basic goals are to reduce the pressure to use and increase control. When a client’s addiction is determined to be related to a co-occurring disorder, the psychiatric disorder also needs to be addressed by the mental health care provider.
Cognitive therapy focuses on how certain thinking patterns or beliefs cause symptoms. Distorted or unproductive thoughts or cognitions can produce negative moods such as anxiety and depression, which can ultimately provoke more maladaptive thinking and/or behaviors that do not help facilitate positive change or affect. Cognitive therapy strategies focus on thought processes, recognizing that emotions and behaviors are best addressed by considering the faulty thought processes that precede such feelings and acts. Specifically, cognitive therapists collaborate with clients to define problems, explore beliefs, reexamine appraisals and thoughts about their use of substances, and modify these thoughts to promote more favorable and adaptive cognitions, which, in turn, impact positively both behaviors and mood. In addition, coping skills training expands this emphasis on thought processes by focusing clients on accepting stressors in their lives and constructively pursuing strategies to change their valence and tendency to pursue substances to escape and/or avoid situations. Although researchers/clinicians affirm the practicality of this approach as well, cognitive therapy cannot comprehensively address all aspects of SUDs without addressing the destructive behavioral inclinations common to substance users.
Behavioral therapy focuses on weakening the connections between troublesome situations and habitual behavioral reactions to them. Strategies included in behavioral therapy include repeated behavioral practice of techniques such as distraction and relaxation and exploring consequences and reinforcement. A major goal of the behavioral component is to weaken the learned association between triggers such as the environment, situation, people, or moods, and the response of drug or alcohol use, and replace it with a more appropriate response. In time, the healthy response will become more familiar and replace the old response of using. Thus in many ways, the behavioral strategies employed are similar to those used for habit reversal or compulsive behaviors. These include teaching relaxation strategies such as deep breathing and progressive muscle relaxation, learning alternative responses such as drinking juice instead of alcohol, employing behavioral distraction, and avoiding triggers or risky situations. Two subtypes of this approach include contingency management (a positive-reinforcement treatment method in which clients are given rewards for constructive actions taken toward their recovery) and community reinforcement (a set of procedures that systematically reinforce treatment retention and substance reduction/abstinence). Clients may be rewarded for specific positive behaviors, such as producing drug-negative urine, returning to therapy, and specific lifestyle changes. These effective behavioral strategies frequently are incorporated into CBT for SUDs. CBT integrates both methods into a logical series of strategies that can identify maladaptive thoughts and resultant actions (via a decisional matrix and functional analysis), disrupt automatic patterns of functioning (through coping skills training and practice), reduce the impact of—and harmful response to—stress, and adopt more prosocial learning and interactions.
The goal of cognitive behavioral therapy can be either abstinence or moderate/controlled drinking or drug use (i.e., harm reduction), and is employed routinely for relapse prevention in abstinent individuals. CBT helps the client to identify his/her own unique high-risk situations for use. Then the client may develop plans and skills that are alternatives to using in these situations. CBT is designed to increase the client’s confidence about his/her ability to resist using. Because SUDs have high rates of relapse, CBT includes effective relapse-prevention components of treatment.
Overview of Cognitive Behavioral Therapy
CBT combines two effective kinds of psychotherapy—cognitive therapy and behavioral therapy—to help clients change their drinking or drug use behavior and related risky attitudes and beliefs. Cognitive therapy teaches individuals how certain thinking patterns contribute to their symptoms by giving them a distorted picture of events and interpersonal interactions in their lives, thus directly contributing to feelings of anxiety, depression, or anger that may provoke them into ill-chosen actions. Behavioral therapy helps individuals weaken the learned connections between troublesome situations and their habitual behavioral reactions to them.
Following the work of the more radical behaviorists (i.e., Skinner, Watson), Albert Ellis applied behavioral concepts to his work on human emotions in early work on addiction. Ellis drew attention to the relationship between events (the “activating event”), personal beliefs, and resultant emotional responses. This model (a main component of rational emotive therapy) came to be known as ABC (A: activating event, B: beliefs, and C: emotional response), highlighting how a personal belief (B) about an activating event (A) could impact emotions (C). Ellis demonstrated that changing maladaptive beliefs (termed “irrational beliefs”) regarding a client’s perceptions of activating events to more rational and practical personal beliefs would lead to more desired emotional self-management. This model is used frequently in CBT and has been shown to be very effective in reducing substance use.
Similarly, Aaron Beck extended Ellis’ work to address irrational beliefs in primarily depressed clients. Because negative mood states have a high concordance rate with SUDs (13%–30%), Beck’s strategies can be very helpful in addressing the myriad of irrational beliefs held by individuals with these disorders. Specifically, Beck identified several common irrational beliefs held by these individuals that serve to reinforce their desires to use substances. These thought patterns include thoughts of helplessness, ideas that drugs improve their functioning, all-or-none thinking, self-criticism, assuming need for perfection, and mind reading. Failure to question the rationality of these thoughts relegates substance-using clients to repeat continuously the ABC cycle, with the addition of behaviorally acting on “C” in a way that further discourages the clients and reinforces the hopelessness that they feel through substance use. Through CBT, however, these irrational thoughts are explored extensively while supplanting drug behavior with healthy coping strategies. The goal of CBT can be to attain either no drinking/drug use (abstinence) or moderate/controlled drinking/use (i.e., harm reduction).
Beck found that underlying addictive beliefs result from dysfunctional core schemas in three areas: personal survival, autonomy, and freedom. These addictive and dysfunctional thought patterns are experienced as taking over the individual’s life, goals, and values, thereby leaving one’s job and families as secondary priorities. The short-term gain of a high or a reduction of internal tension is followed by long-term negative consequences and problems. To break this pattern, clients need to learn to cope directly with problems associated with SUDs, as well as to confront problems of everyday life in a more active and problem-solving manner.
The obstacle, unfortunately, in eliminating the substance use is the dysfunctional beliefs that the individual holds about the substance. These beliefs range from the fear of the side effects of withdrawal to the belief that he/she cannot function without the substance. In addition, permission beliefs are common in addicted individuals. These are conceptualized as thoughts that allow or give permission to the individual to go ahead and use. These thoughts include such self-statements as “Just one drink won’t hurt anything. Go ahead and have one.” Changing these schemas, maladaptive beliefs, thought patterns, and associations with common triggers is at the core of the cognitive approach. Thoughts must be altered to achieve long-term behavioral change.
When utilizing CBT, the client identifies his/her own unique high-risk situations for heavy drinking or drug use with the help of the therapist. Then, using CBT techniques, the therapist helps the client to develop plans and skills that are alternatives to using alcohol or drugs in these situations. Thus, using CBT also increases the client’s confidence about his/her ability to resist using alcohol or drugs. Because people who are addicted typically demonstrate high rates of return to using, CBT also includes relapse-prevention training and strategies to employ when lapses occur.
CBT has been used in both inpatient and outpatient settings. Therapists who provide CBT typically possess at least a master’s-level degree plus specific training in this area, and more typically possess a Ph.D. in clinical or counseling psychology or an M.D. and advanced training in psychotherapy. Longabaugh and Morgenstern recommended at least 12 sessions for clients with SUDs. In this way, CBT not only is clinically effective for substance treatment, but it is also efficient, time-limited, and cost-effective. Prior to initiating CBT, it is helpful for the therapist to assess the client across a number of functional areas in order to customize therapy to the client’s specific needs. A thorough evaluation of readiness to change, mood, anxiety, and other emotional difficulties can be very helpful in defining the content of therapy. Information regarding the most recent negative consequences precipitated by substance use and the client’s current stage of change can be particularly helpful in determining how the therapist should interact with the client initially.
The transtheoretical model of Prochaska and Velicer offers a useful conceptualization of a client’s stage of change that can be used to motivate a client and better inform subsequent psychotherapy. The transtheoretical model of behavior change, or stages of change model, describes a series of six behavioral stages that an individual experiences in modifying a negative behavior in his/her life. These stages include denial, precontemplation, contemplation, preparation, action, and maintenance. Precontemplation is the first stage in this model and refers to individuals who do not consider their current behavior to be problematic and have not thought about stopping/changing their behavior within the past 6 months. If individuals begin to recognize the negative consequences of their behaviors, they find themselves in contemplation, where they begin to think about changing their behavior over the next 1–6 months and making plans for how to implement changes. In the action stage, individuals have made consistent behavior chances and have been able to sustain these changes for up to 6 months. In the maintenance stage, the individual has successfully changed his/her behavior and maintained these behavioral changes for 6 months or longer. By identifying a client’s current stage of change, the cognitive behavioral therapist can better tailor the initial dialog of therapy to address related barriers to the client’s desire to change and level of progress with respect to making changes.
Motivational interviewing combines knowledge of individuals stage of change into a directive, collaborative process that builds self-efficacy through empathetic engagement with ambivalence. Often used in conjunction with CBT, these motivational enhancement strategies can reveal a client’s maladaptive thought patterns that can be explored in more detail as the CBT sessions progress. Strategies such as using open-ended questions, affirming client thoughts, reflecting client statements, and summarizing client messages can be helpful in resolving clients’ confusion and resistance to change. Clients in more advanced stages of change (action and maintenance) can begin CBT immediately. In such cases, motivational interviewing exercises such as the decisional matrix, which involves having the client list the pros and cons of using and not using substances, can be employed to clarify further any remaining ambivalence and reinforce motivation to change.
Cognitive Model of Addiction
Multiple interrelated cognitive models of addiction have been developed and evaluated since Bandura’s classic presentations of social learning theory in the late 1960s and 1970s. For example, Marlatt and Gordon described four cognitive processes related to addictions that reflect the cognitive models: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. According to Beck et al., people try drugs initially to get pleasure, to experience the exhilaration of being high, and to share the excitement of using with others. In addition, often additional positive expectations are associated with use of the drug. For example, with cocaine, individuals expect greater energy, fluency, and creativity. They might desire reduced appetite that can lead to weight loss and greater productivity. For clients with alcohol use disorders, often the prime motivations for early use are greater sociability, reduced anxiety, and relief from boredom. These positive consequences often mask the negative consequences of drug use. Although these desired states may be based partly on real drug effects, substance users begin to distort the valence and importance of these effects over time. Cognitive distortions, in combination with life stressors (which ultimately increase as the person begins to neglect or avoid problems or responsibilities), lead to increased drug and alcohol use in pursuit of greater relief and/or pleasure, or a desire just to feel normal. Such problem-distracting behaviors have been described as self-medicating, whereby the person seeks to reduce the distress and problems associated with using through avoidance behavior and by increasing their use. This increased drug and alcohol use often leads to greater problems in the person’s life and greater problem avoidance through greater and/or more frequent substance use.
In addition to the distorted thoughts that substances users hold regarding the positive effects of using, users have been found to have a significantly greater tendency to ruminate on irrational or automatic cognitive thoughts. These thoughts include beliefs such as “I can’t settle down without a few drinks,” “I can’t stand this feeling,” and “people don’t like me unless I am intoxicated.” Such thoughts often relate to feelings of depression and anxiety, and the substance users seek the substance to reduce the distress of such thoughts. Drugs initially act as a distraction against these automatic and distressing thoughts and allow the person to forget the unpleasant ruminations. In this way, drugs appear to serve an adaptive function by allowing the person to turn off the ruminations temporarily. Unfortunately, this distraction is maladaptive over the long term, in that it prevents the individual from facing and dealing with problems in a healthy manner and creates more functional life problems. As the person becomes physiologically and psychologically dependent upon (or addicted to) the substance, the ability to change cognitive distortions without assistance becomes less and less likely. The goal of the cognitive therapist, then, becomes helping the client to recognize these distortions and to develop self-efficacy to actively address such thoughts in a more adaptive manner.
In the context of development of and relapse from alcohol use disorder, Marlatt and Gordon described the process of developing and relapsing from alcohol use disorders as a cognitive decision-making process. He proposed that substance use is a result of multiple decisions, which may or may not lead to further substance use and SUDs. He explained that although some decisions initially appear to be irrelevant to substance use, they nonetheless may result ultimately in an increased likelihood of relapse because of their incremental push toward higher-risk situations. To the extent that a person expects a greater positive versus negative outcome from drinking or using drugs (one’s outcome expectancies), the person is likely to continue using the substance. Individuals’ attributions of causality regarding substance use also play an important role in their continued use, as those who see their use as out of their own control or predestined (due to external factors) will likely maintain their use. Self-efficacy to cope with demanding or otherwise high-risk situations without the use of the substance are also crucial in the context of relapse, with rates of long-term abstinence likely to vary directly as a function of self-efficacy.
From this perspective, the primary tasks of treatment are to identify and challenge the maladaptive cognitions/beliefs surrounding alcohol and drug use and replace them with more realistic and adaptive thoughts and beliefs in order to facilitate more adaptive behaviors of reduced use or abstinence. When more adaptive cognitive thinking has been restored, behavioral changes consistent with constructive thinking will follow. Fig. 40.1 portrays the cognitive behavioral conceptualization of addiction.
Behavioral Model of Addiction
From the perspective of cognitive behavioral theory, SUDs are viewed as learned behavior that is modeled, acquired, and reinforced through experience and learning. If alcohol or drugs provide or are perceived to provide certain desired results (e.g., good feelings, reduced tension) on repeated occasions, the person may learn that the substance leads to the desired outcome. In other words, the substances and positive feelings become strongly associated with each other. People typically begin using drugs or alcohol as a positive reinforcement in their lives—to celebrate a special occasion, as a reward, to reduce inhibitions, and/or to promote relaxation. In other words, initial use of drugs or alcohol is associated with its positive consequences, becoming the preferred way of achieving those results, particularly in the absence of other ways of meeting those desired ends. For some individuals, chronic use of drugs or alcohol can become a problem in cases where the substance is no longer used to feel good, but to avoid negative thoughts/feelings or to feel normal by reducing withdrawal symptoms. When this happens, substance use becomes a negative reinforcement instead of a positive one. From this perspective, the primary tasks of treatment are to (1) identify the specific needs that alcohol and drugs are being used to meet, and (2) develop skills that provide alternative ways of meeting those needs. In so doing, this breaks the learned associations between using drugs and alcohol and both the positive and negative reinforcements.
Persons with substance problems are highly vulnerable to high-risk stimuli for a variety of reasons. Specifically, as people accommodate their drinking and drug habits, they begin to establish behavioral patterns in a variety of environmental contexts, which reinforce their intention to use as well as their experiential expectations. These environmental contexts become associated with the positive experiences of the drug over time and evolve into triggers that stimulate the user’s desire for the drug. These triggers include both internal and external cues. Internal cues may include positive or negative emotions, pain, and/or frustration. External cues can include time of day (e.g., evening, night), place (e.g., at a friend’s house, at a bar), or even other persons (e.g., friend, family). External cues also can include situations such as getting paid or working in an environment where alcohol is served (waitresses, bartenders). These triggers often activate clients’ erroneous or irrational beliefs and lead them to make risky decisions that bring them closer to using. Such triggers must be identified and explored for underlying beliefs that shape physiological sensations linked to craving.
As is the case in the treatment of other disorders, CBT for SUDs involves a unique case conceptualization for each individual. This forms the basis for a strong collaborative relationship between client and therapist, and effectively guides the content of the sessions. Through such collaboration, the client and therapist proceed to utilize specific, goal-oriented techniques tailored to the client’s individualized needs and goals while simultaneously enhancing the therapeutic alliance and collaborative nature of the work. Individuals are also taught to address and resolve naturally arising ambivalence about treatment to develop their motivation and progress toward their treatment goals. During therapy sessions, as well as through the use of self-help homework assignments, clients pursue solution-focused strategies that address the realities of recovery from addictive disorders. Psychotherapeutic innovations in relapse prevention often are implemented over the course of CBT for alcohol and other drug use disorders through identifying and reducing or learning to cope with high-risk use situations.
Jonas is a 47-year-old man with a history of using alcohol since adolescence. He initially began using alcohol to reduce anxiety and facilitate dating experiences after he divorced his wife in his thirties. He began using alcohol as a way to enhance his ability to generate conversations in social situations. He works as an accountant and believes that others are very critical of him and see him as “stuffy” and “boring.” He uses the alcohol mainly in the evenings when he goes out with business associates after work, although on weekends he has noticed that his drinking often starts early and continues all day long when he is visiting with friends or family.
When Jonas first divorced, he was quite anxious about becoming more social and going out with peers again. He started consuming a few alcoholic beverages as a way to reduce his anxiety and lower his inhibitions about making interesting conversation. In this way, Jonas’s behavior was positively reinforced and he would later remember the situation as enjoyable and without anxiety. Over time, however, his tolerance for alcohol increased and he required more drinks to achieve his perceived degree of calmness required to make good conversation. He started feeling more anxious, and even depressed, if he could not consume alcohol, particularly when meeting with others.
Fig. 40.2 shows a cognitive behavioral case conceptualization of Jonas’s alcohol use.
By understanding the relationships between Jonas’s dysfunctional thoughts and behavioral patterns, insight regarding the nature of his alcohol problems can be gained and an individualized treatment program can be developed to address his unique needs. Since CBT has evidence-based techniques as its foundation, techniques such as recognizing and challenging maladaptive automatic thoughts, cue exposure, drug refusal training, and methods for coping with craving are used to help an individual break his/her pattern of addiction. Furthermore, because addictive disorders often involve deficits in areas such as social skills, management of emotions, and tolerance of difficult emotions, individuals often pursue progress in these areas within CBT. For example:
Jonas was encouraged to keep a diary of his thoughts and behaviors to help him understand and recognize the connection between his maladaptive thoughts and subsequent emotions and behaviors. With this information, Jonas and his therapist were able to challenge the veracity of his anxiety-provoking thoughts and substitute his critical interpretations with more rational views of his reality. In addition, Jonas was taught relaxation techniques (progressive muscle relaxation and imagery) to help manage his anxiety, as well as learning to tolerate some anxiety in his interactions with others. Finally, Jonas learned social skills regarding interactions with others, particularly in regard to his unrealistic expectation that he should always be the entertainer in a conversation. Through these interventions, Jonas began to expose himself to social situations without reaching for a drink.
The rationale of CBT holds that SUDs are learned and, therefore, can be unlearned over time through the use of cognitive behavioral techniques. Understandably, a person with an SUD faces many challenges and, potentially, many serious consequences. However, through CBT, such individuals can take part in an effective, flexible, and evidence-based therapy specifically tailored to the challenges involved in overcoming SUDs and their individual needs. In doing so, they can avail themselves of a solution-focused approach to treatment embedded within a respectful and collaborative therapeutic relationship to facilitate recovery from addiction and the overall lifestyle change that they need.
Application of Cognitive Behavioral Therapy for Addiction
Understanding the theoretical underpinnings of cognitive and behavioral conceptualizations of addiction helps the therapist identify logical cognitive and behavioral targets for therapeutic intervention. This allows the therapist to individualize treatment for each client while remaining consistent with the general theoretical approach.
Therapy typically begins with an introduction to CBT and an opportunity for the client to disclose information about himself/herself. This is an important time for self-disclosure and building of the therapeutic alliance, as well as the beginning of the process of case conceptualization of the client and his/her presenting issues. During these early meetings, initial treatment goals are discussed. These goals are set collaboratively, with the client having the final say in the establishment of his/her goals. Abstinence is encouraged but may not be an absolute requirement. Treatment goals may involve substance use behaviors as well as other aspects of clients’ lives, such as improved relationships, mood states, and level of functioning. Therapists work with clients to ensure that these goals are attainable (the client can produce them), realistic (the environment can produce them), and appropriate (they are related to the designated work to be done in therapy). Goals are revisited and revised as needed throughout treatment, based primarily upon the client’s progress, which is assessed regularly.
The therapeutic process itself includes meeting regularly (usually for an hour weekly) for at least 3–6 months or longer if necessitated by continuation of symptoms or development of additional problems. Within each session, material is presented and reviewed regarding specific areas of concentration that relate to SUDs as well as more general issues related to emotional dysfunction. Session material may be presented orally and in writing (e.g., using written materials, flip charts, or a wipe-off board), and clients are encouraged to take notes, as visual learning significantly augments oral presentation of material and helps clients retain more information and stay involved in the session. There are issues that must be covered for the majority of clients receiving CBT, including: coping with cravings, thinking about using, problem solving, refusal skills, dealing with lapses, and relapse prevention. In addition, there often are additional issues that need to be addressed, such as assertiveness training, anger management, and recognizing and managing negative moods. These issues are addressed on an individual basis, but in a standardized cognitive behavioral conceptualization. Thus evidence-based treatment is tailored to the individual and provided in a consistent manner.
Weekly assignments or homework are assigned at each session and reviewed at the following session. The homework is a major part of CBT and ensures that clients are actively incorporating skills and techniques presented and reviewed in sessions in real life. Clients are encouraged to complete the homework, preferably in writing, and always through real-world practice. Research demonstrates that those clients who complete homework assignments more regularly consistently attain a better outcome from therapy, particularly those higher in readiness to change. Therefore, homework completion is strongly encouraged. Compliance with homework can be increased in many ways: (1) through explaining the reasoning for the assignment and why and how it is theorized to help the client; (2) reviewing in session how to complete the homework; (3) assessing the client’s motivation and ability to complete the homework by asking the client how likely he/she is to complete it and identifying any potential obstacles for completion, and then (4) clarifying ambivalence about homework and planning for obstacles, as well as (5) setting realistic expectations for the length of time and level of difficulty of the homework.
If a client is regularly noncompliant with homework, efforts are made to explore and change this therapy-interfering behavior. Specific techniques are employed to improve homework compliance, including making homework assignments specific and clear and explaining the rationale of the homework as well as the potential benefits of completing the assignment. As stated, setting realistic expectations for the homework is also important. Most assignments take less than 15 min to complete, and this needs to be made explicit to the client or else the client may overestimate the time needed to complete the assignment and may not even attempt it. Behavioral experiments need to be clearly defined and a rationale provided for their use, along with expected benefits. In addition, the client’s level of motivation and commitment to completing the assignments can be assessed prior to the end of the session, so that realistic expectations are made regarding the homework. For instance, if a client understands the rationale of the homework and knows how to complete it and how long it will take, but still states that he/she does not want to do it and does not think that he/she is likely to complete it, then both the therapist and client understand that the homework will most likely not be completed unless the client’s motivation changes. Some authors argue that homework non-compliance, to some degree, is an inevitable feature of CBT and, when effectively addressed, can yield some of the greatest opportunities for therapeutic change. To that end, it is an expected and important component of CBT, and both clients and clinicians are wise to anticipate and prepare effectively for non-compliance issues.
General Components of Manualized Cognitive Behavioral Therapy for Addiction
CBT is commonly provided in a standard, manualized format for conceptualizing drinking and drug use problems and designing interventions that focus on developing healthier coping skills. It is often delivered in a collaborative motivational interviewing style, which facilitates the individual’s progress through stages of change and therapeutic recovery. Manualized CBT is based on the early works of Beck et al., Ellis and Velten, and the later works of Marlatt and Gordon. These works eventually were condensed into the National Institute on Alcohol Abuse and Alcoholism’s treatment protocol, which has been broadly utilized in multi-site national addiction studies, including MATCH and COMBINE.
While there have been many variations and therapy subtypes that fall under the collective umbrella of CBT, this protocol specifically outlines standardized session themes and activities that have been shown to bring positive outcomes (reductions in drinking or drug use) and ensures systematic, effective, reliable, and replicable administration of treatment to individuals. The structure of CBT discussion topics and session activities for SUDs is designed to promote effective management of session time, focus on client thoughts, and development of more effective coping strategies. It should be noted, however, that while this manualized approach has proven helpful and represents one of the most common cognitive behavioral frameworks for treating SUDs, therapists have considerable flexibility in matching unique client strengths and weaknesses to specific cognitive behavioral interventions within the weekly theme (such as role plays, review of take-home assignments, and construction of agenda). As such, the session is approached in a collaborative manner that tolerates modifications to planned activities as necessary. Yet, even with these potential changes and exploration of therapy-related themes, an overall commitment to therapeutic setting and following a set agenda is recommended to provide useful structure to the client problem-solving and coping resolution process.
The following recommendations are based on results from the University of Virginia Center for Leading Edge Addiction Research (formerly the Center for Addiction Research and Education) clinic, which is part of the Department of Psychiatry and Neurobehavioral Sciences. Similar to the the National Institute on Alcohol Abuse and Alcoholism’s CBT manual, the clinic also administered CBT over 12 sessions in either group or individual format. There are seven core sessions, four elective sessions, and a termination session. Specific material is covered in each session as tolerated and has been designed and studied for optimum effectiveness.
There are some contraindications for use of CBT in populations with SUDs. First of all, this approach requires a minimum level of cognitive functioning. Specifically, abstract reasoning is deemed necessary for clients to understand and process session material and apply this knowledge to changing their behavior patterns and coping skills. Clients with serious psychopathology (such as manic episodes, psychosis, or acute intoxication) or low IQ/cognitive impairment may likely to have great difficulty understanding concepts such as cues or automatic thoughts and/or systematically adopting new coping skills. Furthermore, clients with a diffuse set of maladaptive thoughts and behaviors may require a greater number of sessions to achieve abstinence in comparison with those with specific, more circumscribed maladaptive symptoms. Finally, CBT is also directive in nature, with the therapist playing a major role in directing the focus and content of each session. As such, some clients may respond with resistance to this approach or demonstrate slow progress in therapy. Thus, it is important to be aware of the stage of change for your client and consider integrating a motivational interviewing style into your work if it is clear that the client is unwilling to admit that they have an addiction problem or if your client loses motivation at any time during treatment. If clients report that they do not wish to change their behavior, cognitive behavioral strategies, such as listing the pros and cons of using and quitting in the form of a decisional matrix ( Box 40.1 ), clarifying values, examining consequences of use and challenging expectancy beliefs about use can successfully be utilized to clarify ambivalence and help refocus the therapeutic work on change.