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There are numerous treatment approaches for substance use disorder, and different techniques work best for different people. One of the most commonly used approaches, which you’ll find in nearly all addiction treatment programs in some form, is called cognitive behavioral therapy or CBT. Learn what CBT is and how it works, and why it’s considered the standard of care for drug and alcohol addiction.
What is Cognitive Behavioral Therapy?
Cognitive behavioral therapy (CBT) is a form of psychotherapy. CBT’s core principle is that psychological problems (like addiction) are often based on faulty thinking patterns and unhelpful, self-defeating behaviors. By identifying, understanding, and changing these faulty thought patterns, people can learn better ways to cope, relieve their symptoms, and improve their lives.
CBT places an emphasis on a person’s current attitudes and behaviors and on taking action rather than simply talking about problems. Therapy techniques include behavior skills training, challenging unhelpful mental habits, and teaching clients how to regulate their emotions. It’s commonly used to treat addictions and comorbid conditions such as anxiety and depression or PTSD.
How Does CBT Work in Addiction Treatment?
In many ways, CBT is a training process where a mental health counselor assists a client in learning how to uncover their own faulty mental and behavioral patterns and correct them. This allows clients to stop self-destructive tendencies that they may not have been aware of.
Clients first learn the interrelationships between their thoughts, feelings, and behaviors. With the guidance of their counselor or therapist, they challenge habituated beliefs and cognitive distortions. They also learn to evaluate these from a more realistic perspective and use problem-solving techniques to make positive behavioral changes based on their new and healthier perceptions.
Clients may explore why they use alcohol or drugs, identify situations where they might be likely to use (also called triggers), and develop ways to avoid those situations. Discussion and role play can both be used as tools to help the client imagine and mentally practice alternative ways of thinking and acting in such scenarios.
Clients also learn ways to self-monitor their trigger tendencies, urges, and cravings. They are taught techniques like positive self-talk and the use of relaxation techniques to help them resist cravings. They’re encouraged to focus on their longer-term goal of attaining a healthy and productive future and to recognize that this future offers greater rewards than the immediate gratification of drug use.
CBT not only teaches thinking and behavioral skills, but it also helps clients regain self-control and self-esteem overall, so it can benefit your life in ways beyond addiction recovery.
Effectiveness of CBT for Addiction Treatment
Using CBT in addiction treatment has been studied extensively. It has been shown to reduce the frequency and quantity of drug or alcohol use, and to bring about positive psychosocial changes in the addicted person’s life.
CBT combined with other psychosocial interventions in a comprehensive treatment plan provides the most successful outcomes. CBT combined with medication management has also been shown to be more effective than using either of these interventions alone.
How is CBT Used for Addiction Recovery?
CBT can be utilized as part of individual or group counseling. Families might also engage in CBT together.
Individual therapy sessions allow clients to privately discuss personal problems and struggles and enjoy confidentiality. Group counseling enables clients to learn from one another. These sessions also help clients accept constructive criticism and develop a peer support system. Family therapy offers clients the tools to repair relationships, improve communication, and regain the trust of loved ones.
CBT often includes “homework” assignments too, which are tasks that your therapist instructs you to do when outside the therapy environment. Homework might include journaling thoughts and feelings, attending a support group, or practicing regular meditation.
Combining CBT with Other Therapies
CBT can be combined with other therapies, including motivational interviewing (MI) therapy, where a therapist helps their client explore their reasons for seeking treatment, helps them identify and set goals, and helps them identify the changes in attitudes and behaviors they will need to make in order to reach their goals.
CBT can also be combined with contingency management (CM) therapy, where clients receive reinforcement for abstinence by getting periodic rewards for not returning to drug or alcohol use. Rewards can be monetary, in the form of prize items, or in the form of privileges, which are often offered as CM rewards to incarcerated individuals.
Cognitive Behavioral Interventions for Substance Use Disorders
There are numerous ways that therapists can use CBT. Common CBT interventions or treatment procedures include:
- Cognitive restructuring: Involves identifying and changing misconceptions, which CBT calls cognitive distortions, that cause you to act in ways that aren’t helpful to you or your relationships. Common cognitive distortions include:
- All-or-nothing thinking (I don’t think I can commit to lifelong sobriety so I might as well not try)
- Jumping to conclusions (My partner is late coming home, so they must be out drinking)
- Overgeneralizing (I always screw things up)
- Catastrophizing (I made a mistake; now my life is doomed)
In cognitive restructuring, the mistaken belief is challenged with reality and then replaced with a positive self-talk statement (Ex: Well, I don’t always screw up; I just make mistakes sometimes, like everyone else.)
- Functional analysis, also called the ABC method of assessing self-defeating behavior patterns: Involves looking at a problematic situation, breaking apart the steps that led to it, and considering alternative, helpful replacement thoughts and behaviors to use in similar future situations. It is often conducted during a one-on-one CBT session.
For example, a client falls off the wagon and has a drink after being abstinent for a while. The client and therapist examine the steps that led to the event, starting with the initial problematic behavior, called the antecedent, the “A” part of the therapy model. (Ex: The client went into a restaurant bar to meet a friend.) The antecedent is the catalyst that triggered the urge to drink.
Next, the client and therapist explore what the client was thinking and the beliefs, or “B” component, that he had at the time (Ex: I’m stronger now; I should be able to have one drink and be okay.) Such beliefs are usually based on either cognitive distortions or wishful thinking, rather than objective reality.
Finally, the therapist and client review the “C” component in the model, the consequence of the client’s problematic action. (Ex: The client continued drinking after his first drink, effectively relapsing.)
After reviewing the incident using the ABC steps, the client and their therapist discuss how the client can use the understanding he gained to help him be more aware in the future and avoid taking another “A” step.
- Journaling: Writing about personal thoughts, feelings, and insights, whether on paper or in a computer, can help a person gain clarity and greater understanding about a particular experience. As in the ABC method above, journaling can be a way to analyze a situation and come up with a better plan for a future, similar experience.
Journaling is a good CBT homework assignment. It helps the client immediately as they write, and it can help them again if they share an entry with their therapist.
- Keeping thought records: a structured form of journaling. In this process, a person makes a chart, or log, describing an upsetting event and the thoughts and feelings associated with it in a short, concise format. For instance, using 3 columns, one could list 1) the situation, 2) the emotion (with its intensity rated from 0% to 100%), and 3) the thought/belief (with its intensity rated from 0% to 100% as well).
Afterward, the writer would evaluate the record, rationally considering the actual evidence for and against the validity of the upsetting thoughts and emotions. Then they would consider whether they wish to continue responding to this type of upsetting event in the same instinctive, emotional manner, or they want to begin using more rational thinking instead, the next time a similar event occurs.
- Role-playing: Practicing strategies for high-risk situations. A client and their CBT counselor would discuss common circumstances that act as triggers for drug or alcohol use for the client. They would then explore ways to avoid problematic behaviors associated with each high-risk situation, and the client would role-play taking these preventative actions. By “rehearsing” alternative, positive behaviors, the client becomes better able to make good choices, rather than acting from emotion or habit.
CBT and Medication-Assisted Treatment (MAT)
Within the past couple of decades, medication-assisted treatment (MAT) has become a widely used addiction treatment option, especially for opioid addiction. It involves prescribing specialized medications that reduce cravings and withdrawal symptoms to help clients stay sober. MAT is also often used to treat alcohol addiction. Three MAT drugs (methadone, buprenorphine, and naltrexone) are FDA-approved for use as MAT medications.
Clients who receive MAT combined with CBT experience a significant reduction in relapse risk. This protocol helps by reducing cravings for opioids and mitigating painful withdrawal symptoms.
Using MAT in conjunction with CBT has been shown to be more effective than using either alone, especially in the treatment of opioid addiction. MAT can be accessed within both inpatient and outpatient addiction treatment.
Technology-Based CBT for Addiction Treatment
Cognitive behavioral therapy can be accessed remotely as telehealth, either through a phone call or video call. This method of treatment expanded during the pandemic and remains a reliable option for receiving addiction treatment today.
It’s especially helpful for people who live in rural areas where access to face-to-face therapy is limited or difficult. It’s also useful for people with physical limitations that make travel difficult, people without reliable transportation, and those who are reluctant to leave home for other reasons.
Telehealth therapy can provide face-to-face sessions through online video conferencing and phone counseling. Medication management, health screenings, and group education sessions can also be delivered by telehealth. Many 12-step support groups now offer online meetings in addition to in-person meetings.
Smartphones have greatly accelerated the use of technology for addiction treatment, with innovative new options being created regularly. People can now access craving helplines via phone calls or text messages, receive personalized motivational text messages, and receive contingency management rewards via texts.
They can have immediate access to sponsors and automated relapse prevention support messages. They can even download phone apps that use GPS technology to warn them when they are approaching a high-risk area, such as the proximity to a bar or a neighborhood with high drug use. AA and NA have phone apps that provide updated local meeting information and daily reflection messages. All these options involve CBT-related techniques.
The spread of telehealth treatment for substance use issues will likely continue to grow as evidence of its efficacy increases. Technology-based addiction treatment can provide a convenient and reliable way for many people to access the help they need, right at their fingertips.
Finding a CBT Provider for Addiction Treatment
If CBT sounds like a promising therapy for your addiction recovery, as it is for most, we can help you find a treatment provider. Explore our online rehab directory to find treatment centers that use CBT.
