Most people now know that addiction is a chronic—but treatable—condition. We also know that the right treatment is highly effective in helping people get clean and stay that way. But which treatments are most helpful?
There are many to choose from, but the one that has proven time and again to be fundamental in helping treat addictions and a host of mental health issues is Cognitive Behavioral Therapy, or CBT. Other evidence-based therapies that have yielded great success are Contingency Management, the Community Reinforcement Approach, Motivational Interviewing, the Matrix Model, 12-step Facilitation Therapy, and Family Behavior Therapy.1
Talk to nearly any drug and alcohol treatment program, and they will tell you CBT is their cornerstone form of treatment. And for good reason. CBT has been extensively studied and demonstrated to be highly effective during treatment, with the skills learned lasting long after a patient leaves the program.1
The History of CBT
So where did CBT come from? And what is it, exactly? A little background.
CBT was originally developed to treat mental health disorders in young people, and remains the gold standard for treatment in children and adolescents.2 Since its inception, clinicians have expanded CBT to effectively work with other disorders in adults, including anxiety, depression, and substance use disorders.3
CBT incorporates the most effective aspects of behavior therapy and cognitive therapy and operates on the premise that your thoughts create emotions, which lead to behaviors.3 To change your behaviors, then, you must monitor your thoughts, emotions, and behaviors, and replace these negative thoughts with positive ones to create lasting emotional and behavioral change.2,3
It also incorporates aspects of operant learning theory, which proposes that your behaviors are strengthened or lessened by positive and negative reinforcement.2 Additionally, CBT represents a melding of emotional, familial, and peer influences.
How Positive and Negative Reinforcement WorksPositive reinforcement is a behavioral technique that adds in something positive to reinforce a behavior. This works with school-age children when teachers or parents give them stickers for completing an assignment or a pizza party when the class achieves a collective goal. It also works with adults when auto insurance companies give discounts for good driving records, or you earn cash back on certain credit cards. The positive reward reinforces the likelihood that you will continue to do that behavior. Negative reinforcement, on the other hand, is not punishment for undesirable behaviors, as many people think it is. It is actually the removal of an unwanted effect when you do a certain behavior. A simple example is when you take ibuprofen for a sore back and your soreness goes away, thereby increasing the chances that you’ll take ibuprofen next time your back aches. This concept is often misunderstood since most people don’t think of the term negative in these terms.
The numerous intervention strategies that comprise CBT reflect its complex and integrative nature and include such topics as extinction, habituation, modeling, cognitive restructuring, problem-solving, and the development of coping strategies, mastery, and a sense of self-control. CBT targets multiple areas of potential vulnerability (e.g., cognitive, behavioral, affective) with developmentally guided strategies and uses multiple means of intervention to strengthen those vulnerabilities. CBT has shown to positively alter brain activity, suggesting improved overall brain functioning as well.4
Some of the aforementioned CBT techniques include:
- Modeling: Taken from behavior therapy, modeling involves learning appropriate behavior by watching others.2
- Self-instruction training: This technique involves practicing self-talk to control behavior.2
- Problem-solving skills: CBT focuses on identifying and altering thought processes to create behavioral change.2
Changing thought processes is also said to help increase self-control,2 since consciously connecting thoughts and emotions to actions allows the person to be more intentional about which thoughts to dwell on, and therefore, which behaviors to engage in.
Although CBT is often considered the first-line treatment for many psychological disorders in youth, there are some who do not respond well to the traditional approaches. To better serve these people, both more research and adaptation of CBT techniques are needed.
What to Expect in a CBT Treatment Session
In CBT treatment, you work collaboratively with a trained therapist to learn about your thought patterns and how they can contribute to any maladaptive or self-destructive behaviors.4 A typical CBT session may occur in an individual or group setting, and the first few sessions typically involve the therapist gathering information about you, discussing your concerns, and mapping out the best way to treat these concerns.
A typical CBT session generally includes the following:5
- Exploring situations or conditions that may be causing trouble in your life. This is how you and the therapist will collaboratively decide which concerns to concentrate on first.
- Increasing insight into your thoughts, feelings, and views about these concerns. This can include monitoring your self-talk (thoughts) about the situation, how situations are interpreted, and the ideas you hold about yourself, others, and circumstances. You may do this by maintaining a thought journal or completing a thought chart.
- Once this is done, any negative or erroneous thoughts will be identified through a technique known as reality testing. The therapist may ask you to focus on how you respond to different situations, specifically your physical, emotional, and behavioral responses.4,5
- The next step involves cognitive restructuring, which is working to reframe the negative or harmful thoughts you and your therapist identified. This takes a lot of practice on your part: monitoring your self-talk, identifying if your views are accurate or not, and if they are inaccurate, replacing them with more realistic or positive thoughts.
- In CBT treatment, the therapist often assigns homework to help you monitor your thoughts and reactions and to work on creating lasting change.2,4,5
CBT is a relatively brief treatment technique, usually involving between 10 and 20 sessions.5 Follow-up sessions involve reviewing the progress you made in previous sessions and on the homework assignments, and identifying any difficulties, further concerns, or successes.
If you identify that certain situations cause a lot of stress or anxiety, the therapist may introduce relaxation techniques and practice them with you in session.5 Further sessions then focus on maintaining the positive changes made and overcoming any challenges to reaching your goals.
How CBT Works to Treat Addiction
Since CBT operates on the theory that thoughts, feelings, and behaviors are intertwined and work to reinforce each other, it is a particularly effective treatment for addictions, since substances serve as strong reinforcers for behavior.6 People with addictions often use substances to help them in social situations, to have euphoric experiences, to reduce physical or emotional pain or discomfort, to self-medicate underlying mental health issues, or to stave off withdrawal symptoms.6 Especially in the early stages of substance abuse, alcohol and drugs may seem to work on any and all of the issues listed above, reinforcing your substance-abusing behavior. Over time, you come to associate your substance use (and abuse) as rewarding, even after the consequences far outweigh the rewards.
Because CBT treatment explores your inaccurate beliefs about substance use, and rewards positive steps toward sobriety,6 you gain insight into your thoughts, beliefs, and emotions, and learn how to manage all of these effectively so that they can maintain sobriety. Rather than getting reinforcement from substance use, in CBT treatment you will gain positive reinforcement for abstinence-oriented and positive behaviors.6
Common examples of rewards can include vouchers for goods, privileges while in treatment, participation in positive, sober, rewarding activities, and recognition of sobriety through small tokens such as chips or key tags, as seen in 12-step meetings.6
CBT aims to treat substance use disorders in two broad ways. The first is to make sobriety more rewarding than substance use (through the use of token rewards, for instance). The second is to develop the skills you need to maintain sobriety and avoid relapse. This can be accomplished through using any or all of the following concepts:6
- Addressing your ambivalence toward sobriety and increasing motivation to create change.
- Rewarding sober, positive behaviors to motivate you to overcome the strong reinforcing effects of substance use.
- Developing relapse prevention skills by identifying situations that place you at higher risk for relapse. This can include being around people, places, or things associated with substance use or that often trigger use. Relapse prevention also involves developing strategies to reduce the risk of relapse, such as role-playing refusal of substances in social situations, or using your social support. Reality testing may also be used to check the validity of what you expect to be positive effects of substance use.
- Enlisting family and support group members to create situations that reward sober behavior and make substance use less attractive.
- Identifying maladaptive thought patterns and allowing you to reality-test common thoughts that lead to relapse, such as “I’ll only use or drink once”; “I’ll never be able to get better”; or “I’m not hurting anyone but myself.”Many people with substance use disorders hold on to a belief that using will improve or help them deal with an area of life or issue. Debunking this myth is an important step in recovery.
- Developing or strengthening skills that may be lacking due to substance use, such as interpersonal relationships, managing emotions, and problem-solving abilities.This can include strengthening the ability to refuse an offer of alcohol or drugs in social situations. Many people who use substances have a hard time managing uncomfortable emotions, such as fear, anxiety, anger, sadness, or loneliness, so learning how to manage these feelings in sobriety is essential to the recovery process.
Since CBT is so helpful and effective in treating substance use disorders or behavioral addictions, it is essential to find the right treatment program for you. CBT can be provided in private settings and is used in inpatient or outpatient treatment. Aspects of CBT are also often found in 12-step programs.
- National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition): Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine).
- Benjamin, C. L., Puleo, C. M., Settipani, C. A., Brodman, D. M., Edmunds, J. M., Cummings, C. M. & Kendall, P. C. (2011). History of Cognitive-Behavioral Therapy (CBT) in Youth. Child and Adolescent Psychiatric Clinics of North America, 20(2), 179–189.
- Corey, G. (2013). Theory and Practice of Counseling and Psychotherapy (9th edition). Belmont, CA: Brooks/Cole. P.290–324.
- National Alliance on Mental Illness. (2016). Psychotherapy.
- Mayo Clinic. (2016). Cognitive behavioral therapy.
- McHugh, R. K., Hearon, B. A. & Otto, M. W. (2010). Cognitive-Behavioral Therapy for Substance Use Disorders. The Psychiatric Clinics of North America, 33(3), 511–525.