Cognitive-Behavioral Therapy, or CBT, is a short-term form of talk therapy. It is suitable for people of all ages and backgrounds. CBT is based on the idea that how we think affects what we do. Many studies have shown that the mind is a powerful part of recovery.
In a substance abuse context, CBT was first adapted for excessive drinking and later, cocaine addictions. It is now used for most substance use disorders (SUDs), including opioids. Therapists listen and ask questions, and they use logic to motivate patients to pursue and maintain sobriety.
Using CBT, therapists provide patients with a different perspective on their feelings, beliefs and actions. This occurs over multiple sessions. Rather than focusing on the past, CBT focuses on dealing with daily life in the present. It touches on the causes of destructive behaviors like substance abuse. It also pays attention to their consequences.
WHY IS COGNITIVE BEHAVIORAL THERAPY IMPORTANT?
CBT cultivates positive attitudes and often has positive results. Clinical trials support its effectiveness. Experts consider CBT to be the best method for issues like addiction. It’s the most widely used type of therapy. CBT is therefore an essential aspect of most SUD treatment programs.
Patients gain tried and tested practical skills. They learn alternative coping mechanisms for stressful situations and specific problems. Where the problem is using, therapists teach relapse prevention strategies and ways to fight cravings.
CBT can be helpful when used alone. It’s a flexible means of treating a patient’s mental health. But with medication for physical health, CBT forms an effective two-pronged approach to treating SUDs. Co-occurring disorders are common where there are substance abuse issues. Tailored CBT is a way to treat both.
Therapists work with patients to help them recognize and avoid conditioned cues. These triggers cause the urge to use substances. Patients are coached to identify and break negative thought patterns and reactions. CBT breaks down tough problems into small, manageable parts. The goal is for the patient to feel better without resorting to harmful chemicals.
Ultimately, the aim is for the patient to become their own therapist. They become able to re-evaluate situations and regulate their emotions. They can talk themselves down from engaging in addictive behaviors. If they experience a lapse, they don’t see it as a total failure. Rather, they realize they can exercise their willpower again and prevent further substance use.
WHAT ARE COGNITIVE BEHAVIORAL THERAPY TECHNIQUES?
There are a number of different techniques that can be used in CBT. They include:
The clinician can demonstrate a strategy and the patient imitates them to practice it. For example, the patient may be required to act out refusing drugs from a dealer or friend. The therapist could take part in the dialogue. The patient is expected to maintain eye contact and respond quickly and assertively. Alternatively, two therapists could model a behavior, or two patients could role-play in a group setting.
Patients are asked to self-monitor and record various things. They could be tasked with journaling and rating their mood or their ability to cope. Patients receive forms and worksheets to keep tabs on their symptoms. They also need to monitor their progress towards sobriety and other goals discussed with their therapist.
Homework requires the patient to observe negative thinking. Patients need to make mental or actual notes about how they respond to stressors between sessions.
Exposure therapy is used to lessen a patient’s fears. It does this by gradually exposing them to the objects or situations they are afraid of. At first, this happens in a therapist-supported environment. Thereafter, exposure is tackled alone and analysed in therapy.
A member of the military with post-traumatic stress disorder (PTSD) might be confronted with sounds that remind them of combat. With numerous 30-minute exposures, distress becomes less intense over time.
Behavioral experiments are low-stakes opportunities for patients to apply their coping strategies. They present areas for improvement and indicate progress.
A functional analysis considers when, where, why and with whom drug use takes place. It also looks at the consequences of substance abuse. These questions guide patients to see what they need to avoid or be able to cope with.
For example, bars, movies with substance abuse, paydays and leisure time could all be external triggers. Heightened emotions including frustration, anxiety, fear, anger and happiness are internal triggers.
Change Reinforcers and Contingency Management
Bad habits and influences related to substance abuse are to be replaced with positive structure. As far as possible, every hour should be planned. Work, healthier recreational activities, support groups and sponsors all placed into a productive schedule.
Incentives can be offered for doing low-risk activities unrelated to substances. Rewards for decreasing exposure to high-risk situations could include vouchers or personal care items. Staying on schedule often means staying sober.
WHAT IS INVOLVED IN CBT THERAPY?
CBT is fully customized for each individual. Therapists begin the first session by doing two things. They introduce the CBT model and they attempt to build rapport with their patients. A collaborative, trusting therapist-patient relationship is necessary for treatment to be effective.
CBT health professionals provide corrective information, hope, reinforcement and support. Patients usually need to open up and discuss potentially uncomfortable topics to overcome their issues.
Therapists are trained to be non-judgemental. They should be empathetic, but they should not be pushovers. If a patient is not at ease with a particular clinician, they should try working with someone else.
Information shared in therapy is confidential. This confidentiality is only broken if the therapist suspects the patient will self-harm or harm others. Confidentiality is also breached if patients seem unable to take care of themselves.
In CBT, patients learn to challenge the assumptions that contribute towards their problematic behavior.
Some Examples of Negative Thinking Include:
- All-or-nothing thinking which zooms in on failure
- Dismissing the positive and focusing on the downsides
- Overgeneralizing – viewing one bad experience as indicative of similar future situations
- Jumping to worst case scenarios and conclusions
- Assuming full blame for things going wrong
Probing these thoughts is accomplished by doing various exercises. A patient could be given something instructive to read. Some exercises aim to improve interpersonal relationships. Others explore goal-setting, relaxation or resilience.
Homework also normally involves practicing the coping strategies learned. Without homework, CBT is unlikely to bring about positive outcomes. As a result, CBT may be inappropriate for patients with learning difficulties.
CBT tools help patients to identify triggers and high-risk situations earlier. This is followed by a plan of action to avoid using drugs or alcohol as a crutch. CBT paves the way for self-control.
HOW LONG DOES IT TAKE FOR CBT TO WORK?
CBT is a time-limited psychotherapy. It is not like supportive counseling which can go on for years. Sessions are about an hour long. Treatment usually lasts anywhere between 5 and 20 sessions. Initially, these occur once or twice a week. Thereafter, sessions take place every two weeks or once a month depending on how the treatment progresses.
According to SAMHSA, the average patient typically does 16 CBT sessions over a three-month period. Complex conditions can require more than 20 sessions. Results are not instant, but with consistent application the outlook is good.
After a course of treatment, patients can come in for additional maintenance sessions if they want further assistance. This is applicable when someone in recovery is struggling with withdrawal. Booster sessions can offset the risk of having a full-blown relapse.
Besides the speed at which progress is made, there are a number of factors which could affect the duration of treatment. These include:
- Severity of the disorder
- How long a patient has lived with a maladaptive condition
- Strength of social and support network
WHAT HAPPENS IN A CBT SESSION?
CBT sessions are structured and productive. They can take place in groups or online, in inpatient settings or outpatient ones. Both individual and group therapy sessions have their benefits. In the former, there is room for more detail and attention. The latter gives patients a chance to learn from each other.
Sessions are sometimes further divided into three 20-minute segments. These are the general steps followed in a session:
- Mood check – is the patient’s mood improving?
- Bridge – an overview of the previous session is linked to the current one
- Set agenda – both therapist and patient highlight concerns and new material to cover
- Homework review – accountability is built into the CBT process, as is praise for participation
- Address agenda
- New homework is assigned and explained
- Summary and patient feedback
Of course, the therapist would need to deviate from the plan if homework was not done. They explore the reasons for incomplete assignments and ask the patient what would make completion easier for them.
Therapists actively work to keep boredom at bay and to present highly relevant material. Long-term drug use can affect the patient’s memory or ability to grasp new ideas. Concepts are repeated to ensure understanding.