What is CBT?
A Guide to Cognitive-Behavioral Therapy

To treat a disease, doctors often first try to understand why it happens. Surprisingly, for addiction, this process has taken a while. Doctors first thought addiction was a disease that had only physical attachments to drugs or alcohol. 1 Today, doctors understand that addiction is a complex, relapsing behavior that causes a person to lose physical and mental control over their substance abuse.

If substance abuse is a disorder of thinking as well as physical influences, then treatments must be more than just helping with detoxing from a substance. They also must mentally detox and learn how to overcome mental cravings. This is where cognitive behavioral therapy enters the picture. 2 Cognitive behavior therapy is a therapeutic approach involving educating about types of behaviors and thinking that can lead to substance abuse as well as relapse.

What Is Cognitive-Behavioral Therapy?

The theoretical basis for cognitive behavioral therapy is that substance abuse can reinforce behavior in different ways . 3 For example, using substances at a party may result in positive feelings being connected to drinking or using at a party as a way to make a party more fun. A person may also view that substance abuse takes away their views of negative aspects of their lives. Cognitive behavioral therapy aims to help a person see the reinforcing effects of abstinence from substance abuse. An example of this is offering a person a monetary prize or reward for continued abstinence. Another is helping a person find rewarding, stress-relieving activities outside of substance abuse that help a person feel more positively about their life.

Cognitive behavioral therapy is a two-step process. It starts with helping a person identify how the way they think and what they find acceptable in terms of substance abuse is impacting their life. Then, the therapy involves learning the types of behavioral changes that can help them achieve long-lasting sobriety.

History of Cognitive-Behavioral Therapy

Cognitive behavioral therapy likely started in many different areas of the world as an extension and variation of psychotherapy. 4 One of the theorists whose work laid the foundation for behavioral therapy was John B. Watson, who published papers in the 1920s related to behavior and behavior modification techniques. Behavioral therapy was the first iteration of the therapy, which focused on ways to adjust behavior to support positive life transitions. An example of this approach would be when treating a person with anxiety, the therapist would help the person find ways to avoid social situations to reduce anxiety. However, some therapists found this approach did not truly solve the underlying problem of changing the way a person thought about the behavior.

Many psychologists consider the 1960s and 1970s as a “cognitive revolution” where more research and theories surrounding the cognitive portion of therapy was emphasized. Even though cognitive behavioral therapy was emerging at this time, it wasn’t typically used regarding substance abuse treatment. Instead, it was more to treat conditions such as anxiety or depression.

Cognitive behavioral therapy is often used in relapse prevention programs . The history of its use for this purpose dates back to 1978 when G. Alan Marlatt proposed the first cognitive-behavioral model of relapse prevention. Prior to this time, medical experts were largely regarding addiction as a disease where treatments could cure the physical cravings associated with substance abuse. However, this viewpoint did little to address the mental connection a person struggling with alcohol or drug addiction has to the substances they use.

A cognitive-behavioral model for relapse prevention aims to examine and adjust thought process and response when an individual is placed in a high-risk situation that could trigger relapse . In his research for preparing this cognitive model, Marlatt found that people who felt their sobriety was out of their physical or mental control, they were more likely to relapse. Marlatt found if an individual could view a relapse as a learning opportunity and not an inevitable failure, they were more likely to regain their sobriety.

Initially, the cognitive-behavioral model was used to treat those suffering from alcoholism. As time has passed, its use has expanded to treatments for other addiction types, including to drugs, gambling, and other addictions.

By the end of the late 1970s, cognitive behavioral therapy had cemented itself as a lasting and effective therapeutic approach.

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How Does Cognitive-Behavioral Therapy Work?

Cognitive-behavioral therapy is a combination of education, challenging commonly held myths regarding addiction, and correcting maladaptive thoughts . Examples of interventions involved in cognitive-behavioral therapy include: 1

  • learning effective coping strategies, such as stress management
  • identifying triggers that could potentially lead to relapse
  • increasing a person’s self-efficacy (their belief that they have power over their problems)
  • encouraging a person to practice responses to challenging scenarios
  • engaging in relaxation training

Multiple Therapies Used for Addiction Recovery

There are subsets of cognitive behavioral therapy that an addiction treatment specialist may choose to utilize based on their client. Examples of these therapies include:

Contingency management:

This approach involves providing reward strategies as positive reinforcement for drug-free behaviors. An example could be that a person who had a negative drug screen qualifies for putting their name into a drawing for prizes that range from inexpensive at $1 to $5 to those that are worth $50. These incentives can help some people view tangible rewards from their abstinence.

Motivational interviewing:

This treatment involves using communicative techniques to help a person struggling with substance abuse addiction find their personal motivations to becoming and staying sober. This approach is typically utilized in a one-on-one counseling environment.

Relapse prevention:

Relapse prevention in cognitive-behavioral therapy involves identifying situations where a person is at greater risk for temptation to relapse. These include seeing old friends a person used to do drugs with or going to a party. In this instance, cognitive behavioral therapy involves helping a person rehearse how they will think, act, and speak when they are faced with the temptations to relapse.
A cognitive behavioral therapy session usually involves working with a therapist to talk about the decision-making process behind abusing substances or refraining from using them. A session may include a rehearsal of a person being at a party, being offered drugs, and subsequently what the person will say when refusing the drugs.

Misconceptions About Cognitive-Behavioral Therapy

A common misconception about cognitive behavioral therapy is that is it the sole therapy a person uses in their substance abuse treatment . 3 Instead, cognitive behavioral therapy is often one of several approaches a person may use to maintain their sobriety. Doctors may recommend using the therapy along with pharmacotherapy to encourage drug abstinence. A combination of cognitive behavioral treatments with opioid agonist therapies (such as methadone) showed greater effectiveness than each treatment alone. However, there are some instances where combinations of cognitive behavioral therapy and medications haven’t shown greater effectiveness. This is true for the combination of naltrexone and cognitive behavioral therapy in encouraging abstinence from drinking.

Effectiveness of Cognitive-Behavioral Therapy

According to a meta-analysis published in the journal Psychiatric Clinics of North America, researchers found a “moderate” effect of cognitive behavioral therapy in treating alcohol and drug use disorders2. The researchers studied the results of 2,340 patients who described the effects as ranging from small to large.

According to the review, people experienced a more significant treatment effect when cognitive behavioral therapy was used to treat addictions to the following substances:

  • cannabis
  • cocaine
  • opioids
  • addictions to multiple substances
Researchers compared the effects of cognitive behavioral therapy compared to traditional substance abuse treatment therapies, such as drug counseling. According to the authors, one of the studies examined showed that 60 percent of patients in treatment for cocaine dependence provided clean toxicology screens one year after they began cognitive behavioral therapies.

The researchers also found similar results were obtained by other researchers published in the Journal of Studies on Alcohol and Drugs . For this meta-analysis, the researchers examined 53 clinical trials where the researchers used cognitive behavioral therapies to treat those with alcohol or substance abuse disorders. The researchers found that cognitive behavioral treatments showed positive effect in people across a variety of treatments. They also found the therapy was most effective in helping those addicted to marijuana and in treating women.

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What Training Is Required for Cognitive-Behavior Therapy?

A variety of therapy professionals may provide cognitive therapy services. According to the Mayo Clinic, these include:

  • licensed marriage and family therapists
  • licensed professional counselors
  • licensed social workers
  • psychiatric nurses
  • psychiatrists
  • psychologists

Because there are many different types of addiction treatment therapists, a person should ask about an individual’s specific training regarding cognitive behavioral therapy.5 For example, psychiatrists are medical doctors who can prescribe medications in addition to providing cognitive behavioral therapy while licensed social workers or counselors cannot.

Where Can I Find Cognitive-Behavioral Therapy?

Cognitive behavioral therapy can have many names or variations. For this reason, a therapist may offer the behavioral technique, yet a prospective client may not immediately identify the technique by name. Motivational interviewing and contingency management are both names for cognitive behavioral techniques. Sometimes a person should simply ask if the therapies offered are rooted in cognitive behavioral techniques. Because it is a very common approach to therapy it’s likely a person should not have difficulty in finding cognitive behavioral therapists in most treatment centers or psychiatric private practices.