Beyond Talk: Learning How to Replace Addictive Behaviors Using Cognitive Behavioral Therapy
Overcoming addiction, getting unstuck from unhealthy behaviors, and moving on with your life is tough work. An individual dependent upon or addicted to substances can see a counselor for months or years to gain insights into why he or she abuses alcohol or drugs, engages in compulsive gambling, sex, or other addictive behaviors and still be stuck. After drying out or detoxification and undergoing treatment, however, without some solid strategies in their toolkit, the person will have a rough road ahead in recovery. While talking things out on an individual or group therapy basis is an integral part of the healing process, it’s necessary to go beyond talk: Patients need to learn how to replace addictive behaviors.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do, according to the National Association of Cognitive Behavioral Therapists (NACBT). The National Institute on Drug Abuse (NIDA) says CBT is a short term, focused approach to treatment that attempts to help patients recognize situations in which they are most likely to use drugs (or other substances or engage in other addictive behavior), avoid such situations when appropriate, and learn how to cope more effectively with a range of problems (and problematic behaviors) associated with substance abuse.
CBT doesn’t exist as a distinct therapeutic technique. Rather, according to the NACBT, CBT is a general term for a classification for a number of therapies with similarities. These include Rational Behavior Therapy, Cognitive Therapy, Rational Emotive Behavior Therapy, Rational Living Therapy, and Dialectic Behavior Therapy.
NIDA and the NACBT say that several important features of CBT make it appropriate for use in the treatment of particular types of drug abuse. NIDA publishes a manual where CBT is used for the treatment of cocaine abuse, but CBT has also been used to treat alcoholism and other forms of drug addiction, especially as part of an overall recovery program.
- Short-term – CBT is a relatively short-term (compared to other forms of treatment, including psychoanalysis, which can take years) approach, lasting from 12 to 16 weeks. CBT is time-limited in that the patient is instructed at the outset of the therapy that there will be a point where the formal therapy process will end. This ending date of formal therapy is a mutually-arrived upon decision between the therapist and the patient. Therefore, CBT is not a never-ending treatment approach.
- Evidence of CBT’s effectiveness in this short period of time makes it an attractive approach for clinicians to utilize – alone and in conjunction with other treatment modalities. CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support as a treatment for cocaine abuse, for example. CBT has even proven effective for severely dependent cocaine abusers, according to NIDA data.
- CBT is structured and directive. Therapists have a specific agenda for each session and specific techniques or concepts are taught during each session. CBT is focused on the client’s goals, not what the therapist thinks those goals should be. It is therefore directive in that CBT therapists show clients how to think and behave in ways to obtain their stated goals. The CBT therapist doesn’t tell the patient what to do – they teach the patient how to do what it is they want to do (such as abstain from drug use).
- Flexibility is a key component of CBT. It can be readily adapted to a wide range of patients, settings that include inpatient or outpatient, and formats such as individual or group.
- CBT is a collaborative effort between the patient and the therapist. In order to be able to help the patient, the CBT therapist needs to learn what the patient wants out of life (his or her goals), and then help the patient achieve those goals. The CBT therapist listens, teaches, and encourages, while the role of the patient is expressing concerns, learning, and implementing.
- Speaking of the relationship between the CBT therapist and the client, a sound therapeutic relationship is necessary, but it isn’t the focus of the treatment. A good, trusting relationship is the foundation, but there also has to be more. CBT therapists believe that their clients change because they learn how to think and act differently as a result of their learning. CBT, therefore, focuses on teaching rational self-counseling skills.
- CBT is compatible with a range of other forms of treatment the patient may receive, including pharmacotherapy, self-help groups such as Alcoholics Anonymous and Cocaine Anonymous, family and couples therapy, vocational counseling, parenting skills, and so on.
- CBT is based on an educational model. The therapy is based on the assumption that most behavioral and emotional reactions are learned. The goal of CBT, then, is to help patients unlearn maladaptive behavior and learn a new way of reacting that is healthier. The educational benefits of CBT lead to long-term results. When patients understand how and why they are doing well, they know what they need to do to continue those good outcomes.
- Homework is a central feature of CBT. Patients need to complete reading assignments and practice what they’ve learned between sessions.
Key Components of CBT
There are two key components of CBT: functional analysis and skills training.
Functional Analysis: The patient and the CBT therapist work together to identify the feelings, thoughts, and circumstances of the patient before and after he or she drinks or uses drugs. This helps the patient to better understand the risks that will likely lead to a relapse. The functional analysis is critical, especially during the early treatment phase, for the patient and therapist to assess the high-risk situations that are likely to lead to drug use, as well as provide insights into why the patient may resort to using drugs. Some of the reasons may be coping with interpersonal difficulties, escaping from reality, or achieving euphoria not otherwise available in the patient’s life. Further on in treatment, the functional analysis of episodes of drug or alcohol use may identify situations or states during which the patient continues to have difficulty coping.
Skills Training: Think of skills training as a way for patients to unlearn old habits and learn new and healthier behaviors to replace them. Treatment professionals say that by the time a person’s drug habit is severe enough to warrant treatment, they have been using drugs as their primary means of coping with a wide range of interpersonal and intrapersonal problems. The reasons why include:
- They may never have learned effective strategies to deal with challenges in adult life. This is particularly true for those whose substance abuse began early in life (adolescence).
- Due to chronic involvement in a drug-using lifestyle, the individual may have forgotten effective strategies to deal with challenges and stresses. Constantly in drug-seeking, using, and recovering from the effects of drug use, the individual has repeatedly relied only on drug use as an effective coping mechanism.
- Although the individual may have learned effective strategies at one time, their ability to use them may be weakened by the presence of other problems, such as drug use and concurrent psychiatric disorder.
How CBT Works
When the patient (client) takes part in CBT, ideally, the session is just between the therapist and client. However, CBT can be modified to work in group sessions as well, as long as the session is structured to be long enough (at least 90 minutes, as compared to the normal 60 minute session length) so that each patient gets the opportunity to comment on their personal experience in trying out skills, give examples, and participate in role-playing.
The setting is typically an outpatient basis – although it is also effective in residential or inpatient settings. The outpatient setting, however, is preferred because it focuses on understanding what determines the patient’s substance use, and this is best done in the context of the patient’s day-to-day life. It’s important for the CBT therapist to know where and how the individual lives, and who they are, so that individualized functional analyses can be created. The outpatient setting is also more conducive to the patient’s practice of skills training learned during the sessions. They learn what does and doesn’t work for them and discuss new strategies with their CBT therapist.
During sessions, there are some essential interventions that must be part of the CBT in order to be effective. According to NIDA, these include:
- Functional analyses of the substance abuse
- Examining the patient’s cognitive processes relative to substance abuse
- Identification and debriefing of past and future high-risk situations
- Personalized training in recognizing and coping with craving, managing thoughts about substance abuse, solving problems, planning for emergencies, refusal skills (how to turn down invitations to use), and recognizing seemingly irrelevant decisions
- Practicing skills during sessions
- Encouraging and review of extra practice of skills between sessions
During the CBT session, the therapist may do the following, and it is recommended that they do, but these are not unique to CBT:
- Discuss, review, and reformulate with the patient the goals for treatment
- Monitor substance use (drug of choice) and craving
- Monitor use of other substances
- Monitor the patient’s general level of functioning
- Explore with the patient the positive and negative consequences of substance abuse
- Explore the relationship between affect and substance abuse
- Give feedback on the patient’s urinalysis results
- Set the next session’s agenda
- Comment on the process with the patient as warranted
- Discuss the advantages of a goal of abstinence
- Explore any ambivalence about abstinence on the part of the patient
- Use exploration and a problem solving approach to deal with patient resistance
- Support the efforts of the patient
- Assess the patient’s level of family support
- Explain how a slip and a relapse are different
- Include family members (or significant others) in at least two of the CBT sessions
Format of a Typical CBT Session
The flow of the CBT session (in a 60-minute session) may follow the 20-20-20 rule. Using this format, during the first 20 minutes the therapist focuses on the patient’s substance abuse, cravings, and high-risk situations since the last session. The therapist listens and tries to elicit the patient’s response, with the result that this portion of the session usually involves the patient doing most of the talking. In addition, the therapist seeks to find out how the practice of skills went in between the session (the patient’s homework, based on what he/she learned in the previous session). The therapist may ask if the practice session was harder than expected, if the patient had any difficulties performing the practice, if he or she came up with any new strategies, and what worked well or did not work as well?
The second 20 minutes is devoted to the introduction and discussion of the topic for the particular session. In this segment, the therapist does most of the talking, although it is important that the therapist relate the material back to the patient and ensure he/she understands what’s being introduced. A topic may be skills for refusing an offer of cocaine, or what to do in particularly high-risk situations. The therapist may ask if the patient understands the session material or how and why it relates to them, to describe the topic or skill in their own words, and role-play or practice the skill within the session.
Skill topics depend upon the substance abused (or addictive behavior) and are tailored to the patient’s individual needs. As an example, there are eight skill topics for CBT for cocaine abuse. These include:
- Coping with craving
- Shoring up motivation and a commitment to stop
- Refusal skills/assertiveness
- Seemingly irrelevant decisions
- An all-purpose coping plan
- Problem solving
- Case management
- HIV risk reduction
The final 20 minutes involves the patient and therapist having a discussion about the topic introduced. Together, they agree on a practice exercise for the next week, and review plans for the next week and anticipate any high-risk situations.
Here is an example of a practice exercise for cocaine abuse. The patient is asked to write down or record his or her answers (as many answers as apply) to the following questions:
- Trigger – What sets me up to use cocaine?
- Thoughts and Feelings – What was I thinking? What was I feeling?
- Behavior – What did I do then?
- Positive Consequences – What positive thing happened?
- Negative Consequences – What negative thing happened?
Unlearn Old – Learn New
In summary, CBT is an evidence-based form of psychotherapy that focuses on helping the patient to unlearn old drug-using or addictive behavior and learn to replace it with healthier behavior. CBT works for some individuals, but not for others. CBT works best when used in combination with other recovery efforts. While it may be adapted for group use, it is considered most effective when used in a one-on-one therapist/patient basis.
Where can you find CBT therapists? Go to the website of the National Association of Cognitive-Behavioral Therapists and use their search tool to find a mental health professional certified by NACBT in your area. Enter the country, state, age of the potential CBT client, and form of therapy sought (individual, couples, families, gay/lesbian/bisexual, or groups) and click “Submit.”
Also check with residential addiction treatment facilities and outpatient addiction treatment centers to find out if CBT is part of an overall treatment program.
Remember that CBT is a structured and time-limited therapy, usually lasting 12 to 16 weeks. There may be booster sessions, as appropriate, and a long-term (one-year) follow-up that’s part of the therapeutic process. As with other forms of therapy for drug abuse or addictive behavior, the motivation and determination of the patient to a life of abstinence in recovery is a crucial part of the process. By unlearning old behaviors and learning new ones, the road to recovery can be a lot easier to travel.