Cognitive Behavioral Therapy (CBT) for Addiction

How Does Cognitive Behavioral Therapy Work?

CBT is a present-focus approach that has the individual assess their faulty thinking, known as cognitive distortions, to appropriately assess their behavior and thoughts. It does not spend time focusing on the past like other modalities. The core premise of this treatment approach, holds that maladaptive cognitions contribute to the maintenance of emotional distress and behavioral problems.¹ Additionally, these maladaptive cognitions include general beliefs, or schemas, about the world, the self, and the future, giving rise to specific and automatic thoughts in particular situations.¹

CBT was born out of a rejection of many well established therapeutic modalities where the focus was on the past and creating a level of insight into the person. The patient enters into an active collaborative problem-solving process to test and challenge the validity of maladaptive cognitions and to modify maladaptive behavioral patterns.¹

What Conditions Does CBT Address?

CBT is a versatile form of treatment as it can target various symptoms and disorders. It’s adaptable given that it is one of the most extensively researched forms of psychotherapy.² CBT can help with co-occurring substance use disorder issues and other mental health and behavioral issues. It has been well researched for depression, anxiety, schizophrenia, PTSD, anger issues, and eating disorders.²

CBT is an effective treatment for:

• Major depressive disorder
• Anxiety
• Post-traumatic stress disorder (PTSD)
• Addiction
• Eating disorders
• Sexual paraphilias
• Chronic pain
• Schizophrenia and other psychotic disorders
• Bipolar Disorders
• Somatoform disorders
• Anger and Aggression
• Criminal behavior and thinking

How Does CBT Add to Addiction Treatment?

CBT is a highly effective choice for treating substance use disorder as it focuses on targeting the underlying thought patterns, beliefs, and behaviors associated with addiction. CBT empowers patients to develop healthier perspectives and coping strategies as it helps individuals recognize and challenge distorted thinking, such as rationalizations or denial. CBT also teaches patients how to recognize the emotional and environmental triggers as patients need to understand how to manage cravings and to use a relapse prevention plan.

A major strength of CBT for addictions compared to other therapies, is the reliance on teaching techniques and skills so the individual can work on themselves outside of the therapy room. The expectation is for the person to learn with the therapist and then take those lessons into their daily life. CBT helps individuals develop healthier coping mechanisms. CBT can also be beneficial for individuals adopting a California sober approach to managing substance use.

Some of the CBT interventions that are effective in addiction treatment include:

• Motivational interventions: Not everyone is always ready to stop engaging in their addiction. It can take multiple attempts and individuals may need extra motivation and incentive to address the ambivalence they feel.
• Contingency management: The approach for substance use/addiction consists of offering tangible rewards to immediately rival the rewarding aspect of substance use.³
• Relapse prevention: Individuals learn how triggers can promote and continue their addiction. This is necessary as it is those triggers that can entice someone back to using after they have been abstinent from their addiction.
• Homework: Patients are more invested in their treatment and see greater results if they engage in work outside the session. Homework can be worksheets, activities, or trying new behaviors in situations.
• Reframing cognitive distortions: These types of distortions are at the heart of how disorders occur and are maintained. Reframing them allows an individual to get out from under the weight of it and see a situation more accurately.  

CBT Skills Cultivated for Substance Abuse

CBT sessions aim to help patients develop essential skills as part of their addiction treatment by focusing on specific areas that are commonly deficient in individuals struggling with addiction. Some common skill deficiencies include problem-solving skills, emotion regulation skills, coping skills, and assertiveness skills.

CBT provides individuals with practical, tangible tools that they are expected to utilize outside of session in a variety of situations. CBT prepares patients to handle many different challenges as the skills are transferable and cascade into one another. CBT also aims to strengthen a patient’s resolve to fight addiction by fostering self-efficacy and enhancing motivation. It helps individuals build confidence in their ability to overcome addiction by setting achievable goals and celebrating progress. It emphasizes the importance of self-monitoring and self-reflection, allowing individuals to recognize their strengths and accomplishments. It also helps individuals identify and challenge negative beliefs or thoughts that may undermine their resolve. CBT equips patients with the necessary skills to resist relapse and maintain their recovery journey.

CBT skill-building targets three main deficits:

Interpersonal Skills

Interpersonal skills may be impaired due to a number of factors. Some individuals may struggle with communication and assertiveness skills, leading to difficulties in expressing their needs, setting boundaries in relationships, or seeking support. If a person used substances as a way of dealing conflict, they may lack the resolution skills necessary to navigate interpersonal conflicts without resorting to substance use as a coping mechanism. They can also be deficient in building healthy relationships as some of their relationships may have been transactional in obtaining substances or keeping distance from others to prevent feeling judged or confronted.

Skills that can be worked on include effective communication, assertiveness, boundary-setting, active listening, conflict resolution, empathy, and healthy relationship-building. By improving these skills, individuals can enhance their ability to express themselves, develop healthier social connections, and navigate relationships in a way that supports their recovery.

Emotion Regulation

Emotion regulation may be an issue as substances may be sought out when dealing with highly volatile emotions. Emotions can feel scary and overwhelming, especially negative ones, and some may prefer to numb out and not be in touch with these feelings so they do not have to confront and process them. The more someone uses substances as a maladaptive coping skill, the more it becomes reinforced and ingrained. This specific emotional regulation skill is known as distress tolerance as it involves the ability to tolerate and endure distressing emotions without turning to substances as a way to escape or numb the discomfort.

Moreover, long-term substance use can disrupt the brain’s natural reward system and emotional regulation pathways, making it harder for individuals to manage their emotions effectively without relying on substances. A CBT therapist helps to develop emotion regulation skills by educating the patient about the connection between emotions and substance use, helping them understand how their emotions influence their addictive behaviors. The therapist may assist the patient in identifying and recognizing their emotions, teaching them skills for emotional awareness.

Organizational & Problem-Solving Skills

The cognitive effects of substance abuse, such as impaired memory, attention, and executive functioning, can contribute to difficulties in organizing tasks, managing time effectively, and solving problems. Substance abuse can also disrupt one’s motivation, focus, and ability to plan ahead, making it challenging to engage in structured and goal-oriented activities.

A CBT therapist would help individuals build organizational and problem-solving skills by properly assessing the specific deficits and challenges the patient faces in these areas. They may use cognitive restructuring techniques to identify and challenge any negative or self-defeating thoughts that hinder organization and problem-solving abilities. Psychoeducation about the impact of substance abuse on cognitive functioning may also be provided to help the patient understand the connection.

Techniques & Exercises Utilized in CBT for Addiction Treatment

CBT employs various techniques and exercises to help reinforce learning and promote lasting change. These may include cognitive restructuring, where individuals challenge and replace negative thought patterns related to substance use. Behavioral experiments allow individuals to test new behaviors and beliefs surrounding addiction. Coping skills training equips individuals with strategies to manage cravings, stress, and triggers.

Common techniques and exercises utilized in CBT for addiction treatment include:

Thought Records

Automatic thoughts are spontaneous and unconscious and can occur without any type of reason or trigger. The content can be disturbing or disruptive and may bring about feelings of anxiety or depression. Within substance use, these thoughts would work to reinforce negative beliefs about themselves, others, or their ability to recover. These thoughts can contribute to a cycle of self-destructive behavior and maintain the addiction.

Having these thoughts make it difficult to filter out unrealistic and distorted information as it plays on our fears and anxieties. It is challenging to discount contradictory information to have an individual think otherwise. If an individual has a belief that they are incapable of staying abstinent, they may selectively focus on past relapses or failures while disregarding instances of progress or personal strengths. Thought records are a tool to facilitate cognitive restructuring. They involve documenting automatic thoughts, the situation or trigger that elicited them, associated emotions, and any evidence for or against the thoughts.

Behavioral Experiments

A CBT therapist utilizes behavioral experiments to help individuals challenge and test their beliefs and assumptions related to substance use. This approach aims to provide concrete evidence that contradicts negative thoughts or expectations, facilitating a shift in perspective and promoting behavioral change.

One example may involve testing the belief that socializing without substance use is unenjoyable or impossible. The individual would then test this theory out by socializing without substances and evaluate their experience. This helps to accurately judge a situation based on more than their automatic thoughts and distorted beliefs. Behavioral experiments are designed to help individuals develop a more accurate understanding of the relationship between substance use and their beliefs or expectations by contradicting negative beliefs and assumptions.

Imagery Based Exposure

Imagery-based exposure is a therapeutic technique that involves the guided visualization or mental imagery of situations related to substance use or cravings. It aims to expose individuals to these situations in a safe and controlled environment, allowing them to confront and effectively manage their triggers and cravings. It helps desensitize and reduce the intensity of cravings and triggers by putting them in a simulated environment. Individuals can learn to tolerate distress and develop effective coping strategies. Examples include craving exposure, high-risk situations, and negative consequences:

Pleasant Activity Schedule

Someone who has been engaged with substances for a long time may lack the ability to find fun and pleasant activities that do not directly involve substances. They may be so locked into drugs as a form of comfort, that they lose the ability to recognize or find joy in other endeavors. Since their brain chemistry and reward system has also been altered, seeking and using drugs may take on such a pleasurable experience that nothing comes close. This is a big reason why individuals may find it difficult to abstain as anything else is not as satisfying.

This schedule has patients try out new activities that they used to engage in or that they may find enjoyable. They are asked to evaluate how pleasurable it is and are expected to engage in it more than once in order to build a habit. Substances proved to be so pleasant over time that engaging in another activity once or twice will not be enough to counteract all those years of learned responses.

How Does CBT Differ From Other Addiction Treatments? 

An extensive body of evidence from numerous large scale trials and quantitative reviews supports the efficacy of CBT for alcohol and drug use disorders.⁴ Moreover, it is widely believed that CBT is the “gold standard” as a form of therapy.¹ A meta-analytic review of CBT for drug abuse and dependence, including 34 randomized controlled trials found an overall effect size in the moderate range (d = 0.45), with effect sizes ranging from small (d = 0.24) to large.⁴ These robust statistics also hold up over time as evidence supports the durability of treatment.⁴

Despite CBT being held in high regard amongst the field and within meta-reviews, other addiction treatment options exist. As noted earlier, CBT is far and away one of the most researched forms of psychotherapy. Other forms may exist and they might be right for some people. CBT is a goal-directed and collaborative form of therapy, whereas other forms, including AA (Alcoholics Anonymous), adhere to strict guidelines where participants are defined by how long they have been sober.

Are There Complications of CBT for Addiction?

CBT is generally considered a safe and well-tolerated treatment for addiction. While not life threatening or harmful, there are always considerations with which to be aware. Any therapy can bring about a feeling of discomfort as emotions and thoughts are confronted, with addiction issues being prominent. A patient in therapy may feel that they need to withdraw from substances immediately and go cold turkey. Stopping substances immediately can have health complications and it should be explained to patients that it is a process and to seek medical care when discontinuing substances.

Individuals with addiction may also have co-occurring mental health conditions. As such, both issues need to be addressed and it is necessary for a therapist to be adept at focusing on both simultaneously. Not all individuals respond in the same way to CBT or any other treatment modality for that matter. Some may have difficulties engaging with the therapeutic process, struggle with adherence to treatment protocols. Ongoing communication and motivation are crucial to success.

What Other Therapies Work With CBT for Addiction Treatment?

Several therapies can complement CBT. Motivational Interviewing (MI) enhances motivation and commitment to change. Dialectical Behavior Therapy (DBT) helps with emotion regulation and coping skills. Therapies focused on mindfulness foster present-moment awareness and acceptance. Family therapy or couples therapy addresses relational dynamics and provides support. Integrating these approaches with CBT can enhance the effectiveness and comprehensiveness of addiction treatment.

Other therapies that compliment CBT for addiction treatment include:

• Medication management: medications for anxiety and depression can help with the co-occurring mood disorders. Medications can also help with withdrawal symptoms and cravings.
• Support groups: Online group therapy can be supportive and beneficial to individual therapy as it provides a space to speak with individuals with similar experiences.
• Relapse prevention: Relapse prevention is an intervention strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviors.⁵
• Contingency management: Contingency management is behavioral therapy in which tangible positive reinforcers are provided to individuals who misuse substances contingent upon objective evidence of abstinence.

Maximizing the Results of CBT

Several factors are important to get the most out of treatment. Active participation by being present for sessions, being open and honest, and actively applying the skills and techniques learned in therapy to daily life are fundamentals when entering treatment. Part of participating is attending sessions regularly and completing homework sessions with an engaged attitude and not simply completing them as they are a task to complete. Practicing the skills and putting them into your daily life is crucial to ensure that they become ingrained and part of your new routine.

To improve the results of your CBT treatments, you can:

• Stick to the treatment plan and follow the therapist’s instructions
• Be open and honest with your therapist
• Focus on physical health by exercising, eating well, and getting enough rest
• Get plenty of social support from loved ones and support groups
• Complete homework assignments in a timely manner
• Apply the skills and techniques into your life on a regular basis

Deciding If CBT Is Right For Your Addiction Treatment

Deciding what kind of therapy you need for your situation can take time and effort. The treatment modality is not more important than how comfortable you feel with the provider and how motivated you are to meet your goals. If you click with the therapist, that is an important piece of the puzzle. Finding a place where you feel safe and comfortable to speak about the most intimate details of your life is key.

Ask your therapist their experience with addictions and substance use and what type of approaches they use. They should be able to explain how they see disorders develop and maintained.

Finding a Cognitive Behavioral Therapist

There are several ways to find the right therapist. There are a variety of online therapist directories that a therapist and their approach can be researched. Referrals from friends and coworkers can be helpful because it is somewhat vetted. However, a positive referral from a friend does not always translate to you having the same experience with that individual. There are plenty of options for online therapy depending on what the therapist participates in.

How Much Does CBT for Addiction Cost?

Pricing will depend on a variety of factors including experience/license of the provider, if the person accepts insurance, where you live/are looking for services, and the specialty with which you’re seeking. Most insurance plans cover a portion of mental health care, both inpatient and outpatient. Care for substance use issues might be covered under the behavioral health plan.

Cost may also depend on the length with which you’re in treatment. There are recommendations regarding duration of treatment, but you and your provider can periodically assess your progress and decide how long you need to continue your treatment.It should be a collaborative process between you and the therapist to make that determination.

In My Experience

In my experience, CBT is an effective, flexible, and readily accessible way of dealing with substance use and addictions. One of the best features of the modality is that it does not require a person to be in therapy for months or even years. Given that it is predominantly a skills-based approach, individuals can learn new ways quickly and implement them. Success is never guaranteed and individuals enrolling in treatment can be assured that they are under the care of an evidence-based method.