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Cognitive Behavioral Therapy for Substance Use Disorders
Cognitive behavioral therapy (CBT) is one of the most widely used psychotherapies. It was developed in the 1960s by Aaron Beck specifically for the treatment of depression, but its core principles were quickly adapted and applied to a variety of diagnoses. We now have evidence-based CBT interventions not only for depression but also for anxiety, PTSD, bipolar disorder, obesity, insomnia, and substance use disorders (SUDs). Here we’ll go through the basic framework of CBT, how it can be applied to SUDs, and ways to incorporate parts of CBT into your daily addiction treatment practice.
CBT overview
The general treatment approach of CBT is to identify problematic thoughts and behaviors, evaluate what is contributing to those thoughts and behaviors, and then apply new skills to change the outcome of a given situation (Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York, NY: Guildford Press; 2011). Through this process, negative or irrational core beliefs are identified and then changed over time to positive or rational beliefs. For example, the thought “I am terrible at everything and others are better than me” may become “I have strengths and weaknesses, just like other people.” CBT is problem-focused, meaning that a patient identifies specific areas of improvement and generally works on one problem or situation at a time. CBT is also present-oriented; it does not focus on past developmental experiences. The therapist can be directive, taking on the role of a teacher for skills training. The classic CBT model of individual or group-based therapy takes place over about 12 structured sessions, but the concepts we’ll discuss here can also be used in brief medication management visits.
CBT applied to SUDs
When CBT is applied for the treatment of SUDs, several common treatment themes usually emerge, no matter which substance is being used (McHugh RK et al, Psychiatr Clin North Am 2010;33(3): 511–525). The key components of CBT that are helpful in treating SUDs are functional analysis, which is identifying triggers and high-risk situations, and skill building. Together the provider and patient can pinpoint maladaptive behavior patterns, barriers to change, and skill deficits. Examples include identifying high-risk situations, like driving by a liquor store; a related skill that can be developed may involve taking a different route (avoiding) or reciting reasons to quit when passing by the store (coping). G. Alan Marlatt’s relapse prevention therapy incorporates these aspects of CBT into initiating and maintaining positive behavior change; it has been used to treat SUDs for decades (Hendershot CS et al, Subst Abuse Treat Prev Policy 2011;6:17). One common method of skill building involves role-playing exercises between the provider and patient. For instance, the patient may identify a high-risk situation at school or work that involves pressure to use substances. The provider can take on the role of the fellow student or coworker while the patient practices different ways of handling the situation.
12-step programs commonly use CBT techniques when dealing with external and internal triggers for substance use (https://sobernation.com). For external triggers, think of people, places, and things: social contacts the patient hung out with, the place the patient was buying or using drugs, and things associated with the drug use like paraphernalia or favorite drinking glasses. External triggers can even be sensory, like sounds or smells the patient associates with drug use. Internal triggers can be explained using the 12-step acronym of HALT: Hunger, Anger, Lonely, and Tired—all common states that can trigger use. When a craving occurs, patients should stop and evaluate whether they are in one of the HALT states, and then take steps to fix the HALT situation instead of turning to substances. This requires using the CBT techniques of identifying the behavior pattern (functional analysis) and then substituting a positive behavior for the negative one (skill building). For instance, carrying around healthy snacks can stop hunger, having go-to meditation exercises can soothe anger, reaching out to a trusted friend or sponsor can address loneliness, and napping or taking time to relax can help deal with feeling tired.
Does it work?
Do these CBT interventions actually work to decrease a patient’s substance use? The evidence for CBT has been mounting since the 1980s, and a 2009 meta-analysis looked at 53 studies of CBT specifically for SUDs (Magill M and Ray LA, J Stud Alcohol Drugs 2009;70:516–527). Across all studies, there was a small but significant effect size of 0.144, p < 0.005. When breaking the studies down for type of substance, CBT had a small significant treatment effect for each, except for marijuana use where the effect size was moderate at 0.513, p < 0.005. Effect sizes increased when CBT was combined with other psychosocial treatment (0.305, p < 0.005) or with medication management (0.208, p < 0.005). The largest effect size of 0.796, p < 0.005, was seen with the studies that compared CBT to no treatment at all.
Incorporating CBT into your practice
While many of your patients may not have the time or resources to attend a course of structured CBT sessions, there are many ways to incorporate CBT concepts into your daily practice. When patients are in the early stages of change, motivational interviewing can bring them closer to the action stage, and then CBT techniques can be used to learn and practice specific skills to promote and maintain recovery. This can be as simple as asking about triggers for their substance use (functional analysis), then thinking about ways of avoiding or coping with those triggers (skill building). Other skills that can be improved upon in a brief clinical visit include communication skills with friends and family, coping skills for emotional regulation, identifying pleasurable sober activities to replace substance use, and goal-setting (eg, deciding on a quit date). Also, know when to refer a patient for a full CBT course. If you have someone who is ready to learn new skills, capitalize upon that motivation by connecting the patient with group or individual therapy providers.
To learn more about structured CBT sessions and how to incorporate the basics of functional analysis and skill building into your practice, there are some free resources available online. While CBT skills can be applied to recovery from any substance, the National Institute on Alcohol Abuse and Alcoholism has a guide specifically for alcohol use disorder treatment (https://archives.drugabuse.gov/sites/default/files/cbt.pdf). The National Institute on Drug Abuse has a similar guide for cocaine use disorder (https://pubs.niaaa.nih.gov/publications/projectmatch/match03.pdf). Finally, for other ideas on how to incorporate CBT techniques into a medication management visit, the APA offers a book worth checking out (Wright JH, Sudak DM, Turkington D, Thase ME, eds. High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide. Arlington, VA: American Psychiatric Association Publishing; 2010).
CATR Verdict: CBT skills are easy to learn and evidence-based to promote recovery from addiction. It’s definitely worth the time to familiarize yourself with the core concepts of functional analysis and skill building. Learn a few CBT exercises that are high-yield for your patient population as part of your clinical arsenal. These CBT interventions can easily be incorporated into the time frame of medication management visits.
Addiction TreatmentCBT overview
The general treatment approach of CBT is to identify problematic thoughts and behaviors, evaluate what is contributing to those thoughts and behaviors, and then apply new skills to change the outcome of a given situation (Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York, NY: Guildford Press; 2011). Through this process, negative or irrational core beliefs are identified and then changed over time to positive or rational beliefs. For example, the thought “I am terrible at everything and others are better than me” may become “I have strengths and weaknesses, just like other people.” CBT is problem-focused, meaning that a patient identifies specific areas of improvement and generally works on one problem or situation at a time. CBT is also present-oriented; it does not focus on past developmental experiences. The therapist can be directive, taking on the role of a teacher for skills training. The classic CBT model of individual or group-based therapy takes place over about 12 structured sessions, but the concepts we’ll discuss here can also be used in brief medication management visits.
CBT applied to SUDs
When CBT is applied for the treatment of SUDs, several common treatment themes usually emerge, no matter which substance is being used (McHugh RK et al, Psychiatr Clin North Am 2010;33(3): 511–525). The key components of CBT that are helpful in treating SUDs are functional analysis, which is identifying triggers and high-risk situations, and skill building. Together the provider and patient can pinpoint maladaptive behavior patterns, barriers to change, and skill deficits. Examples include identifying high-risk situations, like driving by a liquor store; a related skill that can be developed may involve taking a different route (avoiding) or reciting reasons to quit when passing by the store (coping). G. Alan Marlatt’s relapse prevention therapy incorporates these aspects of CBT into initiating and maintaining positive behavior change; it has been used to treat SUDs for decades (Hendershot CS et al, Subst Abuse Treat Prev Policy 2011;6:17). One common method of skill building involves role-playing exercises between the provider and patient. For instance, the patient may identify a high-risk situation at school or work that involves pressure to use substances. The provider can take on the role of the fellow student or coworker while the patient practices different ways of handling the situation.
12-step programs commonly use CBT techniques when dealing with external and internal triggers for substance use (https://sobernation.com). For external triggers, think of people, places, and things: social contacts the patient hung out with, the place the patient was buying or using drugs, and things associated with the drug use like paraphernalia or favorite drinking glasses. External triggers can even be sensory, like sounds or smells the patient associates with drug use. Internal triggers can be explained using the 12-step acronym of HALT: Hunger, Anger, Lonely, and Tired—all common states that can trigger use. When a craving occurs, patients should stop and evaluate whether they are in one of the HALT states, and then take steps to fix the HALT situation instead of turning to substances. This requires using the CBT techniques of identifying the behavior pattern (functional analysis) and then substituting a positive behavior for the negative one (skill building). For instance, carrying around healthy snacks can stop hunger, having go-to meditation exercises can soothe anger, reaching out to a trusted friend or sponsor can address loneliness, and napping or taking time to relax can help deal with feeling tired.
Does it work?
Do these CBT interventions actually work to decrease a patient’s substance use? The evidence for CBT has been mounting since the 1980s, and a 2009 meta-analysis looked at 53 studies of CBT specifically for SUDs (Magill M and Ray LA, J Stud Alcohol Drugs 2009;70:516–527). Across all studies, there was a small but significant effect size of 0.144, p < 0.005. When breaking the studies down for type of substance, CBT had a small significant treatment effect for each, except for marijuana use where the effect size was moderate at 0.513, p < 0.005. Effect sizes increased when CBT was combined with other psychosocial treatment (0.305, p < 0.005) or with medication management (0.208, p < 0.005). The largest effect size of 0.796, p < 0.005, was seen with the studies that compared CBT to no treatment at all.
Incorporating CBT into your practice
While many of your patients may not have the time or resources to attend a course of structured CBT sessions, there are many ways to incorporate CBT concepts into your daily practice. When patients are in the early stages of change, motivational interviewing can bring them closer to the action stage, and then CBT techniques can be used to learn and practice specific skills to promote and maintain recovery. This can be as simple as asking about triggers for their substance use (functional analysis), then thinking about ways of avoiding or coping with those triggers (skill building). Other skills that can be improved upon in a brief clinical visit include communication skills with friends and family, coping skills for emotional regulation, identifying pleasurable sober activities to replace substance use, and goal-setting (eg, deciding on a quit date). Also, know when to refer a patient for a full CBT course. If you have someone who is ready to learn new skills, capitalize upon that motivation by connecting the patient with group or individual therapy providers.
To learn more about structured CBT sessions and how to incorporate the basics of functional analysis and skill building into your practice, there are some free resources available online. While CBT skills can be applied to recovery from any substance, the National Institute on Alcohol Abuse and Alcoholism has a guide specifically for alcohol use disorder treatment (https://archives.drugabuse.gov/sites/default/files/cbt.pdf). The National Institute on Drug Abuse has a similar guide for cocaine use disorder (https://pubs.niaaa.nih.gov/publications/projectmatch/match03.pdf). Finally, for other ideas on how to incorporate CBT techniques into a medication management visit, the APA offers a book worth checking out (Wright JH, Sudak DM, Turkington D, Thase ME, eds. High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide. Arlington, VA: American Psychiatric Association Publishing; 2010).
CATR Verdict: CBT skills are easy to learn and evidence-based to promote recovery from addiction. It’s definitely worth the time to familiarize yourself with the core concepts of functional analysis and skill building. Learn a few CBT exercises that are high-yield for your patient population as part of your clinical arsenal. These CBT interventions can easily be incorporated into the time frame of medication management visits.
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