Cognitive Behavioral Therapy for Addiction

Cognitive Model of Addiction

Multiple interrelated cognitive models of addiction have been developed and evaluated since Bandura’s classic presentations of social learning theory in the late 1960s and 1970s. For example, Marlatt and Gordon described four cognitive processes related to addictions that reflect the cognitive models: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. According to Beck et al., people try drugs initially to get pleasure, to experience the exhilaration of being high, and to share the excitement of using with others. In addition, often additional positive expectations are associated with use of the drug. For example, with cocaine, individuals expect greater energy, fluency, and creativity. They might desire reduced appetite that can lead to weight loss and greater productivity. For clients with alcohol use disorders, often the prime motivations for early use are greater sociability, reduced anxiety, and relief from boredom. These positive consequences often mask the negative consequences of drug use. Although these desired states may be based partly on real drug effects, substance users begin to distort the valence and importance of these effects over time. Cognitive distortions, in combination with life stressors (which ultimately increase as the person begins to neglect or avoid problems or responsibilities), lead to increased drug and alcohol use in pursuit of greater relief and/or pleasure, or a desire just to feel normal. Such problem-distracting behaviors have been described as self-medicating, whereby the person seeks to reduce the distress and problems associated with using through avoidance behavior and by increasing their use. This increased drug and alcohol use often leads to greater problems in the person’s life and greater problem avoidance through greater and/or more frequent substance use.

In addition to the distorted thoughts that substances users hold regarding the positive effects of using, users have been found to have a significantly greater tendency to ruminate on irrational or automatic cognitive thoughts. These thoughts include beliefs such as “I can’t settle down without a few drinks,” “I can’t stand this feeling,” and “people don’t like me unless I am intoxicated.” Such thoughts often relate to feelings of depression and anxiety, and the substance users seek the substance to reduce the distress of such thoughts. Drugs initially act as a distraction against these automatic and distressing thoughts and allow the person to forget the unpleasant ruminations. In this way, drugs appear to serve an adaptive function by allowing the person to turn off the ruminations temporarily. Unfortunately, this distraction is maladaptive over the long term, in that it prevents the individual from facing and dealing with problems in a healthy manner and creates more functional life problems. As the person becomes physiologically and psychologically dependent upon (or addicted to) the substance, the ability to change cognitive distortions without assistance becomes less and less likely. The goal of the cognitive therapist, then, becomes helping the client to recognize these distortions and to develop self-efficacy to actively address such thoughts in a more adaptive manner.

In the context of development of and relapse from alcohol use disorder, Marlatt and Gordon described the process of developing and relapsing from alcohol use disorders as a cognitive decision-making process. He proposed that substance use is a result of multiple decisions, which may or may not lead to further substance use and SUDs. He explained that although some decisions initially appear to be irrelevant to substance use, they nonetheless may result ultimately in an increased likelihood of relapse because of their incremental push toward higher-risk situations. To the extent that a person expects a greater positive versus negative outcome from drinking or using drugs (one’s outcome expectancies), the person is likely to continue using the substance. Individuals’ attributions of causality regarding substance use also play an important role in their continued use, as those who see their use as out of their own control or predestined (due to external factors) will likely maintain their use. Self-efficacy to cope with demanding or otherwise high-risk situations without the use of the substance are also crucial in the context of relapse, with rates of long-term abstinence likely to vary directly as a function of self-efficacy.

From this perspective, the primary tasks of treatment are to identify and challenge the maladaptive cognitions/beliefs surrounding alcohol and drug use and replace them with more realistic and adaptive thoughts and beliefs in order to facilitate more adaptive behaviors of reduced use or abstinence. When more adaptive cognitive thinking has been restored, behavioral changes consistent with constructive thinking will follow. Fig. 40.1 portrays the cognitive behavioral conceptualization of addiction.

Behavioral Model of Addiction

From the perspective of cognitive behavioral theory, SUDs are viewed as learned behavior that is modeled, acquired, and reinforced through experience and learning. If alcohol or drugs provide or are perceived to provide certain desired results (e.g., good feelings, reduced tension) on repeated occasions, the person may learn that the substance leads to the desired outcome. In other words, the substances and positive feelings become strongly associated with each other. People typically begin using drugs or alcohol as a positive reinforcement in their lives—to celebrate a special occasion, as a reward, to reduce inhibitions, and/or to promote relaxation. In other words, initial use of drugs or alcohol is associated with its positive consequences, becoming the preferred way of achieving those results, particularly in the absence of other ways of meeting those desired ends. For some individuals, chronic use of drugs or alcohol can become a problem in cases where the substance is no longer used to feel good, but to avoid negative thoughts/feelings or to feel normal by reducing withdrawal symptoms. When this happens, substance use becomes a negative reinforcement instead of a positive one. From this perspective, the primary tasks of treatment are to (1) identify the specific needs that alcohol and drugs are being used to meet, and (2) develop skills that provide alternative ways of meeting those needs. In so doing, this breaks the learned associations between using drugs and alcohol and both the positive and negative reinforcements.

Persons with substance problems are highly vulnerable to high-risk stimuli for a variety of reasons. Specifically, as people accommodate their drinking and drug habits, they begin to establish behavioral patterns in a variety of environmental contexts, which reinforce their intention to use as well as their experiential expectations. These environmental contexts become associated with the positive experiences of the drug over time and evolve into triggers that stimulate the user’s desire for the drug. These triggers include both internal and external cues. Internal cues may include positive or negative emotions, pain, and/or frustration. External cues can include time of day (e.g., evening, night), place (e.g., at a friend’s house, at a bar), or even other persons (e.g., friend, family). External cues also can include situations such as getting paid or working in an environment where alcohol is served (waitresses, bartenders). These triggers often activate clients’ erroneous or irrational beliefs and lead them to make risky decisions that bring them closer to using. Such triggers must be identified and explored for underlying beliefs that shape physiological sensations linked to craving.

Case Conceptualization

As is the case in the treatment of other disorders, CBT for SUDs involves a unique case conceptualization for each individual. This forms the basis for a strong collaborative relationship between client and therapist, and effectively guides the content of the sessions. Through such collaboration, the client and therapist proceed to utilize specific, goal-oriented techniques tailored to the client’s individualized needs and goals while simultaneously enhancing the therapeutic alliance and collaborative nature of the work. Individuals are also taught to address and resolve naturally arising ambivalence about treatment to develop their motivation and progress toward their treatment goals. During therapy sessions, as well as through the use of self-help homework assignments, clients pursue solution-focused strategies that address the realities of recovery from addictive disorders. Psychotherapeutic innovations in relapse prevention often are implemented over the course of CBT for alcohol and other drug use disorders through identifying and reducing or learning to cope with high-risk use situations.

Case Example

Jonas is a 47-year-old man with a history of using alcohol since adolescence. He initially began using alcohol to reduce anxiety and facilitate dating experiences after he divorced his wife in his thirties. He began using alcohol as a way to enhance his ability to generate conversations in social situations. He works as an accountant and believes that others are very critical of him and see him as “stuffy” and “boring.” He uses the alcohol mainly in the evenings when he goes out with business associates after work, although on weekends he has noticed that his drinking often starts early and continues all day long when he is visiting with friends or family.

When Jonas first divorced, he was quite anxious about becoming more social and going out with peers again. He started consuming a few alcoholic beverages as a way to reduce his anxiety and lower his inhibitions about making interesting conversation. In this way, Jonas’s behavior was positively reinforced and he would later remember the situation as enjoyable and without anxiety. Over time, however, his tolerance for alcohol increased and he required more drinks to achieve his perceived degree of calmness required to make good conversation. He started feeling more anxious, and even depressed, if he could not consume alcohol, particularly when meeting with others.

Fig. 40.2 shows a cognitive behavioral case conceptualization of Jonas’s alcohol use.

By understanding the relationships between Jonas’s dysfunctional thoughts and behavioral patterns, insight regarding the nature of his alcohol problems can be gained and an individualized treatment program can be developed to address his unique needs. Since CBT has evidence-based techniques as its foundation, techniques such as recognizing and challenging maladaptive automatic thoughts, cue exposure, drug refusal training, and methods for coping with craving are used to help an individual break his/her pattern of addiction. Furthermore, because addictive disorders often involve deficits in areas such as social skills, management of emotions, and tolerance of difficult emotions, individuals often pursue progress in these areas within CBT. For example:

Jonas was encouraged to keep a diary of his thoughts and behaviors to help him understand and recognize the connection between his maladaptive thoughts and subsequent emotions and behaviors. With this information, Jonas and his therapist were able to challenge the veracity of his anxiety-provoking thoughts and substitute his critical interpretations with more rational views of his reality. In addition, Jonas was taught relaxation techniques (progressive muscle relaxation and imagery) to help manage his anxiety, as well as learning to tolerate some anxiety in his interactions with others. Finally, Jonas learned social skills regarding interactions with others, particularly in regard to his unrealistic expectation that he should always be the entertainer in a conversation. Through these interventions, Jonas began to expose himself to social situations without reaching for a drink.

The rationale of CBT holds that SUDs are learned and, therefore, can be unlearned over time through the use of cognitive behavioral techniques. Understandably, a person with an SUD faces many challenges and, potentially, many serious consequences. However, through CBT, such individuals can take part in an effective, flexible, and evidence-based therapy specifically tailored to the challenges involved in overcoming SUDs and their individual needs. In doing so, they can avail themselves of a solution-focused approach to treatment embedded within a respectful and collaborative therapeutic relationship to facilitate recovery from addiction and the overall lifestyle change that they need.

Application of Cognitive Behavioral Therapy for Addiction

Understanding the theoretical underpinnings of cognitive and behavioral conceptualizations of addiction helps the therapist identify logical cognitive and behavioral targets for therapeutic intervention. This allows the therapist to individualize treatment for each client while remaining consistent with the general theoretical approach.

Therapy typically begins with an introduction to CBT and an opportunity for the client to disclose information about himself/herself. This is an important time for self-disclosure and building of the therapeutic alliance, as well as the beginning of the process of case conceptualization of the client and his/her presenting issues. During these early meetings, initial treatment goals are discussed. These goals are set collaboratively, with the client having the final say in the establishment of his/her goals. Abstinence is encouraged but may not be an absolute requirement. Treatment goals may involve substance use behaviors as well as other aspects of clients’ lives, such as improved relationships, mood states, and level of functioning. Therapists work with clients to ensure that these goals are attainable (the client can produce them), realistic (the environment can produce them), and appropriate (they are related to the designated work to be done in therapy). Goals are revisited and revised as needed throughout treatment, based primarily upon the client’s progress, which is assessed regularly.

The therapeutic process itself includes meeting regularly (usually for an hour weekly) for at least 3–6 months or longer if necessitated by continuation of symptoms or development of additional problems. Within each session, material is presented and reviewed regarding specific areas of concentration that relate to SUDs as well as more general issues related to emotional dysfunction. Session material may be presented orally and in writing (e.g., using written materials, flip charts, or a wipe-off board), and clients are encouraged to take notes, as visual learning significantly augments oral presentation of material and helps clients retain more information and stay involved in the session. There are issues that must be covered for the majority of clients receiving CBT, including: coping with cravings, thinking about using, problem solving, refusal skills, dealing with lapses, and relapse prevention. In addition, there often are additional issues that need to be addressed, such as assertiveness training, anger management, and recognizing and managing negative moods. These issues are addressed on an individual basis, but in a standardized cognitive behavioral conceptualization. Thus evidence-based treatment is tailored to the individual and provided in a consistent manner.

Weekly assignments or homework are assigned at each session and reviewed at the following session. The homework is a major part of CBT and ensures that clients are actively incorporating skills and techniques presented and reviewed in sessions in real life. Clients are encouraged to complete the homework, preferably in writing, and always through real-world practice. Research demonstrates that those clients who complete homework assignments more regularly consistently attain a better outcome from therapy, particularly those higher in readiness to change. Therefore, homework completion is strongly encouraged. Compliance with homework can be increased in many ways: (1) through explaining the reasoning for the assignment and why and how it is theorized to help the client; (2) reviewing in session how to complete the homework; (3) assessing the client’s motivation and ability to complete the homework by asking the client how likely he/she is to complete it and identifying any potential obstacles for completion, and then (4) clarifying ambivalence about homework and planning for obstacles, as well as (5) setting realistic expectations for the length of time and level of difficulty of the homework.

If a client is regularly noncompliant with homework, efforts are made to explore and change this therapy-interfering behavior. Specific techniques are employed to improve homework compliance, including making homework assignments specific and clear and explaining the rationale of the homework as well as the potential benefits of completing the assignment. As stated, setting realistic expectations for the homework is also important. Most assignments take less than 15 min to complete, and this needs to be made explicit to the client or else the client may overestimate the time needed to complete the assignment and may not even attempt it. Behavioral experiments need to be clearly defined and a rationale provided for their use, along with expected benefits. In addition, the client’s level of motivation and commitment to completing the assignments can be assessed prior to the end of the session, so that realistic expectations are made regarding the homework. For instance, if a client understands the rationale of the homework and knows how to complete it and how long it will take, but still states that he/she does not want to do it and does not think that he/she is likely to complete it, then both the therapist and client understand that the homework will most likely not be completed unless the client’s motivation changes. Some authors argue that homework non-compliance, to some degree, is an inevitable feature of CBT and, when effectively addressed, can yield some of the greatest opportunities for therapeutic change. To that end, it is an expected and important component of CBT, and both clients and clinicians are wise to anticipate and prepare effectively for non-compliance issues.

General Components of Manualized Cognitive Behavioral Therapy for Addiction

CBT is commonly provided in a standard, manualized format for conceptualizing drinking and drug use problems and designing interventions that focus on developing healthier coping skills. It is often delivered in a collaborative motivational interviewing style, which facilitates the individual’s progress through stages of change and therapeutic recovery. Manualized CBT is based on the early works of Beck et al., Ellis and Velten, and the later works of Marlatt and Gordon. These works eventually were condensed into the National Institute on Alcohol Abuse and Alcoholism’s treatment protocol, which has been broadly utilized in multi-site national addiction studies, including MATCH and COMBINE.

While there have been many variations and therapy subtypes that fall under the collective umbrella of CBT, this protocol specifically outlines standardized session themes and activities that have been shown to bring positive outcomes (reductions in drinking or drug use) and ensures systematic, effective, reliable, and replicable administration of treatment to individuals. The structure of CBT discussion topics and session activities for SUDs is designed to promote effective management of session time, focus on client thoughts, and development of more effective coping strategies. It should be noted, however, that while this manualized approach has proven helpful and represents one of the most common cognitive behavioral frameworks for treating SUDs, therapists have considerable flexibility in matching unique client strengths and weaknesses to specific cognitive behavioral interventions within the weekly theme (such as role plays, review of take-home assignments, and construction of agenda). As such, the session is approached in a collaborative manner that tolerates modifications to planned activities as necessary. Yet, even with these potential changes and exploration of therapy-related themes, an overall commitment to therapeutic setting and following a set agenda is recommended to provide useful structure to the client problem-solving and coping resolution process.

The following recommendations are based on results from the University of Virginia Center for Leading Edge Addiction Research (formerly the Center for Addiction Research and Education) clinic, which is part of the Department of Psychiatry and Neurobehavioral Sciences. Similar to the the National Institute on Alcohol Abuse and Alcoholism’s CBT manual, the clinic also administered CBT over 12 sessions in either group or individual format. There are seven core sessions, four elective sessions, and a termination session. Specific material is covered in each session as tolerated and has been designed and studied for optimum effectiveness.