Cognitive Behavioral Therapy (CBT) is a goal-oriented form of psychotherapy (aka "talk therapy") originally designed to treat depression. It is now a widely used therapeutic modality used to treat a number of issues, including drug and alcohol addiction.
What is CBT?
CBT primarily explores the relationship between a person's thoughts, feelings, and behaviors. By discovering and identifying a person's distorted thought patterns and beliefs, the therapist and client can work together to restructure them into realistic, adaptive, and healthy thoughts.
CBT is shown to alter brain activity, which suggests that not only is the brain capable of change, but that brain functioning can be improved with CBT.
What does CBT treat?
- Drug and alcohol addiction
- Behavioral addictions like eating disorders, sex addiction, and gambling addiction
- Depression and anxiety
- Mental illnesses like schizophrenia, bipolar disorder, and PTSD
- Chronic pain
- Sleep issues
- Sexual and relationship problems
How does CBT work?
Cognitive behavioral therapy was invented in the 1960s by psychiatrist Aaron Beck, when he realized his clients were having internal dialogues with themselves. These inner "conversations" affected clients in their decisions and actions in the world. Beck came to realize the critical nature of the link between a person's thoughts and behavior.
For example, if a person feels lonely, their thoughts might say, "No one likes or values me", or, "I'm not good enough". Naturally, they would feel upset about this and think negatively about themselves. However, they would also likely only focus on the "upper thoughts" about how they're not good enough, instead of getting to the bottom or what Beck called "automatic thoughts".
Automatic thoughts are the deep emotional thoughts and beliefs that start the wheel spinning and keep a person in a place of negativity. An example could be a root belief of, "I am unlovable", which prompts all the other thoughts. Such "stuck" thoughts and feelings are then often acted out in negative behaviors, such as substance abuse.
CBT is designed to help clients identify these dysfunctional beliefs, or "automatic thoughts", and shift them to ones that are healthier. With practice, a client learns to adjust unhealthy thoughts patterns on their own and becomes able to adapt emotionally and live a healthier life.
What is a session like?
CBT sessions are practiced by a licensed therapist that specializes in CBT. While usually practiced individually, CBT can also be incorporated into group or family sessions. Sessions are tailored to client needs, but tend to follow a similar structure.
At the beginning of treatment, a particular goal is discussed. The focus is on the client's desire to solve an issue in their life (such as wanting to end drug or alcohol addiction and get sober). Sessions work towards attaining this goal. In each session, the client and therapist discuss the issues they want to address for the week, as well as progress in the client's homework from the previous session. At the end of each session, another homework assignment is planned.
Client homework is an important part of CBT therapy, and varies based on individual needs. For example, since loneliness is a common trigger for many kinds of addiction, a client may be asked to keep a journal of incidents, interactions, or times they felt lonely that week. When they felt lonely, what were the automatic thoughts that came up? Which beliefs were triggered?
Another assignment could be to keep a "thought log". For example, someone struggling with alcohol addiction might write down their thoughts and feelings before, during, and after drinking. The purpose is to start to understand and record things like, what happened right before the desire to drink alcohol? What were the thoughts or feelings? Again, the purpose is to become aware and consciously track unhealthy beliefs, thoughts, and triggers.
By the end of treatment, the goal is for clients to feel empowered enough to continue what they do in sessions on their own.
What are the advantages of CBT?
When a person changes the way they think, they can often change the way they feel, and the way they behave. For example, feeling lonely and having thoughts automatically go to, "No one likes you. You're all alone and worthless", is different than feeling lonely and thinking, "I'm feeling lonely right now. I should call a friend".
In the first case, it's likely that a person struggling with addiction would go back to drinking alcohol or taking drugs to numb the pain of feeling worthless. Being able to stop at the original thought and evaluate it (rather than just react to it) can stop the pattern at its root. With time, this can help someone end the pattern their own addiction.
Every person is different and no one therapy works for everyone. However, CBT has been shown to be quite successful for certain individuals, particularly those recovering from drug and alcohol addiction and issues related to substance abuse.
Changing one's thoughts can change one's entire perception of self and the world. This can, in turn, allow a person to to see other possibilities instead of being fixated on an unhealthy belief. CBT and therapy in general has the potential to help people self-regulate, empower themselves, and become more flexible, resilient, and happy.
What Do Journals Say About CBT?
A meta analysis is a type of research that combines data from multiple studies to see if the results are still valid. This type of research was done in 2012 and 269 meta analysis studies were used to look at the efficacy of CBT in over eight categories of mental disorders. Those categories included but were not limited to depression, psychosis, personality, anxiety, and criminal disorders etc.
While across the board, CBT does seem to help alleviate symptoms, especially when compared to drug placebos and wait-list patients, it was not a better choice of treatment for aggression, borderline personality disorder, chronic psychosis or post-traumatic stress disorder (PTSD). For those patients, the existing treatment with pharmacotherapy or other therapies worked better or made little difference. What this means for people seeking treatment is there may not be a clear 'best option' and decisions should depend on their own prior experiences. If you have taken psychotropic drugs before and had undesired (side) effects, you will want to consider starting with psychotherapy or vice versa.
What Is CBT and How Does It Relate to Anxiety?
As described in the study above, CBT is a "reliable first line approach" to anxiety. Theorized and practiced beginning in the sixties, it was an approach to psychotherapy that shifted the dynamic between therapists and patients. It gives the patient more control to drive the treatment's direction with the therapist simply acting as a guide. More importantly, it gives structure to the therapy sessions with achievable goals for patients to work on outside of therapy. These goals or activities, often called 'homework,' are key for anxiety as it builds an alternate explanation for the bouts of disproportionate worry or action.
The feeling of anxiety can be simply described as the uncomfortable and unwanted anticipation towards doing something. This is a common feeling that everyone has experienced at some point. On the scale large enough to be a disorder, this unwanted feeling overwhelms individuals and interferes with their daily routine. It might even be severe enough where the person might need to adjust their entire lifestyle to accommodate this feeling. Because CBT actively works with the individual to identify root factors that caused the problem and how to respond to it, it is a choice treatment for anxiety disorders. However, CBT is not considered a more beneficial treatment in comparison to medications for hyperactivity disorder because the problem has little to do with overcoming barriers and more to do with brain chemistry.
Other Types of Anxiety
The most significant improvements with CBT are seen with social anxiety and OCD, both of which have action-orientated problems such as repetitive movements or patterns of behaviors. The same study describes CBT as a "superior performance over psychopharmacology" and the effects are maintained long term. Through identifying, for example, why going to bars are panic-inducing but not to house parties, the therapist can help the patient rationalize the anxiety and suggest actions the patient can take. In response, the patient can try those suggestions and see if they are helpful and adjust their actions and behaviors for favorable outcomes. Furthermore, CBT treatments last six months or less as symptoms are alleviated and thus the therapist's support is no longer needed. Unlike medication which can be required long-term, or even for a lifetime, to reduce or alleviate symptoms.
CBT and Substance Abuse
There has been research done to see if CBT is a worthwhile treatment for substance abuse. It is most effective for substances that are less addictive like alcohol but there are also positive changes for opioid use.
Drug treatments since the 1980s have used similar behavioral approaches but only in the last decade or so has there been a push to make this type of treatment more structured. Instead of just focusing on 'why drugs are bad,' CBT aims on finding people's risk and vulnerability, and thus developing long term coping skills for them.
Recently, there has been research done for online or computer-assisted CBT since many treatment facilities lack the proper training in addition to being over-worked. One study used this method for chronic cocaine abuse and found CBT in combination with the standard treatment (daily dose of methadone) was more effective for preventing relapse when compared to just standard treatment. For an effective public health intervention against substance abuse, accessibility is very important as drug abuse affects a wide spectrum of people, spanning socioeconomic status and geographical location. Having the option of CBT for inpatient, outpatient and self care is great way of providing sustainable long-term help.
How does CBT Compare to other Substance Abuse Treatments?
It is important to point out that treatment is never singular. The most effective method is multifaceted because the issue itself is multifaceted. CBT is a definite way to decipher addiction and what steps can be taken when a person is tempted to relapse. However, since drugs are a substance that can over/under stimulate certain brain chemistry, prescription drugs may be needed to lessen the crave or desire (e.g. methadone). Other options such as motivational interviews and contingency management are also frequently used treatment options in combination with CBT. They help reinforce and reward the positive aspects of being sober.
While those standard treatments are effective, they are reliant on a healthcare provider to give the positive encouragements and to supply the proper drugs. CBT on the other hand is self-sustainable. Another study that compared CBT and contingency management for cocaine use found immediately after the treatment, the outcome was in favor of contingency management. However, when the participants were interviewed a year later, those who underwent CBT did better compared to contingency management and continued to show improvements.
For substance abusers who are not yet adults, combining family or group therapy with CBT has also shown favorable outcomes in decreasing drug use. A study on marijuana use and adolescents (average age was 15) showed family therapy in combination with CBT has significantly improved results. This shows teenagers need to be involved in deciding their own treatment plan with the addition of family support.
Substance Abuse and Other Mental Illnesses
Combining different treatments is highly effective in people with multiple illnesses. With substance abuse, it is associated with depression and anxiety where a downward spiral forms. For those who take drugs to escape the symptoms of feeling down or anxious, some will temporarily alleviate the symptoms but then make them worse, which only encourages a stronger dose. Uncontrollable problems occur when a more dangerous class of drugs are taken or when the drugs are not pure.
To manage the substance abuse also means managing other illnesses. A common trend seen is a mix of alcohol and depression. Many people drink to forget their problems and CBT can help identify what events or situations trigger the depression and form a coping mechanism for it. By managing the depression aspect of drinking, there is one less reason for excessive drinking.
Cognitive Behavioral Therapies are a favorable course of treatment for anxiety disorders because they are a response to specific problems, as compared to an unknowing sense of unhappiness. It is also an effective treatment for substance abuse as it finds the reasons behind the addiction and how to cope them. Through changing the structure to how a person interprets or interacts with certain situations, the patient can manage the anxiety. CBT has shown great potential when compared to other types of treatment for anxiety and should be considered when seeing a therapist. However, this does not mean psychiatric medication is the wrong course of treatment or should be substituted. In fact, for substance abuse the majority of research shows combination is the way to go. Each person reacts to drugs and psychotherapy differently and all options should be thoroughly discussed.