Cognitive behavioral therapy (CBT) is an umbrella term that describes an expansive group of therapies. Although many in number and broad in their approach, they have in common a focus on ‘cognitions’ (including thoughts, beliefs, schemas, and metacognitions) as the central driver of, and the solution to, effective emotion regulation.
The following outlines cognitive behavior therapy and its application to alcohol and other drug use and practice
Cognitive Behavioral Therapy has evolved significantly since its beginnings in the 1950s. At that time psychology more broadly had begun to shift from its psychoanalytic roots into a science-based discipline with an emphasis on the scientific method, and therefore the measurable.
By the 1960s two psychoanalytically trained therapists, psychiatrist Aaron Beck (‘cognitive therapy’) and psychologist Albert Ellis (‘rational emotive behavior therapy’) had, almost simultaneously, began to look beyond behavioral principles to the role of interpretation of events, drawing on ideas from cognitive psychology (Neisser, 1967) and social learning theory (Bandura, 1977). What most people refer to as traditional ‘CBT’ is usually some version of one of these two styles.
The next major development began in the 1990s with the mindfulness-based therapies such as Dialectical Behavior Therapy (DBT) (Linehan, 1993), Mindfulness Based Relapse Prevention (MBRP) (Bowen et al., 2010), and later Acceptance and Commitment Therapy (ACT ) (Hayes and Strosahl, 2011).
Thus, Cognitive behavioral therapy is not a single therapy. It is an umbrella that encompasses a large group of therapies that have in common a focus on cognitions and behavior as both the cause of and the means to resolve, emotional, and behavioral dysregulation. Perhaps more accurately referred to as cognitive behavioral therapy, this group of therapies is based on well-researched theoretical models, they share the underlying assumption that our thoughts, behaviors, and emotional reactions are learned and that the path to wellbeing is through managing thoughts and beliefs, and to some extent behavior.
Cognitive behavioral therapies are the most researched group of therapies in the world and due to the extensive evidence base, they have become a core competency for people in the alcohol and other drug workforce.
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From a cognitive behavioral perspective, alcohol and other drug use and dependence are complicated by genetic, biological and temperamental factors, but these are considered risk factors rather than determinants. Much in the same way as certain people may have a biological or genetic history of heart disease that puts them at higher risk of heart problems, but environmental and learned factors such as eating habits, ability to control stressors, and exercise can prevent or lead to the development of a heart condition.
Learn more about the cognitive behavior view of alcohol and other drug problems.
Cognitive behavioral therapies emphasise the present, at least initially. This is especially important because, for many people who have problems with alcohol and other drugs, focusing on resolving past difficulties, especially those associated with the development of alcohol and other drug use, is often of little benefit unless the day to day issues of drug use are addressed.
For example, there is little benefit in addressing childhood trauma, which may have contributed to the development of a drug problem, if the client is attending sessions intoxicated.
Cognitive behavioral therapies focus on developing skills in the client to enable them to be, in a sense, their own therapist. The session is designed to help clients to develop skills in reflection and self-management, and the emphasis of therapy is what happens outside the session, rather than in it. Hence skill practice (sometimes referred to as ‘homework’) in between sessions is critical.
This can include identifying patterns of thoughts, feelings, and behavior which lead to problematic substance use including triggers for relapse.
Read more about triggers for relapse
Guided discovery, based on Socratic questioning, is the primary tool of the Cognitive Behavior Therapy therapist to support self-reflection.
Socratic questioning is drawn from Socrates’ teaching method of asking questions to promote thinking and reflection. The key difference between Socratic questioning and guided discovery is that Socrates usually had an end in mind, while this is not necessary for guided discovery.
In fact, guided discovery requires genuine collaboration and curiosity (Padesky, 1993) which precludes having an outcome in mind. The assumption behind the use of guided discovery is that the client has the answer to their problems, or at least the means to find an answer, within. The therapist’s role is as a guide or coach rather than an expert.
Cognitive behavioral therapy is driven by the scientist-practitioner approach. That is, the practitioner applies the scientific method to understanding and addressing client issues. Therefore, there is a constantly evolving cognitive behavioral case formulation that poses hypotheses that are then collaboratively tested. This is referred to as ‘collaborative empiricism’.
The scientist practitioner approach also necessitates undertaking and utilising research about outcomes, which is why cognitive behavioral therapies are the most researched group of therapies. In the scientist practitioner approach, cognitive behavioral therapists use science in their practice, continually review science to maintain best practice and contribute to science through research.
In general, cognitive behavioral therapies are relatively brief (usually not more than 12-16 sessions), and even briefer versions have been developed that are designed for delivery between 1 and 6 sessions.
Typically, cognitive behavioral therapies use a structured session plan broken into three or four interconnected sections. Within those sections the work is tailored to the client’s needs, so the session format is both structured and flexible.
Carroll (1998) uses the ‘20-20-20 rule’: 20 minutes on review of the week, homework tasks and issues arising during the week; 20 minutes on discussion and practice of a particular skill or topic linked to an issue from initial assessment or something that has arisen during the week (e.g., “since you’ve had a couple of close shaves this week, I thought we’d talk about high risk situations today”); then 20 minutes on recapping the session, agreeing on homework tasks and planning for the next week. In reality, sometimes the middle 20 minutes takes up slightly more time that the first and third 20 minutes and it may become a 15-30-15 rule.
Mitcheson et al (2010) use a 4-part structure: 1. Setting the agenda and recap of previous session, 2. Dealing with the specific agenda items (the focus of the session), 3. Planning for the next session and 4. Session review.
Structure of some sort is needed because often clients do not have well developed skills in structuring their own lives and this serves as a model to assist them to learn these skills. Therefore, generally in Cognitive Behavior Therapy, the structure is outlined to, and agreed with, the client at the beginning of each session. This practice is referred to as setting an agenda.
‘Structured’ does not mean ‘inflexible’. If issues arise they are incorporated into the agenda as appropriate. The structure is not rigid and practitioners still need to use their clinical judgement and skills to determine what happens within the structure, and when the structure may need to adapt to the immediate circumstances.
The purpose of the structure is both to help the client learn how to apply structure to their own world, and to focus the session to ensure critical therapeutic work is being done, and the session is not just general counselling, or a chat.
For certain clients, such as those who use methamphetamine, flexibility in delivering treatment is crucial.
There is extensive evidence for the effectiveness of cognitive behavioral therapy for a range of mental health problems, including alcohol and other drug disorders.
Overall, Cognitive behavioral therapy appears to be both effective and long lasting when compared with general drug counselling, treatment as usual and no treatment controls.
You can learn more about the evidence supporting Cognitive behavioral therapy or CBT .
A number of brief cognitive behavioral interventions have been developed, primarily based on Relapse Prevention or Coping Skills Therapy. In general, brief Cognitive Behavior Therapy interventions are best utilised for moderate to high risk use and with people who are dependent but are not ready to engage in intensive treatment. They have been found to be effective for a range of people who use alcohol and other drugs, including those who are severely dependent.
Brief cognitive behavioral interventions have also been shown to assist with cocaine, alcohol and polydrug dependences, and with drug-related problems such as insomnia.
A brief six-session intervention for cannabis dependence has also been developed in Australia, using a combination of Motivational Interviewing and Cognitive Behavior Therapy. Sessions include goal setting, planning to quit, dealing with lapses and relapses, refusal skills, managing withdrawal and cognitive and coping skills.
In Australia, Baker et al. (2003) developed an intervention for amphetamine users that combined motivational interviewing with two or four sessions of brief Relapse Prevention, including coping with cravings and lapses, controlling thoughts about using (triggers, seemingly irrelevant decisions, and pleasant activity scheduling) and relapse prevention (refusal skills and relapse planning). Methamphetamine users are notoriously difficult to engage and retain in treatment and a briefer intervention may be more desirable for this group.
‘Low intensity’ interventions are those that are low intensity for the practitioner or service and sometimes, but not always, less intensive for the client. They can be delivered face to face, usually by non-specialists in the field, for example by medical practitioners delivering screening, brief intervention and referral into treatment (SBIRT), and through psychoeducational groups and ‘advice clinics’.
Digital treatments for alcohol and other drug problems are an emerging area of research and appear fruitful for lowering barriers for entry into treatment.
Learn more about digital cognitive behavioral therapy