Cognitive Behavioral Therapy
The importance of therapy in treatment for an addiction problem is an established fact. The word “therapy” itself has become a colloquialism for going through whatever happens at a treatment facility, with the end goal simply understood to mean that a substance abuse disorder is not as much of a problem as it used to be. But what do we mean when we use a word like “therapy,” and what does that tell us about the different types of therapy? This guide to Cognitive Behavioral Therapy, one of the most widely used approaches to treating addiction and related mental health issues, will explain.
Talking About Therapy
Before getting deeply into Cognitive Behavioral Therapy (CBT), it’s important to understand what therapy is by itself. The concept of therapy was originated by Josef Breuer, an Austrian physician who was a mentor of Sigmund Freud. Breuer believed that patients’ health and conditions could be improved if they talked out loud to a sympathetic (and knowledgeable) listener, a process known as “catharsis” (and which has given rise to the popular concept of the purging of emotions, for the purposes of emotional renewal).
The success of such “talking therapies” led to the development of more schools of thought springing up around the idea that a professional with an understanding of human thinking and behavior could curate a patient through his catharsis, helping him articulate the hitherto inaccessible feelings, perspectives and memories that were at the core of his malaise.
Over time, this evolved to what we know and understand as therapy (or psychotherapy, to distinguish it from other forms of therapy like physical therapy or pharmacotherapy) today – mental health problems are treated by the patient talking to a psychiatrist, psychologist, counselor, social worker, member of the clergy, or other experienced, trusted, accredited person. Mayo Clinic explains that the exchanges are a chance for the patient to learn why he feels the way he does, what causes him to behave and react in ways that are potentially damaging, learn tools and skills to re-take control of life, and respond to challenging situations in healthy and positive ways.
Cognitive Behavioral Therapy: A Background
Cognitive Behavioral Therapy was developed by a psychiatrist named Aaron Beck in the 1960s, who noticed that his patients engaged in what we would call an “internal dialog,” having a conversation with themselves entirely in their own minds, and then basing their behavior and reactions (either voluntary or involuntary) off their private trains of thought.
Beck discovered that identifying and expressing these thoughts was pivotal in getting the client to understand why she acted the way she did. Once this understanding was achieved, Beck could work with his patients on how they might tweak their thinking patterns to develop less harmful behaviors.
PsychCentral explains that Beck called this methodology “cognitive therapy,” because of the strong focus on thinking patterns. The mental health community has since amended this to “Cognitive Behavioral Therapy,” because thinking patterns are only one side of the equation; the other side encompasses behavioral techniques, changing actions, habits and responses away from the destructive and towards the constructive.
Changing Neural Pathways
CBT enjoys widespread validation among treatment professionals; the American Psychological Association says that Cognitive Behavioral Therapy is the preferred therapeutic approach by the most experienced and esteemed counselors in the field. The Clinical Psychology Review journal conducted a meta-analysis and found that CBT was used to treat a number of issues, such as:
- Major depression
- Generalized anxiety disorder
- Panic disorder
- Social phobia
- Post-traumatic stress disorder
- Marital distress
- Anger management problems
The Social Anxiety Institute says that CBT is the only type of therapy that has proven effective in permanently alleviating the symptoms of social anxiety and depression. This is because CBT changes the brain’s neural pathways (the fundamental behind the concept of learning), enabling the patient to make permanent modifications to how he approaches situations that might have once precipitated a drinking or drug binge.
That sets up a key characteristic of Cognitive Behavioral Therapy: it is extraordinarily useful in treating people who have a substance abuse problem. The combination of talk therapy (letting people express what’s on their minds and in their hearts in a safe, private and nonjudgmental space) with an understanding of how thinking patterns can shape human behavior is what makes CBT the frontline treatment for a patient who is ready to learn how to get clean and stay clean. The journal of Psychiatric Clinics of North America points to a large number of clinical trials and literature reviews that show how therapists employ CBT to treat addiction problems caused by any number of substances:
- Poly-drug use
Elements of Cognitive Behavioral Therapy
According to the Royal College of Psychiatrists (the primary organization of professional psychiatrists in the United Kingdom), Cognitive Behavioral Therapy helps a patient understand her harmful thought processes (and the effects that those processes have) by examining the cause-and-effect dynamic in five parts.
The first part is known as “the situation,” which refers to the environment, the surroundings, or the specific triggers that prompt the patient to react by drinking or using drugs instead of seeking a healthier alternative to deal with the situation. A therapist may ask a number of questions to try and get as comprehensive a picture of the situation as possible.
The second deals with thoughts. Cognitive Behavioral Therapy holds that the things that really upset patients (to the point of causing mental distress or prompting substance abuse) are the thoughts they ascribe to events. If a thought process is prohibitively negative, it blocks out all other perspectives and deprives them of seeing any alternative to their situation. For example, a patient with depression might forego participating in social or family activities, because her condition convinces her that there is nothing to gain from going out; however, this prevents her from doing anything that might rectify her mental health, and instead feeds into the negativity that the depression breeds.
A CBT approach might involve deconstructing this thought process, poking holes in the depression’s argument to help the patient realize that there is an entire perspective that she is being robbed of.
The third part of the CBT methodology works on emotions. Emotions are developed from the second part of cognitive behavioral treatment, the thoughts. Assuming the worst about a situation, for example, can ruin a mood, which in turn affects behavior. Making this a habit (either knowingly or otherwise) can have a significant impact on everyday life.
But understanding how thinking patterns work, and how thought influences emotions, gives patients the opportunity to cast the way they think into a newer perspective – one that lets them take control and ownership for what they think and how they feel.
The fourth part of the CBT framework is based on physical feelings. In the same way that mental health disorders have physical symptoms (headaches, fatigue, insomnia and weight loss are some of the signs of depression), a counselor using Cognitive Behavioral Therapy to treat a patient might ask her to be mindful of her physical condition when she feels an onset of the mental distress for which she is seeking treatment. Fostering a sense of awareness that is as comprehensive as possible – one that encompasses thoughts, emotions, and feelings – helps the patient recognize warning signs as much in advance as possible. The next time the physical symptoms manifest, the patient will know how to respond and react to head off the sensations of anxiety, tension, panic, stress, or depression that she might have once attempted to self-medicate away.
Lastly, CBT gathers all these factors and points them towards actions – changing behavior. When a patient understands why she thinks about a situation in a certain way (and how she can change that thought pattern), how those thoughts make her feel (and understand that she can control how they feel), how those emotions make her physically feel (and how to recognize those warning signs), then she is truly capable of responding to stress or the temptation to abuse drugs in a more positive, healthier way than she used to.
As summarized by The New York Times, Cognitive Behavioral Therapy helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.
The National Institute on Drug Abuse explains that one of the goals of Cognitive Behavioral Therapy is to help the patient anticipate how his sobriety will be challenged and threatened outside of a treatment setting. While a majority of this anticipation is done in aftercare programs (like 12-Step groups), a common mantra of recovery is to “work the program” – that is, keep the tactics and methods learned in therapy front and center, to stave off the temptation to relapse.
Anticipating the challenges to sobriety ties in with another goal of CBT, which is the prevention of relapse.
However, for all the best efforts of the practitioner and the patient, relapse still happens. When it does, it is important for the patient to accept that this does not mean that the treatment has failed or that they have personally failed; instead, it is an opportunity to go back to the drawing board and come up with a new, improved plan of attack. From a CBT perspective, this may mean re-examining the situation that preceded the relapse, and what the patient was thinking and feeling leading up to the relapse. In the hands of a counselor or therapist, this information will be vital in learning more about what prompted the relapse, in order to close that door in the patient’s mind.
Aftercare and Preventing Relapse
The idea of preventing relapse is so important that it has spun off into its own form of therapy: relapse prevention therapy, which the National Psychologist explains is based in the fundamentals of CBT. Relapse prevention therapy (or RPT) is based on the idea of teaching the patient how she can control her behavior, how to anticipate relapse, and how to cope with the reality of relapse. A therapist may employ RPT if they feel that a patient has a high risk for relapsing, or if a patient has experienced relapse on a number of occasions and that particular danger is worth focusing on.
The idea of anticipating risks and preventing relapse dovetails into what happens after therapy. When a patient is discharged from treatment, it is vital that she remain connected to what she learned from her counselor. This is because the chances of relapse occurring are at their highest within the first few months of the conclusion of formalized treatment, which is why Alcoholics
Anonymous (and other similar organizations) hand out sobriety chips to celebrate short increments of sobriety. The Los Angeles Times quotes the National Institute on Drug Abuse as saying that between 40 and 60 percent of patients have to be readmitted within the first year of finishing treatment.
Aftercare support programs exist as an acknowledgement that for all the therapy in the world, the first few months of abstinence are the hardest. The members of 12-Step groups have been through therapy themselves (whether Cognitive Behavioral Therapy, relapse prevention therapy, Dialectical Behavior Therapy, or another kind), and they can speak a language that a newly abstinent patient will understand. When there is a slipup or a relapse, one of their primary responsibilities is to remind the patient of what she learned in therapy. In this way, the concepts of rehab (and CBT, in this case) live on well beyond a counselor’s office.
The Future of Treatment
Addiction is an issue that morphs and changes with every new drug that hits the streets, but Cognitive Behavioral Therapy will be here for a long time to come. The British Medical Journal says it is efficient, easy to understand and perform, and “produces good results in many instances,” endorsing CBT as “the therapy to beat” because of how it has improved the skills of therapists around the world. Researchers who penned an article for the Academic Psychiatry even entitled their article on Cognitive Behavioral Therapy, “A Blueprint for Attaining and Assessing Psychiatry Resident Competency,” so integral is CBT to modern-day psychotherapy.
The numbers tell the story: The Independent described CBT as “the treatment of first choice” among general practitioners in the United Kingdom, pointing out that the British government set aside the equivalent of $257 million to train an additional 3,600 therapists in CBT practices.
Helping a victim of addiction deconstruct his problem and break it down in terms of thoughts, feelings, sensations, and actions is why Aaron Beck’s Cognitive Behavioral Therapy is, more often than not, the go-to method of treatment for substance abuse and mental distress. CBT gives a patient much-needed perspective on life and teaches him how he can live life on his own terms when he emerges, clean and fresh, into the world again.
 “Behavioral Interventions in Cognitive Behavioral Therapy: Practical Guidance for Putting Theory into Action.” (n.d.) American Psychological Association. Accessed June 4, 2015.
 “The Empirical Status of Cognitive Behavioral Therapy: A Review of Meta-Analyses.” (January 2006). Clinical Psychology Review. Accessed June 4, 2015.
 “Cognitive Behavioral Therapy for Substance Use Disorders.” (September 2011). Psychiatric Clinics of North America. Accessed June 4, 2015.
 “Cognitive Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine).” (December 2012). Accessed June 4, 2015.
 “Relapse Prevention Therapy: A Cognitive Behavioral Approach.” (September 2000). The National Psychologist. Accessed June 4, 2015.
 “Cognitive Behavioral Therapy: “A BluePrint for Attaining and Assessing Psychiatry Resident Competency.” (Fall 2003). Academic Psychiatry. Accessed June 5, 2015.
 “The Big Question: Does Cognitive Therapy Work — And Should the NHS Provide More of It For Depression.” (March 2010). The Independent. Accessed June 5, 2015.