Cognitive Behavioral Therapy (CBT)
The basic concept of cognitive behavioral therapy (CBT) is that our perceptions are far more impactful to how we process our responses than the reality of the experience itself. Our interpretations, responses, thoughts and emotions directly affect, on a profound level, how we approach, react and handle the events of our lives. Over time we become conditioned to respond to our experiences in a habitual way.
CBT helps patients re-educate themselves through a variety of techniques that help change habitual ways of thinking, feeling, perceiving, and reacting to events. In this way, people learn to replace distorted or false thinking with a more realistic (and frequently accurate) approach.
Research into cognitive processes which involve our belief systems, (i.e. recurrent thoughts, assumptions, fantasies, etc.) revealed how these processes play an essential role in mental, emotional, and substance abuse disorders. It showed that people have the potential to control their response to their environment to a large extent.
CBT is collaborative and goal-oriented. The patient and therapist consider and decide together on the appropriate treatment goals, the type and timing of skills training, the nature of outside practice tasks, and so on. Not only does this foster the development of a good working relationship and avoid an overly passive stance by the therapist, but it also assures that treatment will be most useful and relevant to the patient.
Basic Principles of CBT
CBT is based on social learning theory. It is assumed that an important factor in how individuals begin to use and abuse substances is that they learn to do so. The several ways individuals may learn to use drugs include modeling, operant conditioning, and classical conditioning.
People learn new skills by watching others and then trying it themselves. For example, children learn language by listening to and copying their parents. The same may be true for many substance abusers. By seeing their parents use alcohol, individuals may learn to cope with problems by drinking. Teenagers often begin smoking after watching their friends use cigarettes.
Laboratory animals will work to obtain the same substances that many humans abuse (cocaine, opiates, and alcohol) because they find exposure to the substance pleasurable, that is, reinforcing.
Pavlov demonstrated that, over time, repeated pairings of one stimulus (e.g., a bell ringing) with another (e.g., the presentation of food) could elicit a reliable response (e.g., a dog salivating). Over time, substance abuse may become paired with particular places (bars, places to buy drugs), particular people (drug-using associates, dealers), times of day or week (after work, weekends), emotional states (lonely, bored), and so on. Eventually, exposure to those cues alone is sufficient to elicit very intense cravings or urges that are often followed by abuse.
The first step in CBT is helping patients recognize why they are abusing and determining what they need to do to either avoid or cope with whatever triggers their use. This requires a careful analysis of the circumstances of each episode and the skills and resources available to patients. These issues can often be assessed in the first few sessions through an open-ended exploration of the patients’ substance abuse history, their view of what brought them to treatment and their goals for achieving success in recovery.
In identifying patients’ determinants of drug abuse, it may be helpful for clinicians to focus their inquiries to cover at least five general domains:
- Social: With whom do they spend most of their time? With whom do they use drugs? Do they have relationships with those individuals that do not involve substance abuse? Do they live with someone who is a substance abuser? How has their social network changed since drug abuse began or escalated?
- Environmental: What are the particular environmental cues for their drug abuse (e.g., money, alcohol use, particular times of the day, certain neighborhoods)? What is the level of their day-to-day exposure to these cues? Can some of these cues be easily avoided?
- Emotional: Research has shown that feeling states commonly precede substance abuse or craving. These include both negative (depression, anxiety, boredom, anger) and positive (excitement, joy) affect states. Because many patients initially have difficulty linking particular emotional states to their substance abuse (or do so, but only at a surface level), affective antecedents of substance abuse typically are more difficult to identify in the initial stages of treatment.
- Cognitive: Particular sets of thought or cognition frequently precede abuse (I need to escape, I can’t deal with this, I can deal with this if…and so on). These thoughts are often charged and have a sense of urgency.
- Physical: Desire for relief from uncomfortable physical states such as withdrawal has been implicated as a frequent antecedent of drug abuse. While controversy surrounding the nature of physical withdrawal symptoms from substance dependence continues, anecdotally, abusers frequently report particular physical sensations as precursors to substance abuse (e.g., tingling in their stomachs, fatigue or difficulty concentrating)
CBT for substance use disorders captures a broad range of behavioral treatments including those targeting learning processes, motivational barriers to improvement, and a variety of other issues. Overall, these interventions have demonstrated efficacy and may be combined with each other therapeutic modalities to provide more robust outcomes.
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