As implied above, CBT for substance use disorders varies according to the particular protocol used and—given the variability in the nature and effects of different psychoactive substances—substance targeted. However, across protocols a number of core elements emerge. Consistent across interventions is the use of learning-based approaches to target maladaptive behavioral patterns, motivational and cognitive barriers to change, and skills deficits.
One of the core principles underlying CBT for SUDs is that substances of abuse serve as powerful reinforcers of behavior. Over time, these positive (e.g., enhancing social experiences) and negative (e.g., reducing negative affect) reinforcing effects become associated with a wide variety of both internal and external stimuli. The core elements of CBT aim to mitigate the strongly reinforcing effects of substances of abuse by either increasing the contingency associated with non-use (e.g., vouchers for abstinence) or by building skills to facilitate reduction of use and maintenance of abstinence, and facilitating opportunities for rewarding non-drug activities.
Despite these commonalities, as the aforementioned studies demonstrate, length of treatment can vary greatly even within the rubric of CBT for SUD's (e.g. single session MI, 12-session BCT, etc.). Research on duration and intensity of treatment is mixed with some correlational studies indicating a positive relationship between longer duration and positive outcome and others indicating no differential effects of treatment duration. [45
Case Conceptualization and Functional Analysis
During assessment and early treatment sessions, case conceptualization requires consideration of the heterogeneity of substance use disorders. For example, the relative contribution of affective and social/environmental factors can vary widely across patients. A patient with co-occurring panic disorder and alcohol dependence may be experiencing cycles of withdrawal, alcohol use, and panic symptoms that serve as a barrier to both reduction of alcohol consumption and amelioration of panic symptoms. [56
] Alternatively, patients without co-occurring psychological disorders may face different barriers and skills deficits, such as difficulty refusing offers for substances or a perceived need for substances in social situations. Therefore, all of these factors must be considered before embarking upon treatment.
Consistent with general CBT models, treatment for SUDs benefits from the use of a regular structure, including agenda-setting, identification of goals, and the assignment and review of homework. This is particularly important for sub-groups for whom cognitive deficits, difficulty concentrating, or organizational and problem-solving skills deficits are present, as it can help such patients to more easily remember and apply treatment techniques outside of the treatment session. Functional analysis is an important component of treatment from the earliest stages. The identification of antecedents or triggers for use is critical to determining the appropriate situations and behaviors to target. For example, identifying high risk situations for use such as liquor stores or areas where drugs are commonly sold and encouraging the patient to avoid such situations (particularly in the early stages of recovery) can be used in this stage. Such stimulus control strategies may serve as an important precursor to building skills for resilience in these settings as it facilitates initial achievement of abstinence. These analyses will also help clarify for the clinician whether drugs are used as part of social repertoires, used to enhance positive activities, and/or are used to cope with difficult situations or emotions. Independent assessment of drug use motives can also aid this aspect of the functional analysis. For example, the use of the Revised Drinking Motives Questionnaire [57
] may provide important information about the nature of drinking motives and its association to particular triggers, such as mood disturbance. [58
Cognitive and Motivational Strategies
Once high risk situations and events are identified (including people and places, as well as the internal cues such as changes in affect), cognitive behavior therapy can be directed to altering the likelihood that these events are encountered (providing alternative non-drug activities, or activities with non-drug using individuals) as well as rehearsing non-drug alternatives to these cues. Motivational and cognitive interventions can be provided to enhance motivation for these alternative activities as behavior, while also working to decrease cognitions that enhance the likelihood of drug use. In addition to the elements of motivational interviewing (i.e., assessment, dispassionate presentation of information, and elucidation and discussion of ambivalence about drug abstinence), broader cognitive strategies can target the cognitive distortions specific to substance abuse, including, rationalizing use (e.g., “I will just use this once,” “One drink won't hurt me,” “It has been a bad day; I deserve to use”) and giving up (e.g., “Why even try,” “I will always be an addict”). In such circumstances, eliciting evidence from the patient regarding the accuracy of these thoughts can help to identify alternative appraisals that may be more adaptive and better reflect the patient's experience. Similarly, providing psychoeducation on the nature of such thoughts and the role that they may play in recovery can help the patient to gain awareness about how such thinking patterns contribute to the maintenance of the disorder. As with other disorders, rehearsal of cognitive restructuring in the context of drug cues may enhance the availability of these skills outside the treatment setting.[59
As part of cognitive restructuring, expectancies, or beliefs about the consequences of use, are another important target for intervention. It is not uncommon to find that patients maintain a belief that use of a particular substance will help some problematic aspect of their life or given situations. For example, a patient may believe that a family holiday would not be enjoyable without alcohol use. Similar to cognitive restructuring techniques, evaluating evidence for expectancies and designing behavioral experiments can be used to target this issue. In this instance the patient would be encouraged to refrain from drinking at the holiday party and assess the degree to which the event was enjoyable. In addition, the patient could evaluate evidence from past holidays to compare the consequences and benefits of alcohol use in these settings.
As noted, a variety of CM procedures have shown success in helping patients reduce drug use. As such, the cognitive behavioral therapist needs to consider how abstinence is to be rewarded as part of treatment. In addition to consideration of traditional CM rewards—monetary prizes, vouchers for goods, or treatment “privileges” (e.g., take-home doses of methadone)—the arrangement of social contingencies, such as is evident in BCT approaches, should be considered. The question to be addressed in treatment is how contingencies can be arranged to encourage initial experiences of abstinence and entry into non-drug activities. When this goal is achieved, treatment becomes concerned with identification of more naturally-occurring rewards for abstinence (e.g., greater employment, relationship, and social success). As such, problem solving strategies and programming and rehearsal of steps to broader goal attainment may need to be provided, depending on the skills available to the patient.
A number of approaches to the treatment of drug use patterns have emphasized exposure to the cues for drug use. Research has shown moderate success for exposure to external cues for use such as drug paraphernalia or drugs themselves.[60
] Accordingly, attention has also shifted to exposure to internal cues for drug use. Pilot studies in both illicit drug use [62
] and smoking cessation [64
]have provided early support for this approach. For these approaches in smoking cessation, attention has been placed on reduction of fears of anxiety sensations that may amplify the aversiveness of both withdrawal and affective consequences of nicotine cessation. By pre-exposing individuals to some of these sensations in interoceptive exposure procedures, the aversiveness of these sensations can be reduced with resulting reduction in smoking behavior.[64
Skills building can be broadly conceptualized as targeting interpersonal, emotion regulation, and organizational/problem-solving deficits. Clinical trials examining the addition of coping and communication skills training have demonstrated positive outcomes and are common components of CBT for substance abuse.[60
] The use of strategies should be based on case conceptualization, building from patient report and behavioral observation of such deficits. Interpersonal skills building exercises may target repairing relationship difficulties, increasing the ability to use social support, and effective communication. For patients with strong support from a family member or significant other, the use of this social support in treatment may benefit both goals for abstinence and relationship functioning. In addition, the ability to reject offers for substances can be a limitation and serves a challenge to recovery. Rehearsal in session of socially-acceptable responses to offers for alcohol or drugs provides the patient with a stronger skill set for applying these refusals outside of the session. Where relevant, this rehearsal can be supplemented by imaginal exposure or emotional induction to increase the degree to which the rehearsal is similar to the patient's high risk situations for drug use.
Emotion regulation skills can include distress tolerance and coping skills. Through the use of problem-solving exercises and the development of a repertoire for emotion regulation, the patient can begin to both determine and utilize non-drug use alternatives to distress. Strategies for coping with negative affect, such as using social supports, engaging in pleasurable activities, and exercise can be introduced and rehearsed in the session. The development of pleasurable sober activities is of particular importance given the amount of time and energy that is often taken for substance use activities (i.e., obtaining, using, and feeling the effects of substances). When reducing substance use, patients can be left with a sense of absence where time was dedicated to use, which can serve as an impediment to abstinence. Thus, concurrently increasing pleasant and goal-directed activities while reducing use can be crucial for facilitating initial and maintained abstinence.
Finally, goal-setting deficits can be targeted within the session as part of treatment. Guiding patients in setting treatment goals can serve as a first practice of this skill building. Also assisting patients in setting smaller goals in the service of longer term goals is an important exercise. The inability to delay long-term pleasure for short-term pleasure is a characteristic feature of substance use disorders, and thus the ability to set long-term goals may be compromised.[66
] Particularly for patients with more severe substance dependence, skills building may require shifting the patient's relevant skills and goals from that of an illicit lifestyle to that of a more normative lifestyle. Thus, the skills that may have been adaptive while actively using—interpersonal skills needed to obtain drugs and to connect with other substance users, the ability to manipulate those around you, to do things without being caught—may translate poorly to reconnecting with family and sober friends, obtaining and maintaining a job, and building healthy life activities.
There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, medical problems, social stressors, and lack of social resources. In addition, certain populations, such as pregnant women and incarcerated patients, may present particular challenges. In each of these circumstances, the use of functional analysis to arrive at strong case conceptualization and the flexibile utilization of treatment components is important. For example, among individuals with low levels of literacy, the use of written homework forms may need to be replaced by alternative means of monitoring home practice (e.g., using simplified forms or having the patient call to leave a phone message regarding completion of an assignment).
One particular challenge can be the shift in the social and environmental contexts associated with use relative to non-use lifestyles. For example, among individuals who have long histories of substance misuse, there are often significant life consequences, such as unemployment, family difficulties, reduced social networks, etc. In such groups, their fit to society is within the context of others with similar misuse problems. The illicit drug use culture, characterized at times by other illicit behaviors (e.g., drug dealing, theft, prostitution) and the valuation of particular skills (e.g., the ability to make a drug deal at 2:00AM), varies dramatically from a more mainstream culture. Thus, in treatment, the patient not only is being asked to transition to a culture in which he or she may have few skills and resources, but also to relinquish the parts of his or her life in which there is a sense of effectiveness and belonging. The sense of belonging to the substance use culture can increase ambivalence for change, particularly when measurable life changes occur at slow pace. In such cases, it is critical to establish alternatives for achieving a sense of belonging, including both social connection and effectiveness. Depending on the resources available to the patient, this may include joining some type of social group (e.g., a sports club), volunteer work, or other activity-based social opportunities.