Treating Substance Misuse Disorders with CBT


Cory Newman, PhD

If you plan to treat patients suffering from substance misuse disorders, I have good news and bad news. First, the bad news. When people habitually misuse a psychoactive chemical – whether it is alcohol, marijuana, benzodiazepines, stimulants, opioids, hallucinogens, or any other – they typically receive significant, immediate positive reinforcement (e.g., a sense of “high”) as well as powerful, immediate negative reinforcement (e.g., relief from negative emotions and/or withdrawal symptoms). Even when people are motivated to change, these experiences are formidable opponents to healthier, more stable, more meaningful sources of gratification, such as the pride one feels in having the ability to say “no” to urges, the satisfaction of having spent a productive day, and the trust of caring others, including therapists. Thus, effective treatment is at once an uphill climb.

Now, here is the good news. In order for people to overcome a substance misuse disorder, they need psychological tools, and cognitive therapy provides this very well. In a nutshell, this includes skills in self-awareness (e.g., of the onset of cravings and urges), self-instruction, planning, problem-solving, well-practiced behavioral strategies to reduce risk and to increase enjoyable sober activities, and methods of responding effectively to dysfunctional beliefs (about drugs, oneself, and one’s “relationship” to drugs). A chief text for the cognitive therapy of substance abuse (Beck, Wright, Newman, & Liese, 1993) describes seven main areas of potential psychological vulnerability, each of which represents a factor that contributes to the patient’s risk of alcohol and other substance misuse, and each of which suggests a potential area for therapeutic intervention. These include:

  1. High-risk situations, both external (e.g., people, places, and things) and internal (e.g., problematic mood states).
  2. Dysfunctional beliefs about drugs, oneself, and about one’s “relationship” with drugs.
  3. Automatic thoughts that increase arousal and the intention to drink and/or use.
  4. Physiological cravings and urges to use alcohol and other drugs.
  5. “Permission-giving beliefs” that patients hold to “justify” their drug use.
  6. Rituals and general behavioral strategies linked to the using of substances.
  7. Adverse psychological reactions to a lapse or relapse that lead to a vicious cycle.

An overarching benefit that cognitive therapy brings to the treatment of substance use disorders is its emphasis on long-term maintenance. As misusers of alcohol and other drugs are often subject to relapse episodes, therapists need to teach patients a new set of attitudes and skills on which to rely for the long run. These attitudes and skills not only improve patients’ sense of self-efficacy, they also lead to a reduction in life stressors that might otherwise increase the risk of relapse. A short (non-exhaustive) list of some of the attitudes and skills that patients learn in cognitive therapy includes:

  • Learning how to delay and distract in response to cravings, by engaging in constructive activities, writing (e.g., journaling), communicating with supportive others, going to meetings, and other positive means by which to ride out the wave of craving until it subsides.
  • Identifying dysfunctional ways of thinking (e.g., “permission-giving beliefs”) and getting into the habit of thinking and writing effective responses. For example, a patient learns to spot the thought, “I haven’t used in 90 days, so I deserve a little ‘holiday’ from my sobriety,” and to replace it with a thought such as, “What I really deserve is to keep my sobriety streak alive, to support my recovery one day at a time, including today, and to stop trying to fool myself with drug-seeking thoughts.”
  • Developing and practicing a repertoire of appropriately assertive comments with which to politely turn down offers of a drink (or other substance) from someone (e.g., “Thanks, but I’ll just have a ginger ale, doctor’s orders!”).
  • Learning how to solve problems directly and effectively, rather than trying to drown out a problem by getting impaired, which only serves to worsen the problem.
  • Becoming conversant in the “pros and cons” of using alcohol and other drugs, versus the pros and cons of being sober, and being able to address distortions in thinking along the way.
  • Practicing the behaviors and attitudes of self-respect, including counteracting beliefs that otherwise undermine oneself and lead to helplessness and hopelessness (e.g., “I’m a bad person anyway, so I might as well mess up my life by using.”).
  • Utilizing healthy social support, such as 12-step fellowship (12SF) meetings, friends and family who support sobriety, and staying away from those who would undermine therapeutic goals.
  • Making lifestyle changes that support sobriety and self-efficacy, including having a healthy daily routine, refraining from cursing and raging, engaging in meaningful hobbies, and doing things that promote spirituality and serenity (e.g., yoga).

To provide accurate empathy to patients, and to ascertain the optimal combination of validation for the status quo versus action toward change, it is important for therapists to assess the patient’s “stage of change.” Some patients are quite committed to giving up their addictive behaviors, and thus are at a high level of readiness for change. Others are more ambivalent, and may waver in their willingness to take part in treatment. Similarly, patients who are uncertain about giving up drinking and drugging may present for treatment with the goal of “cutting back” on alcohol and other drugs. Such patients may disagree that they will need to eliminate their use of psychoactive chemicals, and may decide to leave therapy if the therapist insists that the goal must be abstinence. Of course, there are some patients who are remanded for treatment who otherwise would not seek treatment on their own. They may deny that they have a problem with alcohol and other drugs, and not truly engage in the therapy process at all. The therapist’s understanding of the patient’s stage of change will be vital in helping them know just how directive to be, without going too far for a particular patient to tolerate at a given time in treatment. This sort of sensitivity may allow therapists to get the maximum out of treatment with patients who are most motivated, while retaining less motivated patients in treatment until such time as they begin to feel more a sense of ambition in dealing with their problem.

Cognitive therapy can be used in conjunction with supplemental treatments. For example, cognitive therapy can be woven into a comprehensive program in which patients (for example) take suboxone, and also attend 12SF meetings. Similar to advancements in the treatment of bipolar disorder and schizophrenia, where promise has been shown in combining cognitive therapy with pharmacotherapy, the study of best practices for alcohol and substance use disorders will probably involve more instances of coordinated care. For example, the strength of medication-based treatments that diminish the patients’ subjective desire for their drug(s) of choice can be paired with the strengths of cognitive therapy in modifying faulty beliefs and maximizing skill-building.

Empirical evidence indicates that cognitive therapy has the potential to be an efficacious treatment for alcohol and other substance use disorders, especially with adult patients who present with comorbid mood disorders, and with adolescents. However, improvements in the treatment approach still can be made, most notably via alliance-enhancement strategies that may improve retention in treatment, and more routine incorporation of the “stages of change” model.


Learn more about upcoming workshops on CBT for Substance Use Disorders.


Recommended Readings

Anton, R. F., Moak, D. H., Latham, P. K., Waid, R., Malcolm, R. J., Dias, J. K., & Roberts, J. S. (2001). Posttreatment results of combining naltrexone with cognitive- behavioral therapy for the treatment of alcoholism. Journal of Clinical Psychopharmacology, 21(1), 72-77.

Baker, A., Boggs, T. G., & Lewin, T. J. (2001). Randomized controlled trial of brief cognitive-behavioral interventions among regular users of amphetamine. Addiction, 96(9), 1279-1287.

Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.

Deas, D., & Thomas, S. E. (2001). An overview of controlled studies of adolescent substance abuse treatment. American Journal on Addictions, 10(2), 178-189.

Maude-Griffin, P. M., Hohenstein, J. M., Humfleet, G. L., Reilly, P. M., Tusel, D .J., & Hall, S. M. (1998). Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: Main and matching effects. Journal of Consulting and Clinical Psychology, 66(5), 832-837.

Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.

Nishith, P., Mueser, K. T., Srsic, C. S., & Beck, A. T. (1997). Differential response to cognitive therapy in parolees with primary and secondary substance use disorders. The Journal of Nervous and Mental Disease, 185(12), 763-766.

Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-Step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, 65, 230-240.

Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 303-313). New York: Oxford University Press.

Waldron, H.B., & Kaminer, Y. (2004). On the learning curve: The emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction99, 93-105.


Empirically Validated Treatments

There have been very interesting posts on the listserv this week, about the necessity (1) to validate the theory underpinning a particular treatment approach, (2) to insure that treatment is based on this validated formulation, and (3) to validate the efficacy of the treatment itself. A particular technique or strategy, devoid of a coherent and tested underlying theory, should not be labeled as an “empirically validated treatment,” much less a “system of psychotherapy,” as many are.

Here’s how Dr. Aaron Beck described cognitive therapy on the listserv:

There is no generic cognitive therapy that fits all cases. From the very beginning, we have focused on a specific conceptualization of each of the disorders. The treatment approach then is derived from the disorder-specific formulation. Thus, in obsessions and compulsions, the theoretical formulation followed by the British group and others centers on modifying the beliefs about the obsession and compulsions. These beliefs can then be modified through behavioral experiments (often referred to as “exposure therapy”) and explicit restructuring of the beliefs about the obsessions and compulsions. I’m afraid of using an artificial dichotomy in separating “cognitive” and “behavioral” techniques. Experience (facilitated by actual in vivo behavior) is one of the most powerful ways of achieving cognitive change. Behavior therapy does not have a monopoly on the behavioral techniques, but what does differentiate behavior therapy and cognitive therapy is the theoretical formulation.

—Posted by Dr. Judith Beck, Director, Beck Institute