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.


Cognitive Versus Exposure Therapy for Problem Gambling: Randomised Controlled Trial.

 New Study (1)Abstract


Problem gambling-specific cognitive therapy (CT) and behavioural (exposure-based) therapy (ET) are two core cognitive-behavioural techniques to treating the disorder, but no studies have directly compared them using a randomised trial.


To evaluate differential efficacy of CT and ET for adult problem gamblers at a South Australian gambling therapy service.


Two-group randomised, parallel design. Primary outcome was rated by participants using the Victorian Gambling Screen (VGS) at baseline, treatment-end, 1, 3, and 6 month follow-up.


Of eighty-seven participants who were randomised and started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET = 21). Both groups experienced comparable reductions (improvement) in VGS scores at 12 weeks (mean difference -0.18, 95% CI: -4.48-4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46-7.39).


Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates and reduce drop-out.

Smith, D. P., Battersby, M.W., Harvey, P.W., Pols, R.G., & Ladouceur, R. (2015). Cognitive versus exposure therapy for problem gambling: Randomised controlled trial. Behavior Research and Therapy, 69, 100-110. doi: 10.1016/j.brat.2015.04.008

From Kafka to Cognitive Behavioral Therapy: Using Trial-Based Thought Records on Patients with Social Anxiety Disorder

A recent study investigated the efficacy of Trial-Based Thought Records (TBTR) as an alternative to conventional Cognitive Therapy in the treatment of patients with generalized Social Anxiety Disorder (SAD).  SAD is the most common form of anxiety disorder and an important target of therapy is the modification of patients’ negative core beliefs.  Based on the idea of “self-accusation” suggested in Kafka’s The Trial, Dr. Irismar Reis de Oliveira devised the TBTR intervention in which patients become their own prosecutor and defender in a trial against their negative core beliefs.  TBTR mimics a trial and one technique involves asking patients to report evidence supporting their negative core beliefs, then form an argument against them, and then repeat the process with new evidence. 

The present pilot study looks at the efficacy of TBTR in a randomized population of people with generalized Social Anxiety Disorder.  36 patients with SAD were randomly assigned to either the conventional CT treatment (control group) or the TBTR treatment (experimental group).  Five trained CT-therapists conducted 12, one hour long sessions in a period of 14 weeks following either CT or TBTR manuals.  Patients were asked to fill out a series of self-report measures throughout the treatment and during a 12 month follow-up.  The study showed that TBTR is at least as efficacious as traditional CT; however, patients that underwent TBTR scored lower on the Fear of Negative Evaluation scale than patients with regular CT. 

Alternative and supplementary treatment models are needed to increase the effectiveness of CT for SAD.  This study suggests the advisability of further investigation of Trial-Based Cognitive Therapy and the Trial-Based Thought Record.

De Oliveira, I.  (2011). Kafka’s trial dilemma: Proposal of a practical solution to Joseph K.’s unknown accusation.  Medical Hypotheses. (in press).

De Oliveira, I. R., Powell, V. B., Wenzel, A., Caldas, M., Seixas, C., Almeida, C., Bonfim, T., Grangeon, M. C., Castro, M., Galvao, A., Moraes, R., & Sudak, D.  (2011).  Efficacy of the trial-based thought record, a new cognitive therapy strategy designed to change core beliefs, in social phobia: A randomized controlled study.  Journal of Clinical Pharmacy and Therapeutics.

Cognitive Behavior Therapy of Anxiety for Terminal Cancer Patients

Patients suffering from terminal cancer are often plagued by anxiety over disease progression, pain, decreased functioning, and death. Cognitive Behavior Therapy (CBT) interventions for anxiety are designed to help clients test the reality and functionality of undue worrying. Geer, Park, Prigerson, and Safren (2010) indicate that excessive anxiety may lead to treatment non-adherence, and further diminish quality of life for these patients. The authors propose tailoring CBT to better serve this population.

Three case studies of patients, with incurable lung cancer, were presented in this article.  The patients showed decreased anxiety, improvement in quality of life, ability to manage stress more effectively, and improved communication with family and friends. The authors concluded, “Our tailored treatment approach helped patient gain a sense of personal control and improve quality of life in the face of an uncertain future and unpredictable disease course;” they also added that further research for treating this population of patients with CBT is needed.

The CBT treatment, described by these authors, for terminal cancer patients with anxiety was divided into four modules: “1) psychoeducation and goal setting; 2) relaxation training; 3) coping with cancer fears; and 4) activity planning and pacing.”  Treatment was aimed towards helping patients learn coping skills that reduce anxiety, as well as develop skills in managing symptoms of cancer and the side effects of chemotherapy. This protocol recommends a total of 6 to 7 intensive sessions.

Geer, J.A., Park E.R., Prigerson,H.G., and Safren, S.A. (2010). Tailoring cognitive-behavioral therapy to treat anxiety comorbid with advanced cancer. Journal of Cognitive Psychotherapy. 1; 24(4): 294-313. doi:10.1891/0889-8391.24.4.294.