CBT for Substance Use Disorder: Applying Evidence-Based Interventions Within the Context of Different Treatment Philosophies
By Allen R. Miller, Ph.D., MBA
CBT Program Director, Beck Institute for Cognitive Behavior Therapy
Clinicians often use Cognitive Behavior Therapy (CBT) to treat substance use disorder (SUD). CBT was developed through the process of scientific inquiry and is empirically supported as a treatment for many problems, including SUD. Results of scientific studies provide a guide for clinicians who apply CBT in a myriad of settings to individuals with a myriad of conditions. One might ask, “Why is it necessary to reiterate this well-known fact about the practice of CBT?”
When treating patients who misuse substances, it becomes necessary and useful to remind ourselves how important it is to rely on science.
There are multiple views on not only what constitutes appropriate treatment but also on what constitutes a successful outcome for substance use disorder. Successful outcomes of treatment for other types of problems are rarely in dispute. A reduction in symptoms, improved functioning, and positive life experiences are generally accepted as measures of improvement for depression, anxiety, and most other disorders. It’s not easy to find agreement with SUD, however. Some programs require clients to commit to abstinence as a goal for treatment. Other programs emphasize harm reduction. In addition, some use medications (on a short-term or long-term basis) to help manage symptoms. Which outcomes should be considered successful? Research demonstrates efficacy for abstinence or harm reduction programs with or without medication. Which treatment is best? It depends on the individual patient.
Clinicians with divergent treatment philosophies and treatment methods claim to provide CBT for program participants. How can CBT be used with fidelity in these various programs? The treatment plan for each session and across treatment is based on an ever-evolving individualized conceptualization of the patient. The therapeutic relationship must be sound and ruptures effectively repaired. CBT therapists follow standard principles. For example, they collaborate with individuals to set mutually agreeable goals. They assist patients in identifying and clarifying their aspirations and do not impose their own ideas or values. They help patients solve problems and learn skills, including maintaining motivation, dealing with urges, handling stressful situations, managing interpersonal relationships, and making decisions. CBT therapists use a variety of techniques, such as guided discovery, cognitive restructuring of maladaptive thoughts and beliefs, relaxation and mindfulness for coping with stressful situations, communication skills for interpersonal problems, scheduling activities, and cost/benefit analyses for making large and small decisions. They inform patients of all evidenced-based treatments that may be helpful to them. And they often adapt evidence-based techniques from other psychotherapeutic modalities (such as Motivational Interviewing, Dialectical Behavior Therapy, and Acceptance and Commitment Therapy) into treatment, based on a shared conceptualization.
Collaboration in making treatment decisions is central to the process of CBT.
CBT therapists provide structure to therapy sessions and guide the treatment process. For example, CBT therapists collaboratively set and prioritize agendas with clients; provide a bridge to the previous session (by asking about patients’ action plans [homework], pressing problems, and mood); discuss specific problems, agree on new action plans, and elicit feedback. They apply interventions with precision, guided by principles and procedures established by research to be effective for the individual’s disorder(s). Most importantly, CBT therapists convey a message of hope to their patients. Research tells us that the therapeutic relationship accounts for a significant percentage of patient outcomes. Central to CBT is our fervent commitment to improve the lives of others.
To summarize, research guides our CBT treatment plans. We rely on research to inform the use of the therapeutic relationship and the selection and application of interventions for treatment. With research, an individualized conceptualization, and the principle of collaboration as our guide, we do not have conflicts when we encounter philosophical differences in treating SUD or other conditions.