Patrick McElwaine, PsyD, Beck Institute Faculty

Introduction to CBT for Opioid Use Disorder

Cognitive Behavior Therapy (CBT) is one of the most researched and widely used interventions for treating substance use disorders, including opioid use disorder (OUD). As a clinician and educator—and someone in long-term recovery myself—I’ve seen CBT’s impact from both sides of the therapeutic relationship. It equips clients with tools to understand and shift their thoughts, emotions, and behaviors. When working with individuals who use opioids, CBT offers more than structure—it offers hope grounded in action.

Clients facing OUD often arrive with a complicated mix of shame, fear, grief, and hopelessness. Some have attempted treatment before and “failed.” Others feel disconnected from any sense of purpose or agency. CBT doesn’t rely on motivational speeches or abstract ideals—it meets clients where they are and helps them build skills to move forward. It offers a way to make sense of their experiences while supporting concrete changes in their lives. For many, CBT becomes a roadmap to reclaiming identity, restoring relationships, and reconnecting with deeply held values.

Meeting Clients Where They Are: Collaboration Over Prescription

One of CBT’s greatest strengths in treating OUD is its collaborative nature. Instead of imposing therapeutic goals, CBT emphasizes shared decision-making. I often begin by asking clients a simple but profound question: “What do you want to get out of therapy?” Not what their family, court system, or probation officer wants—but what they want.

This distinction matters deeply. When clients feel ownership of their goals, they’re more invested in the work. For some, the goal might be abstinence; for others, it might be to repair a relationship, return to work, or simply reduce harm. CBT provides the flexibility to support all of these outcomes.

Once motivation is clarified, CBT interventions can begin to address the patterns underlying substance use, including:

  • Cognitive errors that fuel use, such as: “I’ll never get better,” “I’m too far gone,” or “I’m a burden to everyone.”
  • Emotional triggers, including unresolved grief, fear, shame, trauma, and self-directed anger
  • Behavioral patterns, like isolation, impulsivity, avoidance of responsibilities, or associating with high-risk peers

CBT helps clients connect the dots between these domains, creating insight and a framework for change.

The Values Card Sort: A Bridge to Motivation and Meaning

One of the most powerful tools I use early in therapy is the Values Card Sort Activity. Clients are presented with a deck of 83 values, ranging from adventure and stability to connection and service. We begin by sorting the values into three categories: “Very Important,” “Important,” and “Not Important.” After discussion and reflection, clients narrow their selections to their top five core values.

This activity often sparks deep emotional insight. Clients with OUD frequently express surprise at what rises to the surface:

“I picked honesty, but I haven’t been honest with myself or my family in years.”

“Health showed up in my top five. I haven’t taken care of my body since I was a teenager.”

The Values Card Sort is more than a motivational tool—it becomes a cornerstone for treatment planning. These values help shape behavioral goals, guide cognitive restructuring, and inform relapse prevention strategies. We revisit them throughout therapy, especially in moments of uncertainty or setback. When clients struggle, reconnecting with their values can help re-anchor their recovery.

Case Example: Connecting Thoughts, Values, and Change

Marcus, a 34-year-old referred through drug court, arrived in therapy with his arms crossed—literally and figuratively. He didn’t see therapy as helpful and viewed it as just another box to check.

In our second session, Marcus completed the Values Card Sort. His top five were Freedom, Family, Health, Spirituality, and Growth. That list surprised him. He hadn’t felt aligned with any of those values in years. But seeing them laid out provided a spark of motivation.

In subsequent sessions, we explored how his current behaviors either aligned with or conflicted with those values. Through cognitive restructuring—using tools like the “Testing Your Thoughts” exercise and the “RAP Technique” (Realistic, Adaptive, Positive thinking)—Marcus began identifying and evaluating beliefs such as:

 “I’m a lost cause.”

“I need pills just to survive the day.”

“Nothing’s going to change, so why try?”

We explored the evidence for and against these beliefs using Socratic questions, explored alternative interpretations, and practiced realistic, adaptive thinking. He began keeping a daily record of his automatic thoughts and used behavioral experiments to test their accuracy.

By session five, Marcus was no longer passively attending therapy—he was participating. He set goals tied to his values, such as walking three mornings a week to improve health and writing weekly letters to rebuild trust with family members. CBT gave him a structure to stay focused; his values gave him the reason to keep going.

Skills That Support Recovery

CBT offers a robust set of interventions that can be tailored to every phase of recovery. Some core skills that support individuals with OUD include:

Trigger Mapping: Clients identify internal and external triggers, helping them understand patterns that lead to cravings or use. This builds self-awareness and opens the door to proactive planning.

Cognitive Restructuring: Automatic thoughts are brought into awareness and tested for accuracy. Clients learn how their thinking shapes emotional and behavioral responses. I often incorporate strategies like the RAP to support clients in developing more balanced and empowering perspectives, particularly after setbacks.

Behavioral Activation: Many clients with OUD struggle with low motivation and anhedonia. CBT helps them re-engage in meaningful activities—even small ones—to overcome that stuck, disconnected feeling that often accompanies early recovery.

Relapse Prevention Planning: Clients learn to identify early warning signs, practice coping skills, and develop “if-then” strategies for high-risk situations. Setbacks are framed as learning opportunities rather than failures.

I frequently introduce the CBT Triangle early on—thoughts, emotions, and behaviors—as a way to illustrate how each element influences the others. Clients begin to see how even small changes in thinking can ripple outward and shift how they feel and act.

The Power of Language: From “Failure” to “Feedback”

Language plays a powerful role in recovery. Many clients come into therapy with internalized stigma and shame, shaped by years of hearing terms like “junkie,” “addict,” or “relapse” used as judgments. In CBT, we work intentionally to reframe these narratives.

I often use the RAP framework—Realistic, Adaptive, and Positive thinking—to help clients respond to setbacks with compassion and perspective.

Rather than, “I relapsed. I’m hopeless,” we might explore:

  • “What did I learn from this experience?”
  • “What could I try differently next time?”
  • “What does progress look like right now—not perfection?”

This shift isn’t about minimizing substance use–related consequences—it’s about affirming that clients are still worthy of recovery, even when things don’t go according to plan.

CBT helps turn self-criticism into self-awareness and shame into strategy.

CBT as a Compass Leading to Change

CBT is more than a collection of techniques—it is a collaborative, structured, and deeply human approach to change. For individuals navigating opioid use disorder, CBT provides a compass. It helps clients understand how their thoughts, emotions, and behaviors interact—and how to shift those patterns in meaningful ways.

By integrating values-based work, thought-challenging tools, and behavioral strategies, CBT allows clients to rediscover who they are beyond their substance use. In doing so, they don’t just reduce symptoms—they rebuild lives.

References:

Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Marlatt, G. A., & Donovan, D. M. (Eds.). (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (2nd ed.). Guilford Press.

Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press