Patients sometimes express curiosity about their therapists by asking them personal questions. When treating patients who suffer from alcohol and other substance use disorders, it is not uncommon for therapists to be on the receiving end of questions such as, “Are you in recovery too?” or “Have you ever used [insert name of substance]?” or “Haven’t you ever binge-drank?”
CBT can help alleviate suffering for patients who have chronic pain and use opioids with the hope of getting relief. The CBT therapist uses many strategies.
There are multiple views on not only what constitutes appropriate treatment but also on what constitutes a successful outcome for substance use disorder.
CBT provides a powerful set of interventions for the treatment of patients suffering from substance use disorders (Beck, Wright, Newman, & Liese, 1993; Newman, 2008), and works in a complementary fashion with 12-step approaches that provide patients with valuable social support and a methodology for change (Ouimette, Finney, & Moos, 1997). At times our patients pose questions about the compatibility of lessons they learn in their 12-step meetings with the principles of self-help they are learning in CBT. While it is important to acknowledge that there are differences between the two approaches, these differences can be bridged so that patients can avail themselves of both sets of methods without an undue sense of confusion or conflict.
In 12-step philosophy, persons must admit that they are “powerless” in the face of their addictions, and that their lives have become unmanageable. Patients sometimes ask us, “How can I take part in CBT self-help if I have to admit to being powerless?” Our answer is that the “powerlessness” which they are acknowledging has to do with their prior behavioral and cognitive habits that were maintaining their problems with substances. Indeed, when patients are actively involved in using their chemical(s) of choice, it is folly for them to continue to enact the same behavioral habits and to manifest the same problematic beliefs and yet expect to recover, and/or to have their lives improve. By utilizing CBT self-help skills, patients are trying something new that gives them a chance at positive change, whereas reverting to old patterns will disempower them and make their lives less manageable.
Patients sometimes enter therapy in a “stage of change” (see Prochaska & Norcross, 2002) in which they do not wish to become abstinent from drinking or using other psychoactive drugs. Instead, they profess to wish to reduce or “control” their drinking and/or using, but not to discontinue altogether. They may avoid 12-step meetings based on the expectation that they can attend only if they agree to an absolute cessation of drinking or using. Such patients may view CBT as a more user-friendly venue, especially if they have read about the concept of “harm reduction” (e.g., Roberts & Marlatt, 1999). These patients may jump to the conclusion that “a little bit” of drinking and/or using is “allowed” in CBT. In response to this assumption, we as CBT practitioners can make it clear that while we generally eschew “all-or-none” thinking, and while we believe it is better to make improvements in stages (via the behavioral concept of “shaping”) rather than make no changes at all, we also recognize that abstinence is indeed the safest outcome. Nevertheless, gaining “admittance” into outpatient CBT typically is not contingent upon a commitment to total abstinence, as it is important for practitioners to positively reinforce any attempts by patients to take part in treatment. Further, it is our intention that by teaching patients skills such as self-monitoring, tolerating unpleasant emotions, minimizing exposure to high-risk situations, postponing acting on cravings, and modifying addiction-related beliefs, they will gradually move closer to the goal of abstinence (something which may never happen if we insist on abstinence from the start).
We also do not want our patients to respond to a lapse by believing that this is as bad as a full relapse, lest they conclude erroneously that they “might as well relapse all the way” by drinking and using as much as they want (now that they’ve broken their abstinence). An important part of utilizing CBT is recognizing how to “nip a lapse in the bud” by re-doubling efforts to apply self-help skills, reaching out for social support, contacting the therapist to schedule a CBT appointment as soon as possible, and perhaps going to a 12-step meeting. For good measure, CBT therapists point out the all-or-none thinking that patients engage in when they state that they cannot go to a 12-step meeting if they are drinking or using. Not infrequently, 12-step groups will accept such participants, provided that they are honest in their self-disclosures and show genuine motivation to “work the steps.”
The treatment of comorbid substance use disorders with other psychiatric disorders (e.g., unipolar depression, bipolar disorder) often includes appropriate pharmacotherapy. Unfortunately, some patients misconstrue taking medications (such as mood stabilizers) as being synonymous with chemical dependency. In response, CBT therapists provide psycho-education, explaining that while some medications (such as anxiolytics) that are quick-acting, have a short half-life, and can induce an immediately noticeable “altered state” are often contraindicated in patients with chemical addictions, there are other medications that do not pose such a risk. Slow-acting medications (e.g., anti-depressants, mood stabilizers, anti-psychotic medications) that do not create a “buzz” do not pose a risk to the person with substance use disorders. We add that a clinically significant “chemical dependency” refers to the habitual use of chemical(s) that impair the user’s ability to function well in their life roles as family member, friend, student, employee, employer, and citizen. By contrast, taking a properly prescribed and monitored medication that improves and sustains a person’s ability to function well in their important life roles is not a problematic chemical dependency to be avoided. To be fair, it seems that most people who take part in 12-step groups see it this way, too.
This is one area where CBT and 12-step principles agree entirely. A person’s thinking style is a very important part of their overall psychological functioning and recovery goals. The ability to look at oneself and one’s life with greater objectivity, openness to new facts, and a systematic (non-impulsive) process is central to making good decisions, improving self-efficacy, and maximizing healthy, favorable outcomes. Participants in both CBT and 12-step groups (as well as their therapists and sponsors) watch out for such faulty thinking as:
Therapists providing CBT to their patients with substance misuse problems can support the patients’ involvement in 12-steps groups without having to be concerned that the two approaches are incompatible. When patients demonstrate sufficient motivation to take part in both individual CBT and group 12-step meetings, it is important to support them, while at the same time being ready to explain some of the apparent differences in the tenets of the two approaches. Some straightforward reframing (as described above) is typically enough to reduce confusion, and in some areas (e.g., “stinking thinking”) the points of convergence speak for themselves.
Learn more at our CBT for Substance Use Disorders workshop.
References
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.
Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.
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.
Roberts, L. J., & Marlatt, G. A. (1999). Harm reduction. In P.J. Ott, R.E. Tarter, & Ammerman, R.T. (Eds.), Sourcebook on substance abuse: Etiology, epidemiology, assessment, and treatment (pp. 389-398). Needham Heights, MA: Allyn & Bacon.
At this week’s CBT for Substance Use Disorders workshop, we had the pleasure of welcoming Katherin Torres back to Beck Institute.
She and her colleagues from Pathways in San Diego recently attended the CBT for Schizophrenia workshop in April, and now she returned solo to learn more about using CBT with her substance abusing clients.
A pre-licensed MFT intern at Pathways in San Diego, Katherin is a first episode of psychosis specialist, working in the Kickstart program which provides confidential assessment and early assistance for young people between the ages of 10 and 25 who are at risk for mental illness in San Diego County.
First episode of psychosis clients often have comorbidity, and this workshop taught Katherin new ways to treat substance use disorders, address issues with open communication, and provide support to her high-risk clients.
Katherin has a long time affection for CBT, “It’s my therapeutic style: collaborative.”
At the workshop, she enjoyed watching the videos of the instructor, Dr. Cory Newman, in therapy sessions and completing roleplays with fellow participants to put new skills into practice.
This workshop will help her to structure her sessions, remember to set goals, and better understand her clients with substance use disorders. She is most excited to bring what she has learned back to the staff in the Kickstart program.
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:
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:
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. Addiction, 99, 93-105.
AbstractThis study examined the efficacy of a group-based cognitive-behavioral treatment (CBT) for Japanese alcoholic outpatients. Participants (N = 169) were assigned either to a CBT-based relapse prevention group or a TAU (treatment as usual) group. The CBT group received 12-session CBT treatment with a structured treatment workbook once a week. The TAU group received usual daycare treatment including 12-step meeting, vocational training and leisure activities. Participants in the CBT group demonstrated a significantly low relapse rate at the end of treatment. Moreover, coping skills of the CBT group participants were significantly improved than those of the TAU group at the 6-month follow-up period. However, at the 6-month follow-up, the difference in relapse rates diminished. The effectiveness of CBT for alcoholics was well documented in Western countries but few studies were conducted outside of the West. The results provide support for the use of CBT for Japanese alcoholics.
Harada, T., Yamamura, K., Koshiba, A., Ohishi, H., & Ohishi, M. (2014). Evaluation of
cognitive-behavioral therapy for drinking. Outcome of Japanese alcoholic patients.
Nihon Arukoru Yakubutsu Igakkai Zasshi. 49(5), 249-258
Abstract
Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.
Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.
