Cognitive Behavioral Therapy (CBT) for Substance Use Disorders

Basics

Cognitive behavioral therapy (CBT) is a commonly used and effective form of psychotherapy. It has been studied for decades. And it has been shown to produce positive results for a range of mental health, physical health, and addiction issues.

CBT is based on the idea that the way you think, feel, and behave are all closely related. So, if you are experiencing a problem in one of these areas, making a change to the others could help.

CBT is a combination of two other therapy styles: cognitive therapy and behavioral therapy. Rather than placing all of the importance on thoughts or behaviors, CBT sees each as equally important to your health and well-being.

If you’re seeking CBT for a substance use disorder, you will work with your therapist to:

• Understand how your addictions began.

• Identify your thinking and behavior patterns that maintain your addiction.

• Take active steps to change these patterns.

• Learn skills to improve areas like communication, relationships, and self-care.

• Feel a sense of empowerment and control over your life.

Like any treatment approach, CBT will not be a good fit for everyone. But it could be the most helpful option for you.

How does cognitive behavioral therapy work?

CBT is built on the assumption that your thinking and behavior patterns are learned. You learn these patterns from your life experiences and interactions with other people.

CBT works by helping you:

• Strengthen the positive patterns. By doing more of the healthy thinking and activities you already do, you can combat addiction. 

• Unlearn the negative patterns. Addictions bring many harmful patterns of thinking and doing, so recognizing these as negative and breaking the association is necessary.

• Learn new positive patterns. Treatment will offer new coping skills and points of view that can add to your recovery.

If you’re using alcohol or other drugs, you probably have some patterns involving substance use that may be difficult to break. If you feel depressed or anxious, you may think “I need to change this feeling” and turn to substances.

The goal of CBT is to identify this pattern, break the habit, and substitute a healthier alternative. Rather than substance use, a CBT therapist may offer positive coping skills, like physical exercise, positive self-talk, or spending time with a friend as options to avoid substance use.

CBT aims to be short term and led by you, the client. Your needs, wants, and goals are at the center of the treatment.

The therapist works to provide helpful information, skills, and perspective. Then, you take the knowledge and apply it to your life. 

What are the principles of cognitive behavioral therapy for substance use?

CBT uses three core principles to guide treatment:

1. Your problems are based on the issues with your thinking.

2. Your problems are based on the issues with your behaviors.

3. You can learn better ways to cope with your problems to minimize your symptoms.

CBT recognizes that plenty of bad things happen to people, and many of these bad things are extremely difficult to overcome. This therapy approach advocates that, despite the issues from the past, you can overcome them. You can achieve your goals related to addiction and mental health issues.

CBT pays special attention to the present and future. It looks back at the past to better understand your thoughts and actions. But it is not interested in blaming other people or things for your condition.

CBT is focused on solving current problems. By doing so, it will help create a future focused on recovery.

How does CBT help treat substance use?

CBT can help treat substance use, other mental health conditions, or physical health issues. The process will be similar with each approach. Your therapist will help you identify your thoughts, feelings, and behaviors. Then, they will work with you to find healthier alternatives.

Substance use treatment with CBT will always look at the impact of cognitive distortions and core beliefs. Cognitive distortions are the thinking problems you experience.

All people have some level of faulty thinking. Those with substance use likely have more cognitive distortions than the average person.

Examples of cognitive distortions are:

• All-or-nothing thinking: believing that people or things are either all good or all bad

• Fortune telling: jumping to negative conclusions without real evidence

• Emotional reasoning: thinking that something is true because of the way you feel about it

• Labeling: calling yourself or others names

These distorted ways of thinking can fuel your addiction and make it harder to stop. You might think that you are only fun when you drink. Or you may think that you are worthless and then use drugs to quiet that thought.

When cognitive distortions change your thinking patterns, they can start to change your beliefs. CBT is based on the principle that your beliefs impact the way you see things around you.

Core beliefs are the way you see yourself and the world. They are often very simple and clear, like, “I’m not worthwhile.”

To treat substance use disorders, CBT will identify, track, and change your cognitive distortions and core beliefs by changing the way you talk to yourself.

What are some techniques used in cognitive behavioral therapy?

CBT is a practical therapy that provides many specific skills and techniques. These help you identify and treat the substance use that is harming your life.

With the attention on thoughts and behaviors, CBT interventions focus on only one or a combination of both. Whatever the case, the interventions will target cognitive distortions and core beliefs.

CBT provides information or teaches a skill during a session. Your therapist will then assign homework to help you practice these skills or track your thoughts, feelings, and actions between sessions with the goal of promoting recovery.

During a CBT session, your therapist could use techniques like:

• Thought records

• Journaling

• Behavioral activation

• Self-monitoring

• Cognitive reframing/restructuring

• Problem-solving skills

• Relaxation techniques

How does CBT help change thinking patterns?

CBT can help change your thinking patterns by helping you:

• Learn to notice your cognitive distortions and replace them with healthier ways of thinking.

• Improve your ability to understand people’s behavior and motivations. 

• Use new coping skills to deal with difficult situations.

• Build new levels of confidence in yourself.

How does CBT help change behaviors?

While part of CBT is noticing and changing your thoughts, it also places great value on action. CBT helps change behaviors by encouraging you to test yourself and push past your comfort zone by:

• Facing your fears, not avoiding them

• Practicing relaxation skills to calm your mind and body

• Setting up schedules and routines to increase motivation

• Role-playing situations to prepare for a conversation, situation, or event

Can CBT prevent relapse?

CBT for addiction will help you develop a relapse prevention plan. A relapse prevention plan combines many elements of CBT into one document.

This plan outlines:

• Triggers for substance use

• What cravings feel like

• Healthy coping skills to experiment with when urges arise

• People to contact

• Professional treatment services

Your therapist can help you create a plan during a session or give you information to help you create one yourself. These plans can help you avoid future relapses and keep you focused on recovery.

How can you get the most out of CBT for substance use?

Being open and honest is a great way to get the most out of CBT treatment. Since the therapist relies on your experiences, thoughts, and feelings, treatment is only as effective as you make it.

Another important task in CBT is to spend time thinking about yourself and your life outside of your sessions. By doing this, you bring new information to work on with your therapist.

CBT is often only 1 hour per week, so you’ll have to commit to working on your treatment during the rest of the week. Completing your homework can help you ensure that you are applying what you learned in session to your everyday life. Of course, following through with the recommendations of your therapist will be essential.

Are other therapy styles related to cognitive behavioral therapy?

CBT is very influential. It has inspired the creation of several other forms of psychotherapy.

Some therapy styles rooted in the core principles of CBT are:

• Acceptance and commitment therapy (ACT): This is a branch of CBT that stresses the idea of accepting and noticing your thoughts, instead of being frustrated or depressed by them. From there, ACT helps you take action in meaningful ways that are in line with your values.

• Mindfulness-based cognitive therapy: With a focus on the here and now, this therapy approach places importance on observing your thoughts and forming a new relationship with them using mindfulness skills.

• Schema therapy: This is a form of CBT that targets long-term mental health concerns. This therapy aims to help you understand your own schemas, which are unhealthy belief systems developed during childhood. 

• Dialectical behavior therapy (DBT): This type of therapy was originally designed to help chronically suicidal clients and people with borderline personality disorder (BPD). DBT is now used for other personality disorders, depression, trauma, and substance use disorders. It focuses on teaching skills in four main areas: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

These treatments all took the core elements of CBT and branched off in different directions. So, if your therapist is using any of these, they are actually using a variation CBT for substance use disorders.

What types of substance use does CBT help with?

Perhaps more than any other mental health treatment style, CBT can help with many conditions. Studies have demonstrated that CBT can help with addictions and substance use disorders like:

• Alcohol use disorder

• Stimulant use disorder, including cocaine and methamphetamine

• Opioid use disorder

• Marijuana/cannabis use disorder

• Nicotine/tobacco use disorder

Additionally, CBT is helpful for mental health conditions like:

• Anxiety disorders, including panic disorder, phobias, and social anxiety

• Obsessive-compulsive disorder (OCD)

• Post-traumatic stress disorder (PTSD)

• Mood disorders, including depression and bipolar disorder

• Eating disorders

• Schizophrenia

CBT can also assist in the treatment of physical health conditions like:

• Pain

• Fibromyalgia

• Migraines

• Chronic fatigue

• Irritable bowel syndrome

• Insomnia

Finally, it can help with other issues like:

• Poor relationships

• Limited communication skills

• Anger management

• High stress

• Public speaking

Whether you struggle with only one condition or have multiple things you’d like to address, CBT could work for you.

How effective is cognitive behavioral therapy for substance use?

For substance use disorders, CBT is an effective treatment option. Support for CBT is based on science and is backed up by hundreds of studies over the decades.

With any substance use treatment, measuring success is challenging because addictions have periods of recovery and relapse. With that being said, CBT is effective because it:

• Is a cost-effective option

• Can provide good results in the short term

• Can lead to periods of recovery in the long term

• Is appropriate for a wide variety of substances use disorders

• Addresses underlying mental health issues and stressors

Can CBT be combined with other treatments for substance use disorders?

CBT can be a great option as a standalone treatment for someone with an addiction. It can also work well when combined with other treatment options.

Some other therapy styles that interact well with CBT are:

• Motivational interviewing (MI): a way to build internal motivation for change and substance recovery 

• Contingency management (CM): a treatment that offers rewards and prizes for staying in recovery and remaining drug free

In addition, you could use support groups to complement CBT sessions. Options like 12-step groups or SMART Recovery can help you build a recovery community to help extend your professional care. 

CBT also supports the use of psychiatric medications and medications to treat substance use disorders. Many people use medications to boost the success of CBT.

What are the benefits of CBT for substance use?

CBT is one of the most beneficial therapy options. No matter your stress, your symptoms, or situations, chances are good that CBT can help.

The benefits of CBT are that:

• It can help you better understand yourself.

• It addresses the whole you. CBT works to improve you as a complete person.

• It teaches you healthy coping skills to resolve stress, solve problems, and avoid substances.

• It focuses on addressing your problems with a short-term approach.

• It is widely available. CBT is offered in therapy centers, doctors’ offices, hospitals, and other clinics.

• It offers flexibility. As individual, group, or family sessions, CBT can fit a lot of different situations for many conditions.

What are the risks of CBT for substance use?

All treatments carry risks, but those associated with CBT are small and mostly harmless. One possible side effect is the idea that confronting your problems could feel uncomfortable for you.

Also, making active steps to change yourself can disrupt your relationships. This relationship shift could be positive in the long term, though, especially if those people encouraged or enabled your substance use.

How long does CBT take to work?

With its focus on evaluation, education, skills, and homework, CBT can begin producing improvements quickly. Often, they come after just a few sessions.

How long do you have to stay in cognitive behavioral therapy?

In CBT, you and your therapist work together to determine the treatment plan that best meets your needs. Because of this, you could have therapy that lasts just a few weeks or treatment that continues for months or years.

For some people, between six and eight CBT sessions could be enough to shift their thinking and behavior patterns. It is important to remember, however, that longer periods of treatment are linked to longer periods of recovery. You never want to rush treatment.

Where can you find a therapist that uses cognitive behavioral therapy?

CBT is one of the most effective and well-studied therapy methods. It is also one of the most common. Many therapists are drawn to the practical, solution-focused strategies of CBT.

Chances are excellent that at least one therapist at your local mental health agency or addiction treatment center will be skilled in CBT. If you are looking for a professional with advanced certifications, you can search for them through organizations like the Academy of Cognitive and Behavioral Therapies and the Association for Behavioral and Cognitive Therapies.

Keep in mind

There is no single treatment that works for all people all of the time. But CBT is very effective in many situations. If you have substance use issues with or without other mental health concerns, CBT is a safe and helpful choice. 

Why trust our experts?

Written by:

Eric Patterson, LPC

Eric Patterson, LPC, has been a professional counselor in school and outpatient settings — working with clients of all ages to achieve happiness, good mental health, and better lives — for over 15 years. Since 2010, he has provided clinical supervision to other therapists hoping to refine their skills and become licensed professionals.

Reviewed by:

Emily Guarnotta, PsyD

Emily Guarnotta, PsyD, is a licensed clinical psychologist and certified perinatal mental health professional with over 10 years of clinical experience.

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