Substance use disorder (SUD) will be examined in this research as it relates to cognitive behavioral therapy, a popular short-term intervention for mental health issues like addiction. This essay will first review the literature conceptualizing SUD and the use of CBT in addiction treatment. In addition, this literature analysis will examine the efficacy of online-based CBT intervention against SUD and compare the results with the group and individual therapy sessions. The literature review will also discuss the most popular CBT techniques used to treat SUD in adults. The next section of the essay will critique CBT as a therapy option for SUD symptoms in adults. Finally, the paper will discuss potential future steps that clinical social workers could take to use CBT as a treatment option for adults suffering from addiction.
Substance Use Disorder
The latest edition of the DSM manual describes substance use disorders (SUDs) as long-term, maladaptive drug and/or alcohol use that significantly impairs one’s performance in both the personal and professional realms (American Psychiatric Association, 2018). Substance misuse is becoming more widely acknowledged as a mental health issue, according to APA (2018), which declared it an important global public health concern. Unfortunately, the sharp increase in drug and alcohol usage between 2005 and 2018 affected the general public and the clinical professions (Grant et al., 2019). In the last few years, the prevalence of substance use disorder has increased by 12%, while drug use has increased by 18%. (World Drug Report, 2017). Furthermore, the complexity of the issue and its treatment tends to increase when addiction and other mental health issues co-occur.
Due to its prevalence and severity, SUD is currently one of the world’s most common public health concerns. Therefore, it must be dealt with using the greatest and most efficient techniques (Zamboni et al., 2021). There is a need for integrated treatments that combine pharmaceutical and psychological therapy because it has been shown that SUDs are defined not only by faulty physiological pathways but also and especially, by psychosocial ones (Zamboni et al., 2021). Regarding the psychological aspects of SUDs, cognitive behavioral approaches continue to be the most successful approaches for addictive behaviors due to their general recognition as the category of psychological therapies with the most substantial scientific evidence from controlled trials (Zamboni et al., 2021).
Cognitive Behavioral Therapy
Cognitive-Behavioral Therapy (CBT) is a type of psychotherapy that helps people understand and change the thoughts and behaviors contributing to their problems. CBT is based on the idea that how people think (cognition), how they feel (emotion), and their actions (behavior) are all related (Zamboni et al., 2021). CBT can help people learn to change unhelpful thoughts, feelings, and behaviors. According to a study by Zilverstand et al. (2018) that examined research employing neuroimaging data before and after therapy with various cognitive behavioral approaches, this strategy is successful even from a neurobiological perspective. Most existing studies suggest that CBT can reverse the prefrontal areas’ persistent hypoactivation in people with substance use disorders, leading to a reconfiguration of the brain circuits most closely associated with these illnesses (Zamboni et al., 2021). The findings demonstrate that cognitive therapies can stimulate the prefrontal areas of addiction that are consistently hypoactive and linked to cognitive control. Some of the most cited CBT techniques for achieving this include schema therapy, dialectical behavior therapy, acceptance and commitment therapy, mindfulness-based cognitive therapy, and more modern “third-wave” behavior therapies (Zamboni et al., 2021). Because traditional CBT has evolved and involves a wide variety of distinct concepts, beliefs, models, and practices, it is challenging to describe the ideal SUD intervention. Hayes (2016) divided these numerous theoretical processes into three generations to standardize them. Unlike the “first wave” of CBT, traditional CBT focuses more on altering the content of dysfunctional cognitive schemas, subpar information-processing techniques, and irrational beliefs.
Contrary to these “contextual cognitive behavioral therapies,” CBT is more concerned with the context and goal of distressing inner experiences (such as those in SUDs) and less about the content of those experiences. Substance addiction is a common coping mechanism or escape for addicts from the powerful emotions and accompanying discomfort (Gupta et al., 2021). Along with numerous negative effects, one of the reasons people resort to substance misuse is the numbing of unpleasant feelings and sensations (Gupta et al., 2021). These behavioral therapies’ main objective is to reduce the impact of personality traits contributing to drug or alcohol dependence. Third-generation behavioral therapies try to change the conditions that give rise to unfavorable ideas, feelings, and bodily sensations (Gupta et al., 2021). The more traditional cognitive behavioral therapy aims to improve behavior by changing the language content of a person’s ideas.
The primary cognitive behavioral therapy for substance use disorders includes numerous interventions that mainly take the form of group or individual therapy. Patients resistant to changing their drug and alcohol use behaviors can benefit from motivational interventions (MIs), a part of cognitive behavioral therapy (Cakici et al., 2018). MIs can treat various conditions and behaviors for motivation and compliance; these treatments are often brief and provided in an individual setting (Cakici et al., 2018). While group options are also available, longer-term therapy may be more beneficial. In contrast, contingency management (CM), which rewards patients for demonstrating their abstinence from addictive substances, is based on the operant learning principle.
Estimates for CM’s effectiveness across trials are moderate and vary depending on the target molecules, according to a recent meta-analysis by Boness et al. (2022). Another strategy is to take preventative action to minimize the risks of relapse. This method’s primary objective is to pinpoint the specific drug-related triggers that each patient experiences and are finally stopped once the patient has developed the required coping skills for handling these pressures (Boness et al., 2022). This is done to identify and prevent the patient’s drug usage triggers. With this strategy, social workers challenge the patients’ beliefs about the therapeutic benefits of the drugs to which they are addicted. Psychoeducation also gives patients the information they need to make wiser choices in risky situations.
Evidence from numerous large-scale trials and quantitative analyses supports CBT’s efficacy for problems connected to alcohol and drug use. In the case of CBT for drug usage and dependence, for instance, Polak et al. (2021) team’s meta-analytic research showed that the effect size varied from small to substantial, with an overall effect size in the moderate range. It was discovered that this variation was affected by the substance being treated. The review covered 2,340 patients from 34 randomized controlled trials (Polak et al., 2021). Cocaine, opioids, and opioid dependence had the biggest treatment effect sizes, whereas polysubstance dependency had the smallest treatment effect sizes. There was some evidence that contingency management strategies (see below) had bigger impact sizes for each particular therapy type than relapse prevention or other cognitive behavioral therapies. These advantages were always contrasted with the control conditions, frequently general medical care or drug counseling. More evidence demonstrates the treatment’s long-term advantages of CBT in SUD intervention. For instance, according to a study by Kampman (2019) on a psychosocial therapy trial for cocaine addiction, 60% of patients in the CBT condition had clean toxicological testing at a 52-week follow-up.
Internet-based CBT (ICBT)
ICBT, first developed and tested mid-1990s, has been the focus of many studies and debates. This category of interventions includes studies on treatment delivery methods, such as the role of the therapist, as well as the mechanisms of change, efficacy, cost-effectiveness, systematic reviews, qualitative research, and other aspects of therapy delivery. Like online learning, ICBT depends on physician guidance while transferring content over a secure, encrypted link (mainly via text) (Reins et al., 2021). Alternative programs are still available despite data showing that they are less efficient than traditional therapies with therapist support (Reins et al., 2021). Empirical evidence has concluded that traditional, in-person psychological treatment is helpful for many common mental and physical health conditions. Few studies specifically show that ICBT is as successful as in-person and online CBT, but scant evidence suggests it might be. Recent research into the efficacy of ICBT showed side effects such as intense negative emotions after exposure to triggers.
Developing Useful Coping Skills
Coping skills training is a hallmark of both face-to-face and online CBT. CBT teaches patients many useful yet transferable coping skills, such as stimuli management, assertive communication, emotion regulation, problem-solving, and cognitive reappraisal, to lessen and avoid substance dependence (Roos & Witkiewitz, 2017). Both in-person and online CBT for SUD are anticipated to undergo major modifications due to developments in substance-related coping strategies (Roos & Witkiewitz, 2017). In recent empirical studies, the role of drug-related coping strategies as a mechanism of change in CBT for SUD has shown mixed findings (Roos & Witkiewitz, 2017). According to Roos and Witkiewitz (2017), coping skills are the key element of all manual in-person behavioral treatments for SUD, including in-person CBT for SUD.
For instance, a recent study comparing case management, CBT, and network support therapy for alcohol use disorder discovered that reducing the usage of substance-related coping mechanisms from before treatment to post-treatment decreased the efficacy of both therapies (Litt et al., 2018). The effectiveness of the combined behavioral intervention, which integrates cognitive behavioral therapy, motivational interviewing, and 12-step facilitation, was compared to medication management for alcohol use disorder and found to be moderated by the degree to which the patient’s substance-related coping skills had improved after treatment (Witkiewitz et al., 2018). Even though it is likely that this only applies to a small number of people, substance-related coping may be a novel CBT change mechanism. According to one study, 12-step facilitation or motivational enhancement therapy helped outpatients with severe alcohol dependence increase their capacity to manage substance use from before to after treatment more effective than cognitive behavioral therapy (Roos et al., 2017).
Recent research suggests that using computerized CBT as a supplement to traditional therapy affects the effectiveness of substance-related coping mechanisms. According to one study, the computerized cognitive behavioral therapy program CBT4CBT decreased substance use after treatment because it enhanced the quality of coping mechanisms related to addiction, as evidenced by a role-play task from pre- to post-treatment (Kiluk et al., 2010). Lévesque et al.’s (2017) study that examined TES, a web-based program that combines contingency management for SUD, and the Community Reinforcement Approach (which includes several modules on coping skills), found that coping frequency improved between pre- and post-treatment. The effects of an increase in the frequency of substance-related coping mechanisms from pre- to post-treatment were lessened, according to research on the web-based program Thinking Forward for people with PTSD and high-risk drug use (Acosta et al., 2017). However, not all investigations have discovered clear proof of a mediating component.
For patients with cocaine use disorder receiving methadone maintenance therapy, researchers recently looked into the potential mediating role of better substance-related coping between CBT and ICBT. Still, they could not find any evidence of a second-order effect (Kiluk et al., 2017). Most studies of CBT for SUD, whether delivered face-to-face or online, use drug-related coping skill development from the beginning of treatment (i.e., baseline) through the time point of treatment termination as the mediator variable (Kiluk et al., 2017). Treatment for SUD typically lasts between 8 and 12 weeks, explaining why the potential significance of long-term adjustments to substance-related coping strategies as a mediating element of therapeutic outcomes has not been fully investigated.
Since CBT aims to help patients learn coping skills and maintain them long after treatment has ended, a more thorough evaluation of changes in substance-related coping may be required. Because CBT promotes the adoption of transferable coping mechanisms, it is believed to have a long-lasting effect on drug use (Roos et al., 2020). The “sleeper effect” of CBT, in which patients’ reduced substance use persists long after treatment is over, has also been documented in numerous studies (Roos et al., 2020). Many believe this form of therapy has a “sleeper effect” because CBT successfully promotes long-term adoption and generalization of coping mechanisms (Roos et al., 2020). According to Kiluk et al. (2018), the sleeper effect has been demonstrated in both face-to-face and online CBT for SUD.
Another well-researched cognitive-behavioral approach to treating drug use emphasizes the need for a practical understanding of drug use cues and the active training of alternate responses to these cues. Relapse prevention (RP) is a strategy that aims to recognize and prevent situations that could increase a patient’s propensity to use drugs or alcohol (such as favorite bars or around friends who use it) (Livingstone‐Banks et al., 2019). RP approaches to address the patient’s expectation of anticipated positive benefits of use to assist them in making a more informed decision in the risky situation. A meta-analysis of 26 trials that looked at smoking, alcoholism, and drug use disorders, as well as the efficacy of RP, found that it had just a small impact on reducing substance use but a significant impact on boosting general psychosocial adjustment (Livingstone‐Banks et al., 2019).
Similar CBT procedures have also been developed, which, in addition to addressing the functional cues for drug use, may also include a wider range of psychoeducation, cognitive reappraisal, skills training, and other behavioral tactics. Each of these components is included in various CBT programs to differing degrees (Livingstone‐Banks et al., 2019). A cognitive behavioral intervention for cocaine dependence was developed by Livingstone‐Banks et al. (2019) and comprised functional analysis, behavioral techniques to avoid triggers, and the improvement of problem-solving, drug refusal, and coping abilities. With effect size estimates in the low to moderate range using several comparison scenarios and significant effect sizes compared to control groups not getting therapy, meta-analytic reviews of CBT for SUDs demonstrate its efficacy.
Criticism of CBT and Future Direction
Historically, the two primary foundations of conventional treatment for substance use disorders have been drug therapy and behavior therapy, particularly CBT. CBT aims to deal with problems relating to the idea that most people’s thinking is defective or unproductive and that psychological problems are based on taught patterns of the same erroneous or counterproductive conduct (McHugh, Hearon & Otto, 2018). People can change their mental patterns and transform them using specific tools and procedures, enabling them to act more beneficially. Behavior therapies like motivational enhancement therapy have been utilized in addition to CBT and medication (McHugh, Hearon & Otto, 2018). The aim of motivational improvement therapy is rapid, internally motivated change. The initial assessment is followed by two to four individual therapy sessions with a therapist. Patients take part in discussions about high-risk situation coping strategies and get advice on them. The therapist encourages commitment to long-term abstinence or chance in subsequent sessions while keeping an eye on progress and assessing the cessation methods employed.
Clinical depression can range from a slight, passing sadness to a strong, pervasive sadness. The most typical physical signs of depression are feelings of emptiness or melancholy, irritability, loss of interest, trouble sleeping, changes in appetite, anxiety, sluggish speech or movement, and occasionally suicidal thoughts. The co-occurrence of substance use disorders with depression is common (Watkins et al., 2019). Watkins et al.’s 2019 study aimed to better understand CBT therapy’s potential effects on people with severe depression and substance use disorder. The CBT therapies for patients receiving care in residential settings and those for patients receiving care in group counseling settings were contrasted in the study. The study’s main hypothesis was that patients would experience greater benefits from residential therapy in terms of a decline in drug use and an improvement in all depressive symptoms. A self-assessment (PHQ-9) and a physician-guided evaluation (Hamilton-D) were both utilized to look at the signs of a successful recovery (Watkins et al., 2019). The study’s authors concluded that despite improvements in terms of fewer urges to use and a higher capacity to apply problem-solving skills to avoid using, neither the drug use disorder nor the concomitant depression was receiving adequate therapy. This led the researchers to question whether treating depression and substance use disorder concurrently or separately should be the goal of behavior modification therapy.
According to McKee et al. (2019), CBT has been demonstrated to be effective in improving treatment outcomes in groups that use cocaine. Despite being a successful and often used therapy in treating these individuals, the capacity of CBT to impact and effectuate real and meaningful change early on is, at best mixed. Additionally, CBT fails to address a person’s engagement and motivation in the transformation process. Motivational enhancement treatment was used as a cutting-edge therapeutic strategy to reinforce the principles of CBT. The reasoning for this is that by combining these two treatments, one can assist the other in overcoming its weaknesses by utilizing their complementary methods (McKee et al., 2019). While some studies have found evidence in favor of combining these two approaches, the researchers note that there haven’t been many empirical evaluation studies to determine whether conventional approaches, like using CBT as a stand-alone therapy, can be enhanced or sufficiently modified to yield better results. Full-scale randomized studies, according to the researchers, are also too costly and time-consuming to do, which is possibly why they haven’t been done before. They suggest smaller, more targeted trials as a substitute to ascertain the effects of individual MET and CBT components on outcomes.
The study by Barry et al. (2019) showed that those who were enrolled in CBT + MET attended more therapy sessions even though there were no increases in the participants’ actual completion rates. The desire to stay sober was notably stronger, there was more hope that they would succeed, and there was more worry about their ability to do so among those who did participate more. The CBT with MET patients did not demonstrate a higher commitment to abstinence in the weeks following therapy. Furthermore, the use of prescription medicines didn’t appear to be decreasing. The study’s overall conclusions were mixed, and it was recommended that more research be done.
Along with sleep disturbance, anxiety, melancholy, and mood changes, people with opioid use disorders frequently have unrelieved pain. Methadone maintenance therapy is a common treatment for those with chronic pain and probable opioid use disorder. It has been shown that CBT is effective in helping people who are showing signs of a substance use problem to change (Barry et al., 2019). 12 CBT sessions were provided to participants in a study by Barry et al. (2019) to teach them how to manage their use disorder and chronic pain. It took between 35 and 45 minutes for each session. Participants also got access to a four-session, 15-20-minute-long case management program that was a part of a methadone drug treatment program (Barry et al., 2019). The didactic approach was built on the 12-step rehabilitation program. Urine was examined to determine how much opioid was taken throughout the experiment. The study’s results revealed incredibly high rates of therapy attendance and treatment completion. According to the authors, CBT and methadone maintenance therapy effectively treat chronic pain and opioid use disorder. CBT was associated with increased participant acceptability and a desire to keep participating. Overall, the study discovered that when CBT and MMT were utilized together, people’s non-medical opioid use decreased more (Barry et al., 2019).
Although most of the literature indicates that CBT for drug use disorder has established efficacy, there appears to be a knowledge gap regarding research on using CBT for prolonged periods without medication (Ray et al., 2020). Alcohol and drug abuse can be treated with CBT, but further research is needed to determine how well it will work for polysubstance abuse (Ray et al., 2020). None of the studies addressed the utility of CBT for substance use disorders among people with various medical conditions, in prison populations, or relation to pregnant women.
One of the biggest flaws in the literature was the lack of consideration of the social and environmental factors that influence overall cognitive health and the potential for someone to develop a substance use disorder. The impacts of substance use disorders can and do affect all socioeconomic classes. Still, it is unclear what, if any, influences the local environment, resources available, long-term learning patterns, and cultural differences may have. Only around half of the content referenced the individuals’ racial or cultural origins, proving this. Those that did focus mostly on Caucasian groups (McHugh, Hearon & Otto, 2018). The literature was consistent in describing and applying cognitive behavioral therapy for substance use disorders. Most research agrees that CBT can help substance users achieve the necessary changes and maintain sobriety. The question of whether CBT is always the best course of treatment comes up even though it is efficient and commonly used. CBT received widespread acclaim in the literature, but it didn’t appear to have enough support to become a widely used methodology (Watkins et al., 2019).
SUD is one of today’s most widespread and serious global public health problems. There is a growing body of research suggesting that cognitive behavioral therapy (CBT) can help people with substance use disorders recover from their condition by rewiring the brain regions most closely related to these diseases. Numerous large-scale trials and quantitative analyses have shown that CBT effectively addresses issues related to substance abuse. The data for ICBT’s efficacy is sparse, although it may be on par with in-person and online CBT. Both in-person and virtual CBT emphasizes the development of adaptive coping mechanisms. CBT educates patients on a wide range of practical yet transferable coping mechanisms, such as stimulus control, assertive communication, emotion regulation, problem-solving, and cognitive reappraisal to minimize and avoid substance dependence. Another well-studied cognitive-behavioral approach to drug addiction treatment stresses the importance of acquiring a working knowledge of drug use cues and actively training alternative responses to these cues. The goal of relapse prevention (RP) is to help patients avoid returning to drug or alcohol use by identifying and mitigating risk factors for relapse.
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