Cognitive Behavioral Therapy in Addiction Treatment

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Introduction

Cognitive-behavioral therapy is a psychological treatment approach that has been empirically demonstrated to be effective in addressing a range of psychiatric issues and mental health problems, ranging from depression and anxiety to addiction and substance abuse disorders. It relies on teaching the patient alternative ways to cope with their issues that do not involve self-destructive behaviors. Numerous studies prove the efficacy of CBT in improving the quality of life and function in individuals with mental health problems or addiction (Fulton, n.d.). CBT is highly valuable as a therapeutic approach in which methods are developed based on ample scientific evidence that shows specific changes or positive outcomes for patients (McLeod, 2019). However, it is still relatively new, and its uses have not been explored fully yet. This essay will discuss its application in the treatment of patients who are affected by addiction.

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Addiction is a powerful compulsion toward specific stimuli, often alcohol or drugs, that eventually causes the person to lose control over their use despite the adverse consequences of doing so. In the past, the treatment of addiction has involved withdrawing the stimulus in question from the patient and supervising them until they are no longer dependent. In the case of alcoholism and drug addiction, the process can have significant side effects on the patient’s physical and mental health. As such, recent research suggests that addiction requires long-term care, including mental health and therapy (McKay, 2018). Substance use disorders (SUDs) are heterogeneous conditions that can be described as recurrent and unhealthy use of a psychoactive substance. They are associated with distress and disability, as well as several other harmful factors. SUDs occur frequently compared to many other conditions, with lifetime rates of SUDs or dependence reaching over 30% for alcohol and 10% for other drugs (McHugh et al., 2010).

CBT is based on the core idea that psychological problems are based on faulty thinking and learned patterns of unhealthy behaviors. Therefore, individuals with psychological problems can manage their behavior by learning to cope with them through changes to thinking patterns. CBT strategies focus on shifting these thought patterns, mainly through self-reflection and efficacy. Individuals learn to deal with their thoughts and triggering situations, eventually creating coping mechanisms that assist them in their everyday life. CBT strategies focus on individuals recognizing distortions in their thought patterns that create problems and reevaluating them in reality. To achieve this goal, they have to understand their behavior and motivations as well as those of others and to be confident in their abilities to address problematic interactions or triggers (American Psychological Association, n.d.).

This paper will present the analysis of the available literature on the topic of using CBT for substance abusers with a focus on the discussion of the main study’s results, strengths and weaknesses, and implications for practice.

The rationale for the subject and its importance in the field of addiction and healthcare

SUDs continue to contribute heavily to the burden of disease in the country and create high costs due to economic loss, health care spending, and crime. However, SUDs are preventable and treatable on a public health level through the appropriate methods. Despite high levels of substance abuse prevalence, it is estimated that more than 50% of people living with a diagnosis of a mental health disorder or addiction do not receive necessary medical treatment or psychotherapeutic intervention (American Addiction Centers, 2019). The reason for this pattern is unclear, though it is likely that it is a combination of negligence, high costs, and dismissal of SUDs as inadequately severe to warrant treatment. CBT plays an essential role in such contexts as a widely available and well-researched therapeutic approach that can be implemented at a greater scale in healthcare delivery to treat SUDs.

With that said, despite the benefits that CBT has demonstrated in various areas, adoption has been slow, at least partially because of a lack of evidence-based research. According to NIDA (2018), the method is currently in development and is generally used in combination with other therapies, both standard treatments, and specialized medications. CBT is not currently considered an approach that can resolve the problem of SUDs independently. One of the reasons is the perception of CBT as a traditional and immutable approach, which fails to make possible modifications into account. Boog et al. (2018) make a case for schema therapy, which is based on a combination of CBT and several other frameworks, for patients with co-occurrent SUDs and personality disorders. Additional studies are necessary for the formulation of evidence-based practices that can be applied globally to improve the well-being of the patients.

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Structured critical review

  • Neurobiology
    Excessive and chronic consumption of many addictive substances can cause significant changes in brain circuit function that oversees pleasure, learning, stress, self-control, and decision-making. Most addictive drugs, including alcohol, produce a surge of the neurotransmitter dopamine in the basal ganglia region upon consumption. Ordinarily, this area controls rewards and the ability to learn based on rewards, since dopamine surges commonly lead to pleasure in humans. However, the brain eventually adapts and starts reducing its reaction to the hormone so that it can continue operating normally (U.S. Department of Health and Human Services, 2016). On a physical level, this forces individuals to increase the amount of addictive behavior (either in frequency or volume) in order to achieve a feeling of pleasure. Meanwhile, changes to the extended amygdala leave a person in extreme physical and emotional distress when not using the substance. The prefrontal cortex responsible for decision-making is compromised, and all other priorities other than the substance become irrelevant (U.S. Department of Health and Human Services, 2016).
    CBTs are based on principles of operant or classical conditions. They seek to heighten an individual’s awareness of cues that they associate with substance abuse. By reducing exposure to these triggers and teaching the patient to recognize and manage them, CBTs counter the neurobiological effects of drugs on the brain. The neural mechanisms behind CBT are complex and poorly understood, primarily due to the multi-faceted nature of the therapy. Since it consists of different modules, it is believed that each coping strategy or module may influence different parts of the brain or specific neural circuits. For example, modules for coping strategies will affect brain regions that are implicated in cue-induced drug cravings, such as the medial prefrontal and anterior cingulate cortices. Individuals who demonstrate greater functional connectivity between prefrontal cortical regions and interoceptive processing (insula) show superior success in the treatment of SUDs with CBT (Potenza et al., 2011). With future research, humanity will eventually achieve a superior understanding of the reasons why CBT works. However, current evidence is sufficient to justify putting it into practice.
  • Epidemiology
    It is estimated that approximately 19.7 million people in the United States aged 12 and older have had a substance abuse disorder related to the use of alcohol or illicit drugs in the last year. The primary cause was alcohol and illicit drugs for 14.5 million and 7.5 million individuals, respectively (SAMHSA, 2017). In the United States, alcohol use disorder affects 8% of men and 7.7% of women. Meanwhile, approximately.37% of American adults have had opioid use disorder for at least 12 months, males more so than females (NIH, 2020). Approximately 17-19% of the population suffers from substance abuse, which makes it the second most prevalent of DSM-5 disorders. According to the World Health Organization, problematic substance abuse continues to rise year over year, leading to 3.3 million deaths globally. Western countries are generally experiencing a rapid increase in the prevalence of substance abuse in comparison to other countries, despite a decrease in SUDs among adolescents in these regions (Morin et al., 2017).

Research and ethical subjects: the study by Jean-François G. Morin et al. (2017)

This paper will review a study by Morin et al. (2017), who conducted a literature review of the various CBT treatments for substance use disorders. The authors took six CBT treatment models and examined them separately, discussing the overview, procedure, and supporting literature evidence with theoretical background, adding a brief analysis of the efficacy of the strategy chosen. The examined modalities were: “relapse prevention (RP) and mindful-based relapse prevention (MBRP), guided self-change (GSC), community reinforcement approach (CRA), behavioral couples therapy (BCT), and personality-targeted brief interventions” (Morin et al., 2017). The study is a literature review of theoretical and practical therapeutic concepts; therefore, there are no evident ethical concerns.

The study found that there are several available and effective CBT treatments for SUDs. Some strategies, such as guided self-change (GSC), are beneficial for non-severe addiction patients and helpful to frontline health providers, to whom time efficiency may be vital. However, GSC cannot be the sole method of treatment because there are patients for whom it is ineffective, who do not benefit from additional sessions. An alternative to it, BCT, is a treatment approach for consistent addiction that involves the help of a loved one and is recognized by the American Psychological Association as useful for treating alcoholism due to the evidence that it has generated. For individuals with difficulties in personal and professional life, the multimodal approach of CRA can be personalized to address the patient’s immediate needs. The CRAFT approach is a more innovative method that reinforces social support for those experiencing difficulties, particularly for treatment-refusing patients or ones for whom conventional treatments have failed. MBRP is also an unorthodox approach to therapy in the area of addiction, integrating mindful meditation to manage relapse prevention or avoidance of triggers. However, it may not be suitable for individuals who are unable to engage in meta-cognition or exert control in high-risk situations. Personality-targeted CBT builds upon existing CBT principles to develop a model for young adolescents or concurrent psychiatric problems (Morin et al., 2017).

As noted by Morin et al. (2017), the models they have reviewed show evident differences, and it is difficult to identify which is more effective. However, they are all based on underlying principles of CBT, which seeks to orient clients towards an objective in treating SUDs. It teaches them skills for managing and achieving that goal and establishing plans to deal with risks or relapses (Morin et al., 2017). These conclusions match the original goal of CBT, which is to address the unhealthy mental environment that is created by addiction in the context of negative thoughts, change of emotions, and compulsions. In a situation where it is challenging to manage thoughts and emotions, crippling a person’s life, CBT offers professional guidance and coping strategies that build a foundation for recovery (Addiction Campuses, n.d.). As such, all of these therapies warrant further investigation and are likely suitable for usage in medical environments.

The approach used by Morin et al. (2017) in this literature review to examine various modalities of CBT is critical. According to McGovern et al. (2011), SUDs differ significantly between cases and require a significant degree of therapy personalization to address. The study also found that integrated CBT was more effective than individual counseling in addressing SUDs. Ultimately, the limitations of learning models, as well as the growth of social learning and cognitive theories, gave rise to these various cognitive-behavioral models to study substance use. The social cognitive theory developed by Bandura serves as the foundation of CBT, suggesting that the constructs of self-efficacy and outcome expectancies are associated with substance consumption and coping with said addiction. The origins of CBT can be traced back to learning theories. Since CBT is a structured and time-limited psychological intervention, it is a direct application of the theories above in understanding the addiction and targeting the maintaining factors of addictive behaviors to prevent relapse (Sudhir, 2018).

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Strengths and weaknesses of the undertaken literature review

CBT programs have various strengths due to their flexibility, compatibility, and widespread applicability to both individual and group therapy treatments. The structure of CBT is adaptable and involves various types of activities that are selected based on patient type or needs and the care setting. As a result, it continues to be a popular method of therapy for treating SUDs, being combined with both pharmacotherapy (Vitiello, 2010) as well as other types of treatments, such as motivational interviewing (Randall and McNeil, 2017). This ability is a significant strength since combination therapies often demonstrate greater efficacy and better outcomes than monotherapy of any type in addiction treatment. CBT has also proven to be useful in dual-diagnosis treatments and many other behavior-based mental health situations. The therapy emphasizes the active involvement of the patient and a proactive course of action, with profound importance put on education and self-sufficiency in managing behaviors after the therapy is completed (Osilla et al., 2009).

A potential weakness regarding research around CBT, and potentially the therapy itself, is that it lacks cultural competence. It is a psychological therapy based on a wide range of emotional and behavioral disorders, many of them oriented around Western culture and way of life. However, there is a notable lack of applicability to non-Western cultures and patients. For example, a study by Al-Noor et al. (2018) found that CBT is less effective for Arab individuals since participants misinterpret their symptoms, and, despite the similarity in cognition to Western individuals, more emphasis was placed on negative social evaluation. This finding suggests that a culturally sensitive approach to CBT is required for various patients and in international settings. Furthermore, several clinical challenges can arise during the treatment of SUDs that can be identified as a weakness. These issues include acute and chronic cognitive deficits, medical issues, social stressors, or a lack of social resources. Individuals with low levels of literacy, for example, may have difficulty navigating the therapy. Patients may have various challenges in the socio-economic and environmental contexts associated with use relative to non-use lifestyles. Professionals should use functional analysis to achieve strong case conceptualization and enable flexible use of treatment components to achieve critical objectives with CBT (McHugh, Hearon, and Otto, 2010).

Western conceptions likely cannot be transplanted directly to Arab populations due to cultural differences. Moreover, the author has also identified a gap in addiction research in Arab countries that concerns senior populations. The information about their circumstances is lacking, which can affect them adversely through a lack of necessary interventions. Without information about the condition of senior people as a population category, it is challenging to determine whether addiction is a problem for them. As such, the problem can develop unchecked, while the issue is not being regarded as significant no research into effective countermeasures is ongoing. To prevent this scenario, it is critical to monitor the different aspects of health for many different population categories, identify emerging and current problems, and develop interventions. Overall, additional research into the usage of CBT for Arabic populations, particularly for senior populations, is necessary.

Possible practical or academic implications for the review

The literature review offers insight into the practices, benefits, and applicability of CBT in various contexts of SUD treatment. As identified by Morin et al. (2017), there are many readily available and practical approaches to CBT in treating SUD. Therefore, both in terms of practice and further research, it is vital to continue applying these CBT strategies or a combination of them. It is difficult to state in terms of efficacy which intervention is better than the other, and there is no standardized measure by which to evaluate CBT treatments. Seemingly, the choice of an appropriate treatment model should be made based on the client’s needs and circumstances. A qualified and skilled psychotherapist will be necessary to implement such an approach successfully and consistently. Another aspect that warrants consideration for practice is comorbidity. While it was mentioned that CBT had been identified as beneficial in cases of dual diagnosis, further research and practical study are necessary to address it. Therapies that are derived from it, such as schema therapy, may be appropriate in such situations. The future of CBT used for SUD treatment should begin with the development of models for patients with other mental health disorders such as PTSD, alongside SUDs, as these patients are inherently more complex, and it is unknown how effective CBT might be in such cases.

Summary and concluding remarks

Substance abuse disorders (SUDs) remain prevalent in healthcare and mental health issues in the United States. Cognitive-behavioral therapy (CBT) is an evidence-based method that has been effective at preventing, treating, and managing SUDs in clinical and therapeutic settings. This paper examined a study by Morin et al. (2017) that identified and evaluated six CBT treatment models. It was found that intervention components often share similar objectives in providing skills and orienting clients toward reducing substance abuse. The findings are well-supported by other research on the topic and have significant practical and academic implications in clinical settings that can be utilized for SUD treatment. Overall, CBT plays an essential role in modern therapy approaches to substance abuse disorder, and the research foundation should be built upon to improve effectiveness.

Reference List

Addiction Campuses. (n.d.) Using Cognitive Behavioral Therapy (CBT) In Addiction treatment. Web.

Al-Noor, Z. et al. (2018) ‘The impact of culture on anxiety related cognitions: an exploration with Saudi-Arabian individuals’, Mental Health, Religion & Culture, 21(5), pp.515–533. Web.

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Randall, C. L. and McNeil, D. W. (2017) ‘Motivational interviewing as an adjunct to cognitive behavior therapy for anxiety disorders: a critical review of the literature’, Cognitive and Behavioral Practice, 24(3), pp.296-311. Web.

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Vitiello, B. (2009) ‘Combined cognitive-behavioral therapy and pharmacotherapy for adolescent depression: does it improve outcomes compared with monotherapy?’, CNS Drugs, 23(4), pp.412–420. Web.

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PsychologyWriting. 2022. "Cognitive Behavioral Therapy in Addiction Treatment." January 31, 2022. https://psychologywriting.com/cognitive-behavioral-therapy-in-addiction-treatment/.

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