Substance Use Disorders (SUDs) can be defined as “a cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (APA, 2013). It can arise from a maladaptive pattern of behaviours and emotions related to the use of psychoactive substances, like alcohol, cannabis, cocaine, opioids and others. According to the World Drug Report 2018, about 275 million people globally, or 5.6% of the people aged 15-64 years, use drugs.
In comparison to other countries, Canada, the United Kingdom and the United States are undergoing a swift upsurge in the growth of SUDs. There are several issues that occur along with substance use including family or social relationships, legal matters, job concerns and co-occurring psychiatric conditions. Thus, the high rate of substance abuse makes the detection of effective treatment a significant priority.
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The publication of Marlatt and Gordon (1985) on “Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviour” proves to be an essential blueprint for CBT approaches to addictive behaviours and since then it has been the most-studied treatments for SUDs (Brian et al., 2017). While treating SUDs, the therapist helps the client to identify potential triggers that increase the risk of relapse and teaches behavioural and cognitive coping strategies (Carroll & Onken et al. 2013). All models seem to include five CBT strategies:
- Functional analysis of substance use,
- Identification of triggers for relapse,
- Coping skills training,
- Behavioural skills training for drug refusal, and
- Increased activities not related to substance use.
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Effectiveness of the CBT Approach
Currently, cognitive behavioural approaches have maximum empirical support from high-intensity clinical trials and are largely recognised as evidence-based approaches to SUDs (U.S. Department of Health and Human Services, 2016) and incorporated in a wide scope of practice guidelines. CBT proves to be effective for SUDs (Irwin et al.,1999), including alcohol addiction (Miller and Wilbourne 2002), marijuana use (Marijuana Treatment Project Research Group 2004; Stephens et al.,2000) and cocaine addiction (Rohsenow et al 2000).
A current and all-inclusive meta-analysis has included 53 controlled trials for alcohol and drug use disorders and stated a small but substantial treatment effect (g=0.15) for CBT (Magill and Ray 2009). However, in a seminal review by Morgenstern (2000), CBT showed very little scope for improvement in coping skills for CBT for substance use disorder.
The evidence assisting the effectiveness of CBT can also be generated from multisite studies including Project MATCH and Project COMBINE for alcohol (Anton et al.,2006; Project MATCH Research Group,1997), the NIDA Cooperative Cocaine Treatment Study (Critis et al.,2006) and Marijuana Treatment Project (MTP Research Group,2004). CBT proves to be effective with other treatments like pharmacotherapies for substance use (Carroll et al.,2004), Motivational Interviewing (Baker et al.,2005) and Contingency Management (CM) (McKee et al.,2007). Unfortunately, a high drop-out rate of 40-45% has been documented amidst different behavioural treatments, including CBT whereas Contingency Management has exhibited the lowest drop-out rate (29%) and is used along with CBT for SUDs (Dutra et al.,2008).
However, research also suggests that CM have strong instantaneous effects on substance use that incline to weaken once the contingencies are terminated (Podus et al.,2006), while CBT has uncertain effects initially but is comparatively much more robust (Finney et al.,2006). Although there are mixed findings concerning stabilizing effects on drug use outcomes, evidence suggests that adding motivational improvement to the initial stages of CBT can help increase motivation and improve treatment maintenance.
In an extremely well-conducted study, Waldron et al (2001) randomly assigned 120 individuals who were users of illicit drugs, to one of the three treatment conditions: Family therapy, CBT, and psychoeducational group. There were larger and more durable reductions in substance use for CBT with persistent treatment effects through a 7-month follow-up. Computerized CBT was found to be effective in enhancing the quality of coping skills of the individual for drug avoidance (Kiluk, Nich et al.,2010).
Also, when traditional CBT is compared with ‘contextual CBTs’, such as Mindfulness-Based Relapse Prevention (Bowen et al.,2009), Dialectical Behavioral Therapy (Linehan,1993) and Acceptance and Commitment Therapy (Hayes et al.,2006), this research is still in its infancy and will require more rigorous trials to determine its effectiveness as to traditional CBT (Stotts et al.,2015). Also, a robust relationship has been indicated between extra-session practice assignments (homework) in CBT and treatment outcomes as well as reduced drug use (Carroll et al.,2008). Although more research is needed in this area, homework in CBT plays an important role in treatment outcomes.
In difference to numerous evidence regarding CBT’s efficacy, less amount of information prevails on mechanisms of how it applies its effects (Kazdin, 2007). As CBT mainly focuses on cognitive and behavioural skills training, a focus on the enhancement of these skills would act as a mediator for treatment outcomes. Overall, CBT does prove to be effective for SUDs. Thus, while few systematic reviews and high-intensity clinical trials are evaluating CBT for SUDs, those that have been done, suggest that CBT has modest but long-lasting effects.
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Challenges Faced
Relapse is a fundamental barrier to the treatment of SUDs (Brandon et al.,2007). 12-month relapse rates for alcohol and tobacco cessation range from 80-95% (Brandon et al,2007; Miller,1999) and similar relapse persists across other classes of substance use (Brandon et al,2007; Hunt et al.,1971). Thus, preventing relapse and minimizing its effect is a prerequisite for long-term changes in addictive behaviours. Another important barrier faced by CBT is withdrawal. Although withdrawal is a physiological process, recent theory highlights the importance of the behavioural withdrawal process and that the unavailability of drugs, may leave the individual incapable of dealing with the stress thus prolonging the symptoms (Baker et al.,2006).
In light of this, Negative affect is a relapse trigger and plays an important role in the maintenance of addictive behaviours (Marlatt, 1978). Baker et al (2006) proposed that these factors can interfere with CBT, such that adaptive coping and decision-making may be affected.
Other difficulties that may be faced in the treatment are severe cognitive deficits, medical problems, social stressors, lack of social resources, issues of contact, stigma, financial expenses, confidentiality, and others (Carroll & Rounsaville, 2010; Kazdin & Blase, 2011).
Challenging populations may include pregnant women and imprisoned patients. In these circumstances, the use of practical evaluation to arrive at strong case formulation and the adapting the use of treatment components is important, demonstrating the therapist’s expertise. For example, using simple forms and calling the patient for homework assignments would be helpful for clients with low literacy levels. Helping the patients to shift their Locus of Control from external orientation “Control is beyond me” to internal orientation “I can expect some control over myself and my drug use” proves to be a process (Marlatt,1985).
It appears to be challenging to transfer CBT to prevalent clinical practice, like other evidence-based approaches (Harvey et al.,2015). Barriers include lack of guidance and certification programs, cost of training, evaluation of fidelity in delivering therapy, limited focus on sustainability and others (Harvey et al.,2015; Barlow, 2010; Institute of Medicine,1998). Moreover, the a lack of authority for the substance use treatment system to track the progress of treatment outcomes (Humphreys & McLellan, 2011) and weak, inconsistent efforts to improve those outcomes (Carroll,2014).
In recent years, the various methods used to train clinicians on how to use evidence-based therapies have concluded that monitoring and guidance are more effective than workshop-based training (Sheidow et al.,2013; Kendall et al.,2010). Another challenge in treating SUDs with CBT is the lack of training, supervision and feedback to clinicians. The lack of guidance and supervision of CBT and other EBPs may show little similarity to the more thoroughly examined versions of randomized controlled trials representing their effectiveness (Martino et al.,2016).
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Conclusion
Overall, the evidence gathered so far is modest yet encouraging. What is also needed is research in environmental, social and clinical conditions that can effectively help patients living in the community most cost-effectively. CBT addresses specific targets of patients who are poorly targeted by medications, engaging in occupational activities and impacts self-esteem, coping skills and adaptive functioning. Considering the importance of social relationships, occupational functioning, and emotional well-being for the quality of life of individuals, further research in CBT for SUDs should focus on how to integrate intervention components from various models to provide clients with the best care possible.
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