CBT for Substance Abuse: Insights from a Counselor Interview

Introduction: CBT as a Leading Approach to Substance Abuse

For this interview, I selected a substance abuse counselor — referred to here by a pseudonym — who approaches his practice from the perspective of Cognitive Behavioral Therapy (CBT). CBT has become one of the most popular therapies for treating substance abuse. When asked why, he replied simply: "because it works."

Substance abuse has long been regarded as one of the most intractable problems in the mental health profession. It has a biological cause, is often exacerbated by environmental factors such as growing up in a society where drug use is normalized and prevalent, and then fundamentally rewires the subject's reward center in the brain — so that the pleasures of the drug come to outweigh all other pleasures. One of the few techniques capable of 'unwiring' this negative pattern has been CBT. The counselor holds a strong belief in the CBT format: he holds an M.A. in clinical psychology and also received specialized training in the technique, which is quite specific in its orientation and approach.

CBT's Focus on the Present and Rational Thinking

In previous forms of therapy, according to the counselor, the focus was placed on the subject's past — on uncovering which early experiences lay at the root of the addiction. "This doesn't do much to cure the addiction," he explained. "Often, you end up talking and talking about things that happened in the past that are really irrelevant to the subject's life. It's important instead to focus on the here and now."

CBT helps the substance abuser identify irrational behavior patterns and replace them with rational thoughts. For example, instead of thinking, "it would be so much easier to get through this if I could just take a drink," CBT encourages the client to recall all the times he or she tried to take a drink to relax and actually made things worse. The counselor might prompt the client: "Did it make things easier when you took a drink at the last work function you attended?" To which the client might respond: "No, I got drunk and embarrassed myself."

CBT also teaches clients positive coping mechanisms such as deep breathing, pausing before acting or speaking, and setting weekly goals to work toward abstinence.

Goal-Setting and the Structure of CBT Sessions

CBT operates on the principle that by changing someone's thoughts, it is possible to change their actions, and vice versa. The counselor works with his clients to set positive, clearly definable, and concrete goals — helping them change both the structure of their lives and the patterns of their thinking. He placed particular emphasis on the word concrete when discussing goal-setting in CBT. A goal is not simply "to do better." Rather, the client must commit to something specific — for example: "to go to the gym every day after work instead of going to a bar."

Advantages of CBT's Compressed and Goal-Oriented Format

The goal-oriented nature of CBT is one of its key advantages. Quite often, clients do not have the luxury of extended time to reflect on their pasts. Addiction is a disease that can ravage the body and mind, and the longer someone remains addicted, the harder it becomes to quit — making a quick-acting therapy essentially necessary. Additionally, clients are often under pressure from the legal system due to drug possession or dealing charges, or DWI charges, that demand a sudden break from past behavior. Insurance companies, too, frequently cover only a limited number of mental health counseling sessions.

CBT turns this compressed format to the therapy's advantage. Rather than cultivating a dependent relationship between patient and therapist, the therapist encourages the client to meet objective goals — not merely to please the therapist — and emphasizes the client's independence from both negative thinking patterns and the drug itself.