When it comes to substance use, CBT treats substance use disorders as learned behaviors that can be modified by targeting the underlying belief systems that drive substance use behavior. This approach is based on the cognitive model of substance use, which outlines a multistep process in which continued use or relapse occurs.
The model begins with an activating event
, which can be a single event or a series of events, that trigger substance-related thoughts. This event can be innocuous and have nothing to do with substance use, but the key is that it begins the thinking process that could lead to substance use. For example, a client’s spouse might muse, “I could really use some time to myself right now.” This activating event directly triggers the person’s initial beliefs, which are deeply engrained and typically skewed toward the negative. For example, after hearing their spouse request some time to themselves, the client may irrationally conclude, “They want time to themselves because I’m a horrible partner,” “I always drive people away,” or “I am not worthy of being loved.”
Our automatic thoughts
flow directly from our beliefs, and we tend to be more aware of these thoughts when compared to our initial beliefs. These thoughts are often a reaction to our initial beliefs and may serve to relieve tension from those beliefs. Continuing with our example, the client might think, “I just want to have a drink” or “I’m going to get high.” Again, this may be the first part of the process that the client is consciously aware of, but itis still being driven by those initial beliefs.
As the client becomes aware of their thoughts, they begin to have physical cravings
and emotional urges
to engage in behaviors connected to what they are thinking about. The client may think about walking into a bar, imagine tasting alcohol, or obsess over feeling high, numb, or relaxed. These cravings and urges then lead to facilitating beliefs
that encourage substance use. This is an important step in the model because it is where the client attempts to justify their urges and cravings. In our example, the client’s facilitating belief might be “Yeah, I deserve a drink.” The essence of CBT is to recognize this process and then try something different. The goal is to help the client to believe “I know that using won’t help me” or “I know these urges and cravings won’t last forever.”
Once a client develops a facilitating belief, they begin to focus on action. For example, the person might call their dealer to purchase drugs or drive to the corner store to purchase alcohol. This then leads to continued use
or a return to use
. The hope is that clients do not get to this stage, as your work in CBT is to limit the opportunities for this to occur.
In order to intervene at each stage of the model and help clients address the problems that often precipitate their SUD, CBT targets five areas:
- Managing cravings: An important part of treatment involves helping clients understand that cravings are a substantial part of SUD. CBT can help them learn how to recognize cravings, how they experience cravings, and how to deal with their cravings.
- Avoiding high-risk situations: Another important part of recovery involves avoiding situations where substances are available, as well as staying away from emotionally charged interactions that could trigger use.
- Case management: The provision of case management helps clients connect with other services they may need that can support their journey toward recovery.
- Mood regulation: With CBT, clients develop a better understanding of their feelings and how these feelings impact their thoughts. It also helps them see how substances are often used to change how they think and feel, and this can help teach them how to regulate their feelings without substances.
- Lifestyle changes: SUD impacts the whole person, so treating SUD involves examining every aspect of a client’s life, seeing all the things that impact their SUD, and making appropriate changes to support recovery.
To help your clients apply the cognitive model of substance use to their own lives, use the following worksheet, which details the steps involved in the cognitive model of substance use. For more worksheets, handouts, and strategies for working with clients with substance use disorders, check out my new book, The Clinician’s Guide to Substance Use Disorders: Practical Tools for Assessment, Treatment & Recovery.