CBT with Substance Dependence

Cognitive-behaviour therapy aims to help substance-dependent people abstain from using by applying the same learning processes that developed the substance dependence initially. In treating substance dependence, the goal of cognitive behaviour therapy is to teach the person to:

  1. Recognise situations in which they are most likely to use the substance,
  2. Avoid these circumstances wherever practical and possible, and
  3. Use more effective ways of coping with the range of various problems and behaviours which may lead to their substance use/abuse in the first place.

While this approach is valuable in the treatment of most addictions, it has proven to be most effective in the treatment of behavioural addictions; for example, gambling.

The cognitive aspect of CBT is based on the process of (1) Identifying a client’s irrational thinking (2) Challenge the irrational thinking identified (3) Identifying core beliefs and (4) Challenge the core beliefs identified. Cognitive behavioural approaches teach clients the skills to evaluate their own thought patterns and core beliefs (McMullin, 2000).

Examples are illustrated below:

Identifying the client’s irrational thinking

Counsellor: Now, Tom, I’d like to spend a few minutes talking about the connection between your thoughts and your emotions. Can you think of some times this week when you didn’t drink alcohol?

Don: Yes. On Wednesday

Counsellor: How did you feel?

Don: I felt tense and anxious

Counsellor: What was going through your mind?

Don: That I need to drink to help me relax

Counsellor: Okay. You just identified what we call an automatic thought. Everyone has them. They are thoughts that immediately pop in to our mind without any effort on our part. Most of the time the thought occurs so quickly, we don’t even notice, but it has an impact on your emotions.

It’s usually the emotion that we notice, rather than the thought. Often these automatic thoughts are distorted in some way but we usually don’t stop to question them.

Challenging the client’s irrational thinking

Counsellor: Ok Don, I want you to think about the automatic thought we’ve just identified, “I have to drink to help me relax”. Tell me… what’s the worst thing that could happen if you didn’t drink?

Don: Well, I guess I would end up feeling pretty damn anxious and restless

Counsellor: And, if this were to happen, could you live through it?

Don: What do you mean live through it? If I don’t drink it doesn’t stop?

Counsellor: Are you sure about that Mitch? Are you saying that if you don’t have a drink you would always be feeling anxious? And that drinking is the only way to stop feeling anxious?

Don: Well, I do get scared about never being able to stop feeling anxious… and drinking just seems to stop it pretty good.

Counsellor: Has there ever been a time when you have not felt anxious and you weren’t drinking?

Don: Well yeah, of course…

Counsellor:  Ok… so you don’t necessarily always need a drink in order for you not to feel anxious?

Don: Hmmm… never thought of it like that…  I suppose I can feel fine sometimes without a drink.

Counsellor: Ok, so you agree… there are times you can feel just fine without having to have a drink to make that happen.

Don: (Smiling with a sense of knowing that his logic has been caught a little short) well yeah… true… very true… when you put it that way… I suppose I don’t always need a drink… and I can feel fine sometimes without having a drink.

Counsellor: Ok, so what’s the worst thing that could happen if you were feeling anxious and you didn’t drink?

Don: Hmm, ok… when I really think about it… I suppose I’d just get over it eventually… I’d feel anxious and spin out for a bit, but then I suppose I’d end up focusing on something else… go for a walk, watch the TV… don’t know… but I suppose I’d get over it.

Counsellor: Is that true? You really couldn’t live without alcohol?

Don: Hmmm, that’s a tough one… When I really think about it though… while I would be a bit nervous… and it’d probably result in some pretty boring parties… deep down I know I could live without it if I really had to…

Counsellor: What if you were feeling really anxious? Could you live without it if you were feeling really anxious?

Don: Well… I wouldn’t really want to but when I think about it if I really had to… yeah. Yes – of course I would be able to live without alcohol… even if I was really anxious. I don’t know what I would do… might go crazy… but yeah; if I had to live without it, I would.

Identifying core beliefs

Counsellor: So you are upset that you can’t stop gambling.

Client: Yes, that’s right. I have to win

Counsellor: So, you’ve got to win because…?

Client: Because if I don’t win I will not be able to provide for my family and it would prove that I’m a worthless and useless failure…

Challenging core beliefs

Counsellor: Do you feel like a worthless and useless failure now?

Client: Yes… I’m pathetic… useless…

Counsellor: You’re pathetic and useless? How pathetic and useless?

Client: Completely useless; and that’s pathetic… I can’t do anything right…

Counsellor: Do you see how extreme you are in your beliefs about yourself? You’re honestly trying to tell me that you can’t do anything right? Absolutely nothing right… If that were true though… how did you even get to this appointment? How did you end up getting married and having a family… you must have done something right there at some point along the way…

Client: Yeah, but I’m just useless. And worthless… my family would be better off without me.

Counsellor: Would your son would be better off without you, his dad?

Client: Yes…

Counsellor: If you just decided to leave home now… never to come back… how would it affect your son…?

Client: He’d get over it…

Counsellor: He’d get over what?

Client: He’d get over me not being around…

Counsellor: But if your son thought you were so useless and worthless why would he need to get over anything if you left and never came back?

Client: I don’t know… its cause he’s a kid… I don’t know…

Counsellor: Do you think that it might be because he might value his dad? Do you think it might be because he doesn’t think you’re as useless as you do?

Client: Yeah, I know… he does look up to his old man… but he’s young he wouldn’t know would he… how useless I am…

Counsellor: Who’s his old man?

Client: Me… Of course

Counsellor: So you son looks up to you?

Client: Yeah…

Counsellor: Your son looks up to you… he thinks you’re all right… he looks up to you?

Client: Yeah… he does?

Counsellor: So he doesn’t think you’re worthless and useless?

Client: No, he doesn’t.

Counsellor: Do you disagree with him…?

Client: Well, no, I… hmmm, I just don’t want to let him down. I want to do the best I can for him… but it’s so hard; bringing up a family is so hard. It’s so easy to get it wrong.

Counsellor: Ok so what you’re saying is that you love your son very much and you want to do the very best you can for him – but sometimes you feel you stuff up with that or that its not always that easy to make sure the best happens for your son?

Client: Yeah… that’s it…

Counsellor: So where does the “I’m useless and worthless” thing come in to it then?

Client: I don’t know… I just wish I could be a better dad…

Counsellor: Well it certainly sounds like you’ve got your heart in the right place… your goal and your desire for your son sounds like a pretty valuable goal to have… and you sound really adamant on trying to achieve it as best you can… how is all this of no value? How do you end up rating such goals and aspirations you have as useless and worthless?

Client: Well because it’s so hard sometimes…

Counsellor: Ok… so you’re saying you are pathetic, useless and worthless because you find it hard to be a parent sometimes? Isn’t that being a bit harsh on yourself?

Client: Yeah… I know… I suppose I might beat myself up a bit too much… you know that’s what my wife says… she says the kids love me and they ‘worship their dad’… I suppose sometimes I just don’t see it… I don’t know…

Counsellor: And you think you can fix it all by gambling? Now really… are you sure about that?

Client: When you put it like that. It does sound pretty stupid and desperate…

Counsellor: Well, there’s better ways of trying to do the best for your family don’t you think?

Client: Yeah…  true… I don’t know what I was thinking…

Source: www.mentalhealthacademy.com.au