Cognitive Behavioral Therapy (CBT) For Substance Abuse

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Last Edited: August 15, 2020

Patricia Howard, LMFT, CADC

Clinically Reviewed
Andrew Lancaster, LPC, MAC

All of the information on this page has been reviewed and certified by an addiction professional.

What is Cognitive Behavioral Therapy and How Does it Work?

Cognitive-Behavioral Therapy (CBT) is a treatment modality for substance abuse that has become significantly popular over the decade. The foundation of this strategy has been developed by some of the greatest minds in psychology originating from classic conditioning, operant learning, and behavioral therapy. CBT focuses on positive thought patterns, attitudes and beliefs about self and stressful situations, and cognitive schema.

CBT focuses on adopting healthy coping mechanisms that will help with cravings and changing negative thought patterns in stressful situations. This treatment strategy avoids identifying and changing beliefs about themselves and their relationship with drug abuse. Educating the recovering addict about the psychology of addiction and identifying triggers that could cause relapse are key in sustaining a lifestyle that does not involve substance abuse.

When the recovering addict is put into a stressful situation the coping mechanisms adopted from CBT will help them handle the situation, their feelings, and destructive behaviors when encountering substance abuse. There are three main elements to CBT that make this treatment modality effective:

  • Functional Analysis
  • Coping Skills Training
  • Relapse Prevention

Three Main Elements of Cognitive Behavioral Therapy

Functional Analysis

Being the first and main aspect of CBT, it is extremely important to properly diagnose the recovering addict’s substance abuse problem and determine if there is any co-existing mental illness problems.

More often than not, a person will resort to drug abuse as a method of self-medication. Schizophrenia, bio-polar disorders, post-traumatic stress disorders; these are just a few mental illnesses that one may self-medicate for unintentionally.

These problems could have existed before the drug abuse spiraled out of control or as a result of the drug abuse. For example, an individual who is suffering from post-traumatic stress may not have been an alcoholic before this disorder developed.

As a method of coping with that stress they might have used alcohol to help them sleep or cope with the disorder. A complete diagnoses of the recovering addict will ensure a full recover not just from the substance abuse but also the co-existing disorders.

With a complete functional analysis a tailored treatment plan can be put into place making the person the focus of treatment and not the substance they are addicted to.

One on one therapy sessions, interviews, questionnaires, mental assessments, and role-playing are tools that can be used to properly assess the person’s condition and the treatment needed for a full recovery.

2. Coping Skills Training

When a person has been abusing drugs or alcohol for so long their go-to coping mechanism becomes the substance that they abuse. Had a stressful day at work-need a drink, car troubles that will cost you an arm and a leg-need to go home and smoke, children misbehaving-need a shot of the strong stuff. These coping mechanisms tend to not solve the problem or help the situation but become the main coping mechanisms for all of life’s problems that the addict needs to get away from.

Learning healthy coping mechanisms to all of life’s little problems that we all encounter is the second element for CBT treatment. The coping skills taught are either specific to drug abuse like refusing the substance when offered or overcoming cravings when a trigger occurs, or general in nature like handling anger or depression. Regardless of the stressor, CBT tailors the skills learned to the recovering addicts needs.

A series of sessions, one on one or group, follow with role playing situations where they practice the coping mechanisms learned. With each trigger identified they rehearse responses and coping skills until it is adopted for that particular situation.

Learning to identify the feeling of a trigger and methods of overcoming that anxiety becomes the focus of each session until the recovering addict is confident in their coping mechanism. Being confident is saying no and meaning it, is why it is rehearsed and practiced in therapy sessions.

3. Relapse Prevention

Self-efficacy becomes the key to this element of CBT. Having the confidence to refuse relapse is important. Relapse often occurs when the person least expects it; having an good time at a family BBQ, getting an overdue bill that was trashed instead of filled are just a few examples. Often times, it is the person’s family or friends that provided the most temptation as people tend to struggle with peer pressure as social acceptance becomes more and more important. To help build a recovering addict’s self-esteem and self-efficacy to execute their coping skills is performance accomplishments.

The recovering addict is drilled to perform an action that they were unable to do before. The difficulty is gradually increased with each successful accomplishment as the risk of relapse also increases with each success. The level of risk and exposure is increased to a point where the person can handle and they will learns to identify the anxiety they feel with each increasing difficulty. It is key in having open communication with the recovering addict about the level of exposure as getting the person to relapse is not the goal, but to strengthen their self-esteem and self-efficacy.

Another part of relapse prevention that is often dreaded in discussion, is the possibility of relapse, thinking of methods of avoiding it all together, and having a backup plan that minimizes harm to the person. Addicts tend to be apprehensive about talking about relapse as they visually see themselves going down an all to familiar path once again. This action in itself can cause anxiety because if you can visualize it, it is more likely to happen. Regardless of the anxiety of discussing it, a plan of action with the therapist is important to have to minimize the harm. Having an emergency plan for the occasion is key before they leave rehab. Lists of 12 step meetings, phone numbers to a support team, and/or a safe place to go where those who care deeply about your sobriety can watch over you is good to have in place.

Key Concepts & Therapeutic Techniques

These key concepts focus on irrational and rational beliefs developed by an individual’s unique philosophy of the world. Based on each person’s belief system their behaviors and feelings manifest accordingly:

  • Individuals develop ways of understanding the world based on their unique philosophy (understandings, beliefs, values, morals) that is developed early on in life. The philosophies that support irrational beliefs tend to cause emotional distress and the philosophies that support rational belief lead to healthy ways of living. Their unique philosophy can change due to life experiences.
  • Creating an environment in therapy sessions that focuses on unconditional acceptance from the therapist and themselves is important.
  • Identifying an individual’s irrational beliefs and analyzing their logic that supports the dysfunctional belief is the beginning of the psychotherapy healing process.
  • Absolutistic mind mentality: When individuals believe they should behave or act in a certain way in life. This can cause anxiety if their absolute way of thinking is not met.
  • Awfulizing: This occurs when an individual exaggerates an event in life cause anxiety or dysfunction (ex. if I don’t get into medical school, my life is over).
  • Demands: Adding unnecessary demands causes stress and anxiety (ex. I need a higher paying job to be happy in my life).


Dr. Albert Ellis

Dr. Albert Ellis became one of most profound theorists of his time as his publications and contributions to psychology and therapy has become the foundation for psychoanalysis. The broken family structure of his youth encouraged his love for psychology as he eventually pursued a masters and Ph.D in clinical psychology. During his graduate studies, Dr. Albert Ellis was a abdicate writer about human sexuality and started a private practice providing clients with psychoanalytical techniques he was learning at Columbia University.

Passionate about his work, he began to question the effectiveness of the traditional techniques like client-centered counseling and focused his passions in writing books and publications. Finally in 1956, Dr. Ellis founded the Society for Scientific Study of Sex and was awarded an editing position for the International Journal of Sexology.

His success continued to grows as his publications and dedication to his field pushed him to develop a therapy that would later be referred to as Rational Emotive Behavior Therapy. Albert Ellis’s Rational Emotive Behavior Therapy (REBT) is the foundation at which Cognitive Behavior Therapy (CBT) is based on in today’s practices. This type of therapy is practiced all over the world as a method of psychotherapy and counseling.

Benefits with Cognitive Behavioral Therapy

  • Recovering addicts learn healthy coping mechanisms that can help prevent relapse and deal with stressful situations.
  • Practicing coping skills with a therapists ensures confidence in the moment of temptation.
  • This type of treatment addresses the person and not just the addiction.
  • Educating individuals about their illness and how they can manage it is an effective way of prevent relapse.
  • 16 to 20 sessions with a therapist practicing and learning how to cope with stressful situations to prevent relapse.
  • Constructs an emergency plan for recovering addicts during moments of weakness involving phone numbers, support groups, or safe place to prevent relapse.
  • Gradual challenges that helps build confidence for trigger and temptations.

Conflicts with Cognitive Behavioral Therapy

CBT does not have any real conflicts with treatment is it focuses on educating the recovering addict about their addict on the triggers that could cause relapse. This therapy does not rely on a religious set of beliefs nor does it conflict with morals or set values.

The only real conflict that this therapy possess is at some point during the person treatment, commonly towards the conclusion, they are challenged. These challenges prepare the recovering addict for possible temptations they might encounter in the real world. During the end of treatment the therapist will discuss with the client the triggers they may face in their environment and the emergency plan they have in place for if they do relapse. Talking about relapse with a recovering addict is difficult as they tend to visualize themselves using and sometimes even visualizing their old behavior can cause relapse in itself.

Neukrug, E. (2011). Counseling theory and practice. Australia: Brooks/Cole, Cengage Learning.
Halasz, G. (2004). Interview: In conversation with Albert Ellis. Australasian Psychiatry, 12(4), 325-333
Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 34.) Chapter 4—Brief Cognitive-Behavioral Therapy.Available from: